Endocarditis medical therapy: Difference between revisions

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Latest revision as of 22:48, 5 March 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Antimicrobial therapy is the mainstay of therapy for endocarditis. Empiric antimicrobial therapy depends on the nature of the valve (native vs. prosthetic) and the onset of endocarditis following valve implantation (less than 1 year vs. more than 1 year). In patients with endocarditis, antithrombotic therapy may be administered when needed. The prothrombin time must be carefully monitored as anticoagulants may cause or worsen hemorrhage in patients with endocarditis. Heparin administration should be avoided if possible.

Medical Therapy

Empirical Antibiotic Therapy

Antibiotic therapy for subacute hemodynamically stable disease, and in those who have received antibiotics recently can be delayed waiting for the results of blood cultures, as this delay allows an additional blood cultures without the confounding effect of empiric treatment, which is very important in determining the causing pathogens.^[1]
On the other hand, the rapid progression of acute cases necessitates the start of empirical treatment antibiotic therapy once the blood cultures have been collected.
Clinical course of infection beside the epidemiological features should be considered upon selecting empirical treatment regimen.
Consultation with an infectious disease specialist for the selection of one of the antibiotic regimens is recommended (see therapy for culture-negative endocarditis). ^[2]

Timing of Initiation of Antibiotics

Antibiotic therapy for the subacute or indolent disease can be delayed until results of blood cultures are known.
In fulminant infection or valvular dysfunction requiring urgent surgical intervention, begin empirical antibiotic therapy promptly after blood cultures have been obtained.

Duration of Antibiotic Therapy

The duration of native valve endocarditis is often 4 weeks.
For prosthetic valve endocarditis (including the presence of a valve ring), treatment should be continued for 6 to 8 weeks.
For each infective agent, the preferred antimicrobial agent, dose, and duration are listed below.

Antimicrobial Regimens

Infective endocarditis^[3]

1. Culture-negative endocarditis

1.1. Culture-negative, native valve endocarditis

Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks
Alternative regimen: Vancomycin 30 mg/kg/24h IV q12h for 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks AND Ciprofloxacin 1000 mg/24 h PO or 800 mg/24h IV q12h for 4–6 weeks
Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q4–6h; Gentamicin 3 mg/kg/24h IV/IM q8h; Vancomycin 40 mg/kg/24h q8–12h; Ciprofloxacin 20–30 mg/kg/24h IV/PO q12h

1.2. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)

Preferred regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 2 weeks AND Cefepime 6 g/24h IV q8h for 6 weeks AND Rifampin 900 mg/24 h PO/IV q8h for 6 weeks
Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Gentamicin 3 mg/kg/24h IV/IM q8h; Cefepime 150 mg/kg/24h IV q8h; Rifampin 20 mg/kg/24 h PO/IV q8h

1.3. Culture-negative, prosthetic valve endocarditis (late, > 1 year)

Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
Alternative regimen: Vancomycin 30 mg/kg/24h IV q12h for 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks AND Ciprofloxacin 1000 mg/24 h PO or 800 mg/24h IV q12h for 6 weeks
Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q4h; Gentamicin 3 mg/kg/24h IV/IM q8h; Vancomycin 40 mg/kg/24h q8–12h; Ciprofloxacin 20–30 mg/kg/24h IV/PO q12h

1.4. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)

Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks AND Rifampin 900 mg/24 h PO/IV q8h for 6 weeks
Alternative regimen: Vancomycin 30 mg/kg/24h IV q12h for 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks AND Ciprofloxacin 1000 mg/24 h PO or 800 mg/24h IV q12h for 4–6 weeks AND Rifampin 900 mg/24 h PO/IV q8h for 6 weeks
Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q4–6h; Gentamicin 3 mg/kg/24h IV/IM q8h; Vancomycin 40 mg/kg/24h IV q8–12h; Cefepime 150 mg/kg/24h IV q8h; Rifampin 20 mg/kg/24 h PO/IV q8h

2. Pathogen-directed antimicrobial therapy

2.1. Bartonella

2.1.1. Suspected Bartonella endocarditis

Preferred regimen : Ceftriaxone sodium 2 g/24h IV/IM in 1 dose for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 2 weeks ± Doxycycline 200 mg/kg/24h IV/PO q12h for 6 weeks
Pediatric dose: Ceftriaxone 100 mg/kg/24h IV/IM once daily; Gentamicin 3 mg/kg/24h IV/IM q8h; Doxycycline 2–4 mg/kg/24h IV/PO q12h; Rifampin 20 mg/kg/24h PO/IV q12h

2.1.2 Documented Bartonella endocarditis

Preferred regimen: Doxycycline 200 mg/24h IV or PO q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 2 weeks
Pediatric dose: Ceftriaxone 100 mg/kg/24h IV/IM once daily; Gentamicin 3 mg/kg/24h IV/IM q8h; Doxycycline 2–4 mg/kg/24h IV/PO q12h; Rifampin 20 mg/kg/24h PO/IV q12h

2.3. Enterococcus

2.3.1. Endocarditis caused by enterococcal strains susceptible to penicillin, gentamicin, and vancomycin

Preferred regimen : Ampicillin 12 g/24h IV q4h for 4–6 weeks OR Penicillin G 18–30 million U/24h IV either continuously or q4h for 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks
Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Gentamicin 3 mg/kg/24h IV/IM q8h

2.3.2. Endocarditis caused by enterococcal strains susceptible to penicillin, streptomycin, and vancomycin and resistant to gentamicin

Preferred regimen : Ampicillin 12 g/24h IV q4h for 4–6 weeks OR Penicillin G 24 million U/24h IV continuously or q4h for 4–6 weeks AND Streptomycin 15 mg/kg/24h IV/IM q12h for 4–6 weeks
Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Streptomycin 15 mg/kg/24h IV/IM q12h for 6 weeks
Pediatric dose: Ampicillin 300 mg/kg/24h IV q4–6h; Penicillin 300 000 U/kg/24h IV q4–6h; Streptomycin 20–30 mg/kg/24h IV/IM q12h; Vancomycin 40 mg/kg/24h IV q8–12h; Streptomycin 20–30 mg/kg/24h IV/IM q12h

2.3.3. Endocarditis caused by enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin

β-Lactamase–producing strain

Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks
Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q6h; Gentamicin 3 mg/kg/24h IV/IM q8h

Intrinsic penicillin resistance

Preferred regimen: Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Gentamicin 3 mg/kg/24h IV/IM q8h

2.3.4. Endocarditis caused by enterococcal strains resistant to penicillin, gentamicin, and vancomycin

Enterococcus faecium

Preferred regimen : Linezolid 1200 mg/24h IV/PO q12h for ≥ 8 weeks OR Quinupristin-Dalfopristin 22.5 mg/kg/24h IV q8h for 8 weeks

Enterococcus faecalis

Preferred regimen : Imipenem/cilastatin 2 g/24h IV q6h for ≥ 8 weeks AND Ampicillin 12 g/24h IV q4h for ≥ 8 weeks OR Ceftriaxone sodium 4 g/24h IV/IM q12h for ≥ 8 weeks AND Ampicillin 12 g/24h IV q4h for ≥ 8 weeks
Pediatric dose: Linezolid 30 mg/kg/24h IV/PO q8h; Quinupristin-Dalfopristin 22.5 mg/kg/24h IV q8h; Imipenem/cilastatin 60–100 mg/kg/24h IV q6h; Ampicillin 300 mg/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM q12h

2.4. HACEK organisms

2.4.1. Endocarditis caused by Haemophilus, Aggregatibacter (Actinobacillus), Cardiobacterium, Eikenella corrodens, or Kingella

Preferred regimen : Ceftriaxone sodium 2 g/24h IV/IM in 1 dose for 4 weeks OR Ampicillin 12 g/24h IV q6h for 4 weeks OR Ciprofloxacin 1000 mg/24h PO or 800 mg/24h IV q12h for 4 weeks
Pediatric dose: Ceftriaxone 100 mg/kg/24h IV/IM once daily; Ampicillin-sulbactam 300 mg/kg/24h IV divided into 4 or 6 equally divided doses; Ciprofloxacin 20–30 mg/kg/24h IV/PO q12h

2.5. Staphylococcus

2.5.1. Native valve endocarditis caused by oxacillin-susceptible staphylococci

Preferred regimen (1): Nafcillin or Oxacillin 12 g/24h IV q4–6h for 6 weeks ± Gentamicin 3 mg/kg/24h IV/IM q8–12h for 3–5 days
Preferred regimen (2): Cefazolin 6 g/24h IV q8h for 6 weeks ± Gentamicin 3 mg/kg/24h IV/IM q8–12h for 3–5 days
Pediatric dose: Nafcillin or Oxacillin 200 mg/kg/24h IV q4–6h; Gentamicin 3 mg/kg/24h IV/IM q8h; Cefazolin 100 mg/kg/24h IV q8h; Gentamicin 3 mg/kg/24h IV/IM q8h

2.5.2. Native valve endocarditis caused by oxacillin-resistant staphylococci

Preferred regimen: Vancomycin 30 mg/kg/24h IV q12h for 6 weeks
Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h

2.5.3. Prosthetic valve endocarditis caused by oxacillin-susceptible staphylococci

Preferred regimen: Nafcillin or Oxacillin 12 g/24h IV q4h for ≥ 6 weeks AND Rifampin 900 mg/24h IV/PO q8h for ≥ 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8–12h for 2 weeks
Pediatric dose: Nafcillin or Oxacillin 200 mg/kg/24h IV q4–6h; Rifampin 20 mg/kg/24h IV/PO q8h; Gentamicin 3 mg/kg/24h IV/IM q8h

2.5.4 Prosthetic valve endocarditis caused by oxacillin-resistant staphylococci

Preferred regimen: Vancomycin 30 mg/kg 24 h q12h for ≥ 6 weeks AND Rifampin 900 mg/24h IV/PO q8h for ≥ 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8–12h for 2 weeks
Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Rifampin 20 mg/kg/24h IV/PO q8h (up to adult dose); Gentamicin 3 mg/kg/24h IV or IM q8h

2.6 Viridans group streptococci and Streptococcus bovis

2.6.1. Native valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)

Preferred regimen: Penicillin G 12–18 million U/24h IV either continuously or q4–6h for 4 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 4 weeks
Alternative regimen (1): (Penicillin G 12–18 million U/24h IV either continuously or q4h for 2 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 2 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
Alternative regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h

2.6.2. Native valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 to ≤ 0.5 μg/mL)

Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q4–6h for 4 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 4 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h

2.6.3. Prosthetic valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)

Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q4–6h for 6 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 6 weeks) ± Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h

2.6.4. Prosthetic valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 μg/mL)

Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q4–6h for 6 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 6 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h

Antithrombotic Therapy

Anticoagulants can cause or worsen hemorrhage in patients with endocarditis but maybe carefully administered when needed.^[4]
The prothrombin time should be carefully maintained at an INR of 2.0–3.0.
Anticoagulation should be reversed immediately in the event of CNS complications and interrupted for 1–2 weeks after an acute embolic stroke.
Avoid heparin administration during active endocarditis if possible.

Class I
"1. Penicillin G or Amoxicilline or Ceftriaxonef(Level of Evidence: A)"
”2. (Paste guideline here) (Level of Evidence: C)"
”3. (Paste guideline here) (Level of Evidence: B)"

References

↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-2708-1.
↑ Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)
↑ Baddour, Larry M.; Wilson, Walter R.; Bayer, Arnold S.; Fowler, Vance G.; Bolger, Ann F.; Levison, Matthew E.; Ferrieri, Patricia; Gerber, Michael A.; Tani, Lloyd Y.; Gewitz, Michael H.; Tong, David C.; Steckelberg, James M.; Baltimore, Robert S.; Shulman, Stanford T.; Burns, Jane C.; Falace, Donald A.; Newburger, Jane W.; Pallasch, Thomas J.; Takahashi, Masato; Taubert, Kathryn A.; Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease; Council on Cardiovascular Disease in the Young; Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia; American Heart Association; Infectious Diseases Society of America (2005-06-14). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): –394-434. doi:10.1161/CIRCULATIONAHA.105.165564. ISSN 1524-4539. PMID 15956145.
↑ Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A. (2005). "Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): 3167–84. PMID 15956145.

[1] Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-2708-1.

[Baddour-2005-2] Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)

[3] Baddour, Larry M.; Wilson, Walter R.; Bayer, Arnold S.; Fowler, Vance G.; Bolger, Ann F.; Levison, Matthew E.; Ferrieri, Patricia; Gerber, Michael A.; Tani, Lloyd Y.; Gewitz, Michael H.; Tong, David C.; Steckelberg, James M.; Baltimore, Robert S.; Shulman, Stanford T.; Burns, Jane C.; Falace, Donald A.; Newburger, Jane W.; Pallasch, Thomas J.; Takahashi, Masato; Taubert, Kathryn A.; Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease; Council on Cardiovascular Disease in the Young; Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia; American Heart Association; Infectious Diseases Society of America (2005-06-14). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): –394-434. doi:10.1161/CIRCULATIONAHA.105.165564. ISSN 1524-4539. PMID 15956145.

[Baddour-4] Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A. (2005). "Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): 3167–84. PMID 15956145.

[1]

[2]

[3]

[4]

@@ Line 2: / Line 2: @@
 {{Endocarditis}}
-{{CMG}}; {{AE}} {{CZ}}; {{AZ}}; {{MM}}
+{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}
 ==Overview==
+[[Antimicrobial]] therapy is the mainstay of therapy for [[endocarditis]]. [[Empiric therapy|Empiric]] antimicrobial therapy depends on the nature of the [[valve]] (native vs. [[Prosthesis|prosthetic]]) and the onset of [[endocarditis]] following [[valve]] implantation (less than 1 year vs. more than 1 year). In patients with [[endocarditis]], [[Antithrombotic therapy|antithrombotic]] therapy may be administered when needed. The [[prothrombin time]] must be carefully monitored as [[anticoagulant]]s may cause or worsen [[hemorrhage]] in patients with endocarditis. [[Heparin]] administration should be avoided if possible.
-[[Blood cultures]] should be drawn prior to instituting antibiotics to identify the etiologic agent and to determine its antimicrobial susceptibility.  Older antibiotics such as [[penicillin]] G, [[ampicillin]], [[nafcillin]], [[cefazolin]], [[gentamycin]], [[ceftriaxone]], [[rifampin]] and [[vancomycin]] are the mainstays of therapy.  Empiric antiomicrobial therapy is started once the blood cultures have been collected.
+==Medical Therapy==
+===Empirical Antibiotic Therapy===
+*[[Antibiotic]] therapy for subacute [[hemodynamically]] stable disease, and in those who have received [[antibiotics]] recently can be delayed waiting for the results of [[blood culture]]s, as this delay allows an additional blood cultures without the confounding effect of [[Empirical|empiric]] treatment, which is very important in determining the causing [[pathogens]].<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-2708-1 | pages =  }}</ref>
+* On the other hand, the rapid progression of acute cases necessitates the start of [[empirical]] treatment [[antibiotic]] therapy once the [[blood cultures]] have been collected.
+* Clinical course of [[infection]] beside the [[epidemiological]] features should be considered upon selecting [[empirical]] treatment regimen.
+* Consultation with an [[infectious]] disease specialist for the selection of one of the [[antibiotic]] regimens is recommended (see therapy for culture-negative [[endocarditis]]). <ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref>
-==Timing of Initiation of Antibiotics==
+===Timing of Initiation of Antibiotics===
-Antibiotic therapy for subacute or indolent disease can be delayed until results of blood cultures are known; in fulminant infection or valvular dysfunction requiring urgent surgical intervention, begin empirical antibiotic therapy promptly after blood cultures have been obtained.
+* [[Antibiotic]] therapy for the [[subacute]] or indolent disease can be delayed until results of blood cultures are known.
+* In [[fulminant]] infection or [[valvular]] dysfunction requiring urgent surgical intervention, begin [[empirical]] antibiotic therapy promptly after blood cultures have been obtained.
-==Duration of Antibiotic Therapy==
+===Duration of Antibiotic Therapy===
-The duration for native valve endocarditis is often 4 weeks. For prosthetic valve [[endocarditis]] (including the presence of a valve ring), treatment should be continued for 6 to 8 weeks. For each infective agent, the preferred antimicrobial agent, dose, and duration is listed below.
+* The duration of native valve [[endocarditis]] is often 4 weeks.
+* For [[prosthetic]] valve [[endocarditis]] (including the presence of a valve ring), treatment should be continued for 6 to 8 weeks.
+* For each infective agent, the preferred [[antimicrobial]] agent, dose, and duration are listed below.
-==Empirical Antibiotic Therapy==
+===Antimicrobial Regimens===
+*[[Infective endocarditis]]<ref>{{Cite journal| doi = 10.1161/CIRCULATIONAHA.105.165564| issn = 1524-4539| volume = 111| issue = 23| pages = –394-434| last1 = Baddour| first1 = Larry M.| last2 = Wilson| first2 = Walter R.| last3 = Bayer| first3 = Arnold S.| last4 = Fowler| first4 = Vance G.| last5 = Bolger| first5 = Ann F.| last6 = Levison| first6 = Matthew E.| last7 = Ferrieri| first7 = Patricia| last8 = Gerber| first8 = Michael A.| last9 = Tani| first9 = Lloyd Y.| last10 = Gewitz| first10 = Michael H.| last11 = Tong| first11 = David C.| last12 = Steckelberg| first12 = James M.| last13 = Baltimore| first13 = Robert S.| last14 = Shulman| first14 = Stanford T.| last15 = Burns| first15 = Jane C.| last16 = Falace| first16 = Donald A.| last17 = Newburger| first17 = Jane W.| last18 = Pallasch| first18 = Thomas J.| last19 = Takahashi| first19 = Masato| last20 = Taubert| first20 = Kathryn A.| last21 = Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease| last22 = Council on Cardiovascular Disease in the Young| last23 = Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia| last24 = American Heart Association| last25 = Infectious Diseases Society of America| title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America| journal = Circulation| date = 2005-06-14| pmid = 15956145}}</ref>
-* Antibiotic therapy for subacute hemodynamically stable disease, and in those who have received antibiotics recently can be delayed waiting for the results of [[blood culture]]s, as this delay allows an additional blood cultures without the confounding effect of empiric treatment, which is very important in determining the causing pathogens.<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-2708-1 | pages =  }}</ref>
+:*'''1. Culture-negative endocarditis'''
+::*'''1.1. Culture-negative, native valve endocarditis'''
+:::* Preferred regimen: [[Ampicillin-sulbactam]] 12 g/24h IV q6h 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks
+:::* Alternative regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks {{and}} [[Ciprofloxacin]] 1000 mg/24 h PO or 800 mg/24h IV q12h for 4–6 weeks
+:::* Pediatric dose: [[Ampicillin-sulbactam]] 300 mg/kg/24h IV q4–6h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Vancomycin]] 40 mg/kg/24h q8–12h; [[Ciprofloxacin]] 20–30 mg/kg/24h IV/PO q12h
-* On the other hand, the rapid progression of acute cases necessitates the start of empirical treatment antibiotic therapy once the blood cultures have been collected.
+::*'''1.2. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)'''
+:::* Preferred regimen : [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 2 weeks {{and}} [[Cefepime]] 6 g/24h IV q8h for 6 weeks {{and}} [[Rifampin]] 900 mg/24 h PO/IV q8h for 6 weeks
+:::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Cefepime]] 150 mg/kg/24h IV q8h; [[Rifampin]] 20 mg/kg/24 h PO/IV q8h
-* Empirical therapy is needed for all likely pathogens, certain antibiotic agents, including aminoglycosides, is preferably avoided for its toxic effects.
+::*'''1.3. Culture-negative, prosthetic valve endocarditis (late, > 1 year)'''
+:::* Preferred regimen: [[Ampicillin-sulbactam]] 12 g/24h IV q6h 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks
+:::* Alternative regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks {{and}} [[Ciprofloxacin]] 1000 mg/24 h PO or 800 mg/24h IV q12h for 6 weeks
+:::* Pediatric dose: [[Ampicillin-sulbactam]] 300 mg/kg/24h IV q4h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Vancomycin]] 40 mg/kg/24h q8–12h; [[Ciprofloxacin]] 20–30 mg/kg/24h IV/PO q12h
-* Clinical course of infection beside the epidemiological features should be considered upon selecting empirical treatment regimen.
+::*'''1.4. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)'''
+:::* Preferred regimen: [[Ampicillin-sulbactam]] 12 g/24h IV q6h 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks {{and}} [[Rifampin]] 900 mg/24 h PO/IV q8h for 6 weeks
+:::* Alternative regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks {{and}} [[Ciprofloxacin]] 1000 mg/24 h PO or 800 mg/24h IV q12h for 4–6 weeks {{and}} [[Rifampin]] 900 mg/24 h PO/IV q8h for 6 weeks
+:::* Pediatric dose: [[Ampicillin-sulbactam]] 300 mg/kg/24h IV q4–6h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Cefepime]] 150 mg/kg/24h IV q8h; [[Rifampin]] 20 mg/kg/24 h PO/IV q8h
-* Consultation with an infectious disease specialist for the selection of one of the antibiotic regimens is recommended (see therapy for culture-negative endocarditis). <ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref>
+:* '''2. Pathogen-directed antimicrobial therapy'''
+::* '''2.1. Bartonella'''
+:::* '''2.1.1. Suspected Bartonella endocarditis'''
+::::* Preferred regimen : [[Ceftriaxone sodium]] 2 g/24h IV/IM in 1 dose for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 2 weeks {{withorwithout}} [[Doxycycline]] 200 mg/kg/24h IV/PO q12h for 6 weeks
+::::* Pediatric dose: [[Ceftriaxone]] 100 mg/kg/24h IV/IM once daily; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Doxycycline]] 2–4 mg/kg/24h IV/PO q12h; [[Rifampin]] 20 mg/kg/24h PO/IV q12h
-==Pathogen-Based Therapy <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''Circulation 2005;111(23):e394-434.''<ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref> and ''Circulation 2008;118(15):e523-661.''<ref name="Bonow-2008">{{Cite journal  | last1 = Bonow | first1 = RO. | last2 = Carabello | first2 = BA. | last3 = Chatterjee | first3 = K. | last4 = de Leon | first4 = AC. | last5 = Faxon | first5 = DP. | last6 = Freed | first6 = MD. | last7 = Gaasch | first7 = WH. | last8 = Lytle | first8 = BW. | last9 = Nishimura | first9 = RA. | title = 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal = J Am Coll Cardiol | volume = 52 | issue = 13 | pages = e1-142 | month = Sep | year = 2008 | doi = 10.1016/j.jacc.2008.05.007 | PMID = 18848134 }}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
+:::* '''2.1.2 Documented Bartonella endocarditis'''
+::::* Preferred regimen: [[Doxycycline]] 200 mg/24h IV or PO q12h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 2 weeks
+::::* Pediatric dose: [[Ceftriaxone]] 100 mg/kg/24h IV/IM once daily; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Doxycycline]] 2–4 mg/kg/24h IV/PO q12h; [[Rifampin]] 20 mg/kg/24h PO/IV q12h
-====Viridans Streptococci or ''Streptococcus bovis''====
+::*'''2.3. Enterococcus'''
+:::*'''2.3.1. Endocarditis caused by enterococcal strains susceptible to penicillin, gentamicin, and vancomycin'''
+::::* Preferred regimen : [[Ampicillin]] 12 g/24h IV q4h for 4–6 weeks {{or}} [[Penicillin G]] 18–30 million U/24h IV either continuously or q4h for 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks
+::::* Alternative regimen : [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks
+::::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h
-<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
+:::* '''2.3.2. Endocarditis caused by enterococcal strains susceptible to penicillin, streptomycin, and vancomycin and resistant to gentamicin'''
+::::* Preferred regimen : [[Ampicillin]] 12 g/24h IV q4h for 4–6 weeks {{or}} [[Penicillin G]] 24 million U/24h IV continuously or q4h for 4–6 weeks {{and}} [[Streptomycin]] 15 mg/kg/24h IV/IM q12h for 4–6 weeks
+::::* Alternative regimen : [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks {{and}} [[Streptomycin]] 15 mg/kg/24h IV/IM q12h for 6 weeks
+::::* Pediatric dose: [[Ampicillin]] 300 mg/kg/24h IV q4–6h; [[Penicillin]] 300 000 U/kg/24h IV q4–6h; [[Streptomycin]] 20–30 mg/kg/24h IV/IM q12h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Streptomycin]] 20–30 mg/kg/24h IV/IM q12h
-{|
+:::* '''2.3.3. Endocarditis caused by enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin'''
-| valign=top |
+::::* β-Lactamase–producing strain
-<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
+:::::* Preferred regimen: [[Ampicillin-sulbactam]] 12 g/24h IV q6h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks
-<font color="#FFF">
+:::::* Alternative regimen : [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks
-'''Native Valve Endocarditis'''
+:::::* Pediatric dose: [[Ampicillin-sulbactam]] 300 mg/kg/24h IV q6h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h
-</font>
+::::* Intrinsic penicillin resistance
-</div>
+:::::* Preferred regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks
-<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
+:::::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Highly PCN Susceptible, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Highly PCN Susceptible, Pediatric'''
-</font>
-</div>
-<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Relatively PCN Resistant, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Relatively PCN Resistant, Pediatric'''
-</font>
-</div>
-<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Highly PCN Resistant'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''Prosthetic Valve Endocarditis'''
-</font>
-</div>
-<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Susceptible, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table07" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Susceptible, Pediatric'''
-</font>
-</div>
-<div class="mw-customtoggle-table08" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Resistant, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table09" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Resistant, Pediatric'''
-</font>
-</div>
-| valign=top |
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC ≤0.12 μg/mL, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 12—18 MU/day IV continuously or q4—6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 4 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 1'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 12—18 MU/day IV continuously or q4—6h x 2 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 2 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 2'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function. <BR> <sup>‡</sup> Two-week regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of less than 20 ml per min, impaired 8th cranial nerve function, or ''Abiotrophia'', ''Granulicatella'', or ''Gemella'' infection. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC ≤0.12 μg/mL, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.2 MU/kg/day IV q4—6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 4 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 1'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.2 MU/kg/day IV q4—6h x 2 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 2 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 2'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function. <BR> <sup>‡</sup> Two-week regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of less than 20 ml per min, impaired 8th cranial nerve function, or ''Abiotrophia'', ''Granulicatella'', or ''Gemella'' infection. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 24 MU/day IV continuously or q4—6h x 4 weeks'''''<sup>†</sup> <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 4 weeks'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Patients with endocarditis caused by Penicillin Resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis. <BR> <sup>‡</sup> Recommended for enterococcal endocarditis. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.3 MU/kg/day IV q4—6h x 4 weeks'''''<sup>†</sup> <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 4 weeks'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg IV q8—12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Patients with endocarditis caused by Penicillin Resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis. <BR> <sup>‡</sup> Recommended for enterococcal endocarditis. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC >0.5 μg/ml}}
-|-
-| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=left | ▸ Endocarditis caused by highly penicillin resistant (MIC >0.5 μg/ml) strains of viridans streptococci, ''Abiotrophia defectiva'', ''Granulicatella'' species, and ''Gemella'' species should be treated with a regimen that is recommended for enterococcal endocarditis.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' PVE, Penicillin MIC ≤0.12 μg/ml, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 24 MU/day IV continuously or q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin therapy should not be administered to patients with creatinine clearance of <30 mL/min <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table07" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' PVE, Penicillin MIC ≤0.12 μg/ml, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.3 MU/kg/day IV q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table08" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' PVE, Penicillin MIC >0.12 μg/ml, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 24 MU/day IV continuously or q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table09" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' PVE, Penicillin MIC >0.12 μg/ml, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.3 MU/kg/day IV q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-|}
-====''Streptococcus pneumoniae'', ''Streptococcus pyogenes'', and Groups B, C, and G Streptococci====
-<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
-{|
-| valign=top |
-<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''''Streptococcus pneumoniae'''''
-</font>
-</div>
-<div class="mw-customtoggle-table10" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Susceptible'''
-</font>
-</div>
-<div class="mw-customtoggle-table11" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Resistant, Without Meningitis'''
-</font>
-</div>
-<div class="mw-customtoggle-table12" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Resistant, With Meningitis'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''''Streptococcus pyogenes'''''
-</font>
-</div>
-<div class="mw-customtoggle-table13" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''''S. pyogenes'' Endocarditis'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''Group B, C, and G ''Streptococcus'''''
-</font>
-</div>
-<div class="mw-customtoggle-table14" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Group B, C, and G ''Streptococcus'' Endocarditis'''
-</font>
-</div>
-| valign=top |
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table10" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''S. pneumoniae'' Endocarditis, PCN Susceptible (MIC ≤0.1 μg/mL)}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 12—18 MU/day IV continuously or q4—6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Cefazolin]] 1—1.5 g IV q6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q24h x 4 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>ǁ</sup> Recommended only for patients unable to tolerate β-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table11" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''S. pneumoniae'' Endocarditis, PCN Resistant (MIC >0.1 μg/mL), Without Meningitis}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 24 MU/day IV continuously or q4—6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Cefotaxime]] 2 g IV q6—8h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q24h x 4 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>ǁ</sup> Recommended only for patients unable to tolerate β-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table12" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''S. pneumoniae'' Endocarditis, PCN Resistant (MIC >0.1 μg/mL), With Meningitis}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q4—6h x 4 weeks'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q12h x 4 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q6h x 4 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 600 mg IV q24h x 4 weeks'''''
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table13" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''S. pyogenes'' Endocarditis}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 12—18 MU/day IV continuously or q4—6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Cefazolin]] 1—1.5 g IV q6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q24h x 4 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>ǁ</sup> Recommended only for patients unable to tolerate β-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table14" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Group B, C, or G ''Streptococcus'' Endocarditis}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 24 MU/day IV continuously or q4—6h x 4—6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 4—6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 4—6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-|}
+:::* '''2.3.4. Endocarditis caused by enterococcal strains resistant to penicillin, gentamicin, and vancomycin'''
+::::* Enterococcus faecium
+:::::* Preferred regimen : [[Linezolid]] 1200 mg/24h IV/PO q12h for ≥ 8 weeks {{or}} [[Quinupristin-Dalfopristin]] 22.5 mg/kg/24h IV q8h for 8 weeks
+::::* Enterococcus faecalis
+:::::* Preferred regimen : [[Imipenem/cilastatin]] 2 g/24h IV q6h for ≥ 8 weeks {{and}} [[Ampicillin]] 12 g/24h IV q4h for ≥ 8 weeks  {{or}} [[Ceftriaxone sodium]] 4 g/24h IV/IM q12h for ≥ 8 weeks {{and}} [[Ampicillin]] 12 g/24h IV q4h for ≥ 8 weeks
+:::::* Pediatric dose: [[Linezolid]] 30 mg/kg/24h IV/PO q8h; [[Quinupristin-Dalfopristin]] 22.5 mg/kg/24h IV q8h; [[Imipenem/cilastatin]] 60–100 mg/kg/24h IV q6h; [[Ampicillin]] 300 mg/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM q12h
-====''Staphylococcus''====
+::* '''2.4. HACEK organisms'''
+:::* '''2.4.1. Endocarditis caused by Haemophilus, Aggregatibacter (Actinobacillus), Cardiobacterium, Eikenella corrodens, or Kingella'''
+::::* Preferred regimen : [[Ceftriaxone sodium]] 2 g/24h IV/IM in 1 dose for 4 weeks {{or}} [[Ampicillin]] 12 g/24h IV q6h for 4 weeks {{or}} [[Ciprofloxacin]] 1000 mg/24h PO or 800 mg/24h IV q12h for 4 weeks
+::::* Pediatric dose: [[Ceftriaxone]] 100 mg/kg/24h IV/IM once daily; [[Ampicillin-sulbactam]] 300 mg/kg/24h IV divided into 4 or 6 equally divided doses; [[Ciprofloxacin]] 20–30 mg/kg/24h IV/PO q12h
-<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
+::* '''2.5. Staphylococcus'''
+:::* '''2.5.1. Native valve endocarditis caused by oxacillin-susceptible staphylococci'''
-{|
+::::* Preferred regimen (1): [[Nafcillin]] or [[Oxacillin]] 12 g/24h IV q4–6h for 6 weeks {{withorwithout}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8–12h for 3–5 days
-| valign=top |
+::::* Preferred regimen (2): [[Cefazolin]] 6 g/24h IV q8h for 6 weeks {{withorwithout}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8–12h for 3–5 days
-<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
+::::* Pediatric dose: [[Nafcillin]] or [[Oxacillin]] 200 mg/kg/24h IV q4–6h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Cefazolin]] 100 mg/kg/24h IV q8h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h
-<font color="#FFF">
-'''Native Valve Endocarditis'''
-</font>
-</div>
-<div class="mw-customtoggle-table15" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin Susceptible, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table16" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin Susceptible, Pediatric'''
-</font>
-</div>
-<div class="mw-customtoggle-table17" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin Resistant, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table18" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin Resistant, Pediatric'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''Prosthetic Valve Endocarditis'''
-</font>
-</div>
-<div class="mw-customtoggle-table19" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin Susceptible, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table20" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin Susceptible, Pediatric'''
-</font>
-</div>
-<div class="mw-customtoggle-table21" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin Resistant, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table22" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin Resistant, Pediatric'''
-</font>
-</div>
-| valign=top |
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table15" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Staphylococcal NVE, Oxacillin Susceptible, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] 12 g/day IV q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Oxacillin]] 12 g/day IV q4—6h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg/day IV/IM q8—12h x 3—5 days'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefazolin]] 2 g IV q8h x 6 weeks'''''<sup>§</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg/day IV/IM q8—12h x 3—5 days'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> For complicated right-sided IE and for left-sided IE; for uncomplicated right-sided IE, 2 weeks. <BR> <sup>¶</sup> Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>‡</sup> For penicillin-allergic (nonanaphylactoid type) patients; consider skin testing for oxacillin-susceptible staphylococci and questionable history of immediate-type hypersensitivity to penicillin. <BR> <sup>§</sup> Cephalosporins should be avoided in patients with anaphylactoid-type hypersensitivity to β-lactams; vancomycin should be used in these cases.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table16" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Staphylococcal NVE, Oxacillin Susceptible, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] 200 mg/kg/day IV q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Oxacillin]] 200 mg/kg/day IV q4—6h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 3—5 days'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefazolin]] 100 mg/kg/day IV q8h x 6 weeks'''''<sup>§</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 3—5 days'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> For complicated right-sided IE and for left-sided IE; for uncomplicated right-sided IE, 2 weeks. <BR> <sup>¶</sup> Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>‡</sup> For penicillin-allergic (nonanaphylactoid type) patients; consider skin testing for oxacillin-susceptible staphylococci and questionable history of immediate-type hypersensitivity to penicillin. <BR> <sup>§</sup> Cephalosporins should be avoided in patients with anaphylactoid-type hypersensitivity to β-lactams; vancomycin should be used in these cases.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table17" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Staphylococcal NVE, Oxacillin Resistant, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 600 mg IV/PO q12h x 8 weeks''''' <BR> OR <BR> ▸ '''''[[Daptomycin]] 6 mg/kg IV q24h x 2—6 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>ǁ</sup> Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table18" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Staphylococcal NVE, Oxacillin Resistant, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 10 mg/kg IV/PO q8h x 8 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>ǁ</sup> Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table19" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Staphylococcal PVE, Oxacillin Susceptible, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] 2 g IV q4h x ≥6 weeks''''' <BR> OR <BR> ▸ '''''[[Oxacillin]] 2 g IV q4h x ≥6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 300 mg IV/PO q8h x ≥6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg/day IV/IM q8—12h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Penicillin G 24 million U/24 h IV in 4 to 6 equally divided doses may be used in place of nafcillin or oxacillin if strain is penicillin susceptible (minimum inhibitory concentration ≤0.1 μg/mL) and does not produce β-lactamase; vancomycin should be used in patients with immediate-type hypersensitivity reactions to β-lactam antibiotics; cefazolin may be substituted for nafcillin or oxacillin in patients with non–immediate-type hypersensitivity reactions to penicillins. <BR> <sup>¶</sup> Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table20" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Staphylococcal PVE, Oxacillin Susceptible, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] 200 mg/kg/day IV q4—6h x ≥6 weeks''''' <BR> OR <BR> ▸ '''''[[Oxacillin]] 2 g IV q4h x ≥6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 20 mg/kg/day IV/PO q8h x ≥6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Penicillin G 24 million U/24 h IV in 4 to 6 equally divided doses may be used in place of nafcillin or oxacillin if strain is penicillin susceptible (minimum inhibitory concentration ≤0.1 μg/mL) and does not produce β-lactamase; vancomycin should be used in patients with immediate-type hypersensitivity reactions to β-lactam antibiotics; cefazolin may be substituted for nafcillin or oxacillin in patients with non–immediate-type hypersensitivity reactions to penicillins. <BR> <sup>¶</sup> Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table21" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Staphylococcal PVE, Oxacillin Resistant, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x ≥6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 300 mg IV/PO q8h x ≥6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg/day IV/IM q8—12h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. <BR> <sup>¶</sup> Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table22" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Staphylococcal PVE, Oxacillin Resistant, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x ≥6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 20 mg/kg/day IV/PO q8h x ≥6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. <BR> <sup>¶</sup> Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
-|}
-|}
-|}
+:::* '''2.5.2. Native valve endocarditis caused by oxacillin-resistant staphylococci'''
+::::* Preferred regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks
+::::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h
-====''Enterococcus''====
+:::* '''2.5.3. Prosthetic valve endocarditis caused by oxacillin-susceptible staphylococci'''
+::::* Preferred regimen: [[Nafcillin]] or [[Oxacillin]] 12 g/24h IV q4h for ≥ 6 weeks {{and}} [[Rifampin]] 900 mg/24h IV/PO q8h for ≥ 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8–12h for 2 weeks
+::::* Pediatric dose: [[Nafcillin]] or [[Oxacillin]] 200 mg/kg/24h IV q4–6h; [[Rifampin]] 20 mg/kg/24h IV/PO q8h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h
-<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
+:::* '''2.5.4 Prosthetic valve endocarditis caused by oxacillin-resistant staphylococci'''
+::::* Preferred regimen: [[Vancomycin]] 30 mg/kg 24 h q12h for ≥ 6 weeks {{and}} [[Rifampin]] 900 mg/24h IV/PO q8h for ≥ 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8–12h for 2 weeks
+::::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Rifampin]] 20 mg/kg/24h IV/PO q8h (up to adult dose); [[Gentamicin]] 3 mg/kg/24h IV or IM q8h
-{|
+::* '''2.6 Viridans group streptococci and Streptococcus bovis'''
-| valign=top |
+:::* '''2.6.1. Native valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)'''
-<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
+::::* Preferred regimen: [[Penicillin G]] 12–18 million U/24h IV either continuously or q4–6h for 4 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 4 weeks
-<font color="#FFF">
+::::* Alternative regimen (1): ([[Penicillin G]] 12–18 million U/24h IV either continuously or q4h for 2 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 2 weeks) {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
-'''PCN/GM/VM Susceptible'''
+::::* Alternative regimen (2): [[Vancomycin]] 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
-</font>
+::::* Pediatric dose: [[Penicillin G]] 200,000 U/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM in 1 dose; [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose or q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h
-</div>
-<div class="mw-customtoggle-table23" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN/GM/VM Susceptible, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table24" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN/GM/VM Susceptible, Pediatric'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''PCN/VM Susceptible, GM Resistant'''
-</font>
-</div>
-<div class="mw-customtoggle-table25" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN/VM Susceptible, GM Resistant, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table26" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN/VM Susceptible, GM Resistant, Pediatric'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''VM/AG Susceptible, PCN Resistant'''
-</font>
-</div>
-<div class="mw-customtoggle-table27" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''VM/AG Susceptible, PCN Resistant, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table28" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''VM/AG Susceptible, PCN Resistant, Pediatric'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''PCN/VM/AG Resistant'''
-</font>
-</div>
-<div class="mw-customtoggle-table29" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN/VM/AG Resistant, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table30" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN/VM/AG Resistant, Pediatric'''
-</font>
-</div>
-| valign=top |
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table23" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Enterococcal Endocarditis, PCN/GM/VM Susceptible, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h x 4—6 weeks''''' <BR> OR <BR> ▸ '''''[[Penicillin G sodium|Penicillin G]] 18—30 MU/day IV continuously or q4h x 4—6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 4—6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended. <BR> <sup>¶</sup> Gentamicin should be administered in close proximity to vancomycin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table24" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Enterococcal Endocarditis, PCN/GM/VM Susceptible, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 300 mg/kg/day IV q4—6h x 4—6 weeks''''' <BR> OR <BR> ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.3 MU/kg/day IV q4—6h x 4—6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 4—6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended. <BR> <sup>¶</sup> Gentamicin should be administered in close proximity to vancomycin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table25" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Enterococcal Endocarditis, PCN/VM Susceptible, GM Resistant, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h x 4—6 weeks''''' <BR> OR <BR> ▸ '''''[[Penicillin G sodium|Penicillin G]] 24 MU/day IV continuously or q4h x 4—6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Streptomycin]] 7.5 mg/kg IV/IM q12h x 4—6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Streptomycin]] 7.5 mg/kg IV/IM q12h x 6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended. <BR> <sup>¶</sup> Streptomycin dosage adjusted to achieve a 1-hour serum concentration of 20 to 35 μg/mL and a trough concentration of <10 μg/mL  Patients with a creatinine clearance of <50 mL/min should be treated in consultation with an infectious diseases specialist. <BR> <sup>ǁ</sup> Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table26" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Enterococcal Endocarditis, PCN/VM Susceptible, GM Resistant, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 300 mg/kg/day IV q4—6h x 4—6 weeks''''' <BR> OR <BR> ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.3 MU/kg/day IV q4—6h x 4—6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Streptomycin]] 40 mg/kg/day IV q8—12h x 6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Streptomycin]] 10—15 mg/kg IV/IM q12h x 6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended. <BR> <sup>¶</sup> Streptomycin dosage adjusted to achieve a 1-hour serum concentration of 20 to 35 μg/mL and a trough concentration of <10 μg/mL  Patients with a creatinine clearance of <50 mL/min should be treated in consultation with an infectious diseases specialist. <BR> <sup>ǁ</sup> Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-|}
+:::* '''2.6.2. Native valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 to ≤ 0.5 μg/mL)'''
+::::* Preferred regimen (1): ([[Penicillin G]] 24 million U/24h IV either continuously or q4–6h for 4 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 4 weeks) {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
+::::* Preferred regimen (2): [[Vancomycin]] 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
+::::* Pediatric dose: [[Penicillin G]] 200,000 U/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM in 1 dose; [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose or q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h
-====Gram-Negative Bacteria====
+:::* '''2.6.3. Prosthetic valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)'''
+::::* Preferred regimen (1): ([[Penicillin G]] 24 million U/24h IV either continuously or q4–6h for 6 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 6 weeks) {{withorwithout}} [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
+::::* Preferred regimen (2): [[Vancomycin]] 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
+::::* Pediatric dose: [[Penicillin G]] 200,000 U/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM in 1 dose; [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose or q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h
-<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
+:::* '''2.6.4. Prosthetic valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 μg/mL)'''
+::::* Preferred regimen (1): ([[Penicillin G]] 24 million U/24h IV either continuously or q4–6h for 6 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 6 weeks) {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
+::::* Preferred regimen (2): [[Vancomycin]] 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
+::::* Pediatric dose: [[Penicillin G]] 200,000 U/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM in 1 dose; [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose or q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h
-{|
+==Antithrombotic Therapy==
-| valign=top |
-<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''Gram-Negative Bacteria'''
-</font>
-</div>
-<div class="mw-customtoggle-table31" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Bartonella spp.'''''
-</font>
-</div>
-<div class="mw-customtoggle-table32" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Escherichia coli'''''
-</font>
-</div>
-<div class="mw-customtoggle-table33" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''HACEK Microorganisms'''
-</font>
-</div>
-<div class="mw-customtoggle-table34" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Klebsiella spp.'''''
-</font>
-</div>
-<div class="mw-customtoggle-table35" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Neisseria spp.'''''
-</font>
-</div>
-<div class="mw-customtoggle-table36" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Proteus mirabilis'''''
-</font>
-</div>
-<div class="mw-customtoggle-table37" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Pseudomonas aeruginosa'''''
-</font>
-</div>
-| valign=top |
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table31" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Suspected ''Bartonella'' Endocarditis, Culture Negative}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg IV/PO q12h x 6 weeks'''''
-|-
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Documented ''Bartonella'' Endocarditis, Culture Positive}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg IV/PO q12h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg IV/PO q12h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 300 mg PO/IV q12h x 6 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Patients with Bartonella endocarditis should be treated in consultation with an infectious diseases specialist. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table32" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Escherichia coli'' Endocarditis}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h x 4—6 weeks''''' <BR> OR <BR> ▸ '''''[[Penicillin G sodium|Penicillin G]] 20 MU/day IV continuously x 4—6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 4—6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1.7 mg/kg IV/IM q8h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table33" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|HACEK Endocarditis, Adult<sup>†</sup>}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 4 weeks'''''<sup>‡</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 1.5 g IV q6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 500 mg PO q12h (or 400 mg IV q12h) x 4 weeks'''''<sup>§</sup>
-|-
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|HACEK Endocarditis, Pediatric<sup>†</sup>}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 4 weeks'''''<sup>‡</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 300 mg/kg/day IV q4—6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 10—15 mg/kg IV/PO q12h x 4 weeks'''''<sup>§</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Prosthetic valve: patients with endocarditis involving prosthetic cardiac valve or other prosthetic cardiac material should be treated for 6 wk. <BR> <sup>‡</sup> Cefotaxime or another third- or fourth-generation cephalosporin may be substituted. <BR> <sup>§</sup> Fluoroquinolone therapy recommended only for patients unable to tolerate cephalosporin and ampicillin therapy; levofloxacin, gatifloxacin, or moxifloxacin may be substituted; fluoroquinolones generally not recommended for patients <18 y old.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table34" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Klebsiella'' Endocarditis}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 4 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 2 weeks'''''<sup>¶</sup> <BR> OR <BR> ▸ '''''[[Amikacin]] 15 mg/kg/day IV q8—12h x 2 weeks'''''<sup>§</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Piperacillin/Tazobactam]] 3.375 g IV q6h x 4 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>§</sup> Peak concentrations (30 to 90 minutes after injection) above 35 μg/mL and trough concentrations (just prior to the next dose) above 10 μg/mL should be avoided. Dosage should be adjusted as indicated.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table35" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Neisseria'' Endocarditis}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 12—18 MU/day IV continuously or q4—6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Cefazolin]] 1—1.5 g IV q6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q24h x 4 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Infectious disease consultation should be obtained in cases in which ''Neisseria'' are resistant to penicillin.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table36" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Proteus mirabilis'' Endocarditis}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 2 g IV q4h x 4—6 weeks''''' <BR> OR <BR> ▸ '''''[[Penicillin G sodium|Penicillin G]] 20 MU/day IV continuously x 4—6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 4—6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1.7 mg/kg IV/IM q8h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table37" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Pseudomonas aeruginosa'' Endocarditis}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ticarcillin]] 3 g IV q4h (or 4 g IV q6h) x ≥6 weeks''''' <BR> OR <BR> ▸ '''''[[Piperacillin/Tazobactam]] 3.375 gm IV q4h (or 4.5 g IV q6h) x ≥6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftazidime]] 2 g IV q8h x ≥6 weeks''''' <BR> OR <BR> ▸ '''''[[Cefepime]] 2 g IV q8h x ≥6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Tobramycin]] 8 mg/kg IV/IM q24h x ≥6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Maintenance of peak and trough concentrations of 15—20 μg/mL and ≤2 μg/mL, respectively.
-|}
-|}
-|}
-==Culture-Negative Endocarditis <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''Circulation 2005;111(23):e394-434.''<ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref> and ''Circulation 2008;118(15):e523-661.''<ref name="Bonow-2008">{{Cite journal  | last1 = Bonow | first1 = RO. | last2 = Carabello | first2 = BA. | last3 = Chatterjee | first3 = K. | last4 = de Leon | first4 = AC. | last5 = Faxon | first5 = DP. | last6 = Freed | first6 = MD. | last7 = Gaasch | first7 = WH. | last8 = Lytle | first8 = BW. | last9 = Nishimura | first9 = RA. | title = 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal = J Am Coll Cardiol | volume = 52 | issue = 13 | pages = e1-142 | month = Sep | year = 2008 | doi = 10.1016/j.jacc.2008.05.007 | PMID = 18848134 }}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
+*[[Anticoagulant]]s can cause or worsen [[hemorrhage]] in patients with [[endocarditis]] but maybe carefully administered when needed.<ref name="Baddour">{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
+* The [[prothrombin time]] should be carefully maintained at an [[INR]] of 2.0–3.0.
+*[[Anticoagulation]] should be reversed immediately in the event of [[CNS]] [[complications]] and interrupted for 1–2 weeks after an acute [[embolic]] [[stroke]].
+* Avoid [[heparin]] administration during active [[endocarditis]] if possible.
-<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
-{|
+{| class="wikitable"
-| valign=top |
-<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''Native Valve Endocarditis'''
-</font>
-</div>
-<div class="mw-customtoggle-table38" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Culture-Negative NVE, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table39" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Culture-Negative NVE, Pediatric'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''Prosthetic Valve Endocarditis'''
-</font>
-</div>
-<div class="mw-customtoggle-table40" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Culture-Negative PVE, Adult (Early, ≤1 year)'''
-</font>
-</div>
-<div class="mw-customtoggle-table41" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Culture-Negative PVE, Pediatric (Early, ≤1 year)'''
-</font>
-</div>
-<div class="mw-customtoggle-table42" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Culture-Negative PVE, Adult (Late, >1 year)'''
-</font>
-</div>
-<div class="mw-customtoggle-table43" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Culture-Negative PVE, Adult (Late, >1 year)'''
-</font>
-</div>
-| valign=top |
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table38" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Culture-Negative Native Valve Endocarditis, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 3 g IV q6h x 4—6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 4—6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 4—6 weeks'''''<sup>ǁ</sup>
 |-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
+| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
+| bgcolor="LightGreen" |
 |-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 4—6 weeks'''''<sup>¶</sup>
+| bgcolor="LightGreen" |"'''1.'''  Penicillin G or Amoxicilline or Ceftriaxonef''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  A]])''"
+| bgcolor="LightGreen" |
 |-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
+| bgcolor="LightGreen" |”'''2.'''  (Paste guideline here) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
+| bgcolor="LightGreen" |
 |-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 500 mg PO q12h (or 400 mg IV q12h) x 4—6 weeks'''''
+| bgcolor="LightGreen" |”'''3.'''  (Paste guideline here) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
-|-
+| bgcolor="LightGreen" |
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table39" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Culture-Negative Native Valve Endocarditis, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 300 mg/kg/day IV q4—6h x 4—6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 4—6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 4—6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 4—6 weeks'''''<sup>¶</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 10—15 mg/kg IV/PO q12h x 4—6 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table40" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Culture-Negative Prosthetic Valve Endocarditis, Adult (Early, ≤1 year)}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 2 g IV q8h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 300 mg PO/IV q8h x 6 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table41" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Culture-Negative Prosthetic Valve Endocarditis, Pediatric (Early, ≤1 year)}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 2 weeks'''''<sup>¶</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefepime]] 50 mg/kg IV q8h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 20 mg/kg/day PO/IV q8h x 6 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table42" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Culture-Negative Prosthetic Valve Endocarditis, Adult (Late, >1 year)}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 3 g IV q6h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 6 weeks'''''<sup>¶</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 300 mg PO/IV q8h x 6 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 6 weeks'''''<sup>¶</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 500 mg PO q12h (or 400 mg IV q12h) x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 300 mg PO/IV q8h x 6 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table43" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Culture-Negative Prosthetic Valve Endocarditis, Pediatric (Late, >1 year)}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 300 mg/kg/day IV q4—6h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 6 weeks'''''<sup>¶</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 20 mg/kg/day PO/IV q8h x 6 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 1 mg/kg IV/IM q8h x 6 weeks'''''<sup>¶</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 10—15 mg/kg IV/PO q12h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Rifampin]] 20 mg/kg/day PO/IV q8h x 6 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
 |}
 ==References==
@@ Line 1,218: / Line 159: @@
 [[Category:Emergency medicine]]
 [[Category:Cardiology]]
-[[Category:Infectious disease]]
 [[Category:Intensive care medicine]]
 [[Category:Up-To-Date]]
+[[Category: Infectious Disease Project]]