Sandbox endocarditis: Difference between revisions

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==Empirical Antibiotic Therapy==
==Streptococci==
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>


*Antibiotic therapy for subacute disease, and in those who have received antibiotics recently can be delayed waiting 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.<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>
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<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: 70px; line-height: 30px; width: 250px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Native Valve Endocarditis Caused by Viridans Group Streptococci and Streptococcus Bovis'''
</font>
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<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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Viridans Group Streptococci and Streptococcus Bovis Highly Penicillin-Susceptible'''
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<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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Viridans Group Streptococci and Streptococcus Bovis Relatively Penicillin Resistant (MIC >0.12 μg/mL- ≤ 0.5 μg/mL)'''
</font>
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<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: 70px; line-height: 30px; width: 250px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Prosthetic Valves Endocarditis Caused by Viridans Group Streptococci and Streptococcus Bovis'''
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<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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Viridans Group Streptococci and Streptococcus Bovis Penicillin-Susceptible Strain (MIC ≤ 0.12 μg/mL)'''
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<div class="mw-customtoggle-table14" 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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Viridans Group Streptococci and Streptococcus Bovis Penicillin Relatively or Fully Resistant Strain (MIC >0.12 μg/mL)'''
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</div>


*On the other hand, the rapid progression of acute cases necessitate the start of empirical treatment antibiotic therapy once the blood cultures have been collected.
<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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin-Resistant Streptococci (MIC 0.2–0.5 µg/ml)'''
</font>
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*Empirical therapy is needed for all likely pathogens, certain antibiotic agents, including aminoglycosides, is preferably avoided for its toxic effects.
<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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Relatively Penicillin-Resistant Streptococci (MIC > 0.5 µg/ml)'''
</font>
</div>


*Clinical course of infection beside the epidemiological features should be considered upon selecting empirical treatment regimen.
<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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Unable to tolerate Penicillin or Ceftriaxone'''
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*Consultation with an infectious disease specialist for the selection of one of the antibiotic regimens is recommended(See therapy for culture-negative endocarditis). <ref>{{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>
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{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table11" style="background: #FFFFFF;"
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{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="height: 50px; 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|Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis}}
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>''''' ( 4 wks )
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''


{|
|-
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] † 12–18 million U/24 h IV either continuously or in 4-6 equally divided doses x 4 Wks'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone|Ceftriaxone sodium]] 2 g/24 h IV/IM in 1 dose x 4 Wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose ₳}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] 200 000 U/kg q24h IV either continuously or in 4-6 equally divided doses x 4 Wks'''''<BR>''OR''<BR> ▸'''''[[Ceftriaxone]] 100 mg/kg q24 h IV/IM in 1 dose x 4 Wks'''''
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Alternative Regimen</u>''''' ( 2 wks )
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]]‡ 12–18 million U/24 h IV either continuously or in 6 equally divided doses x 2 Wks'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone|Ceftriaxone sodium]] 2 g/24 h IV/IM in 1 dose x 2 Wks'''''
|-
!style="padding: 0 5px; font-size: 80%; background: #F8F8FF" align=left | '''''PLUS'''''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin| Gentamicin sulfate]] ฿ 3 mg/Kg per 24h 1 dose x 2 Wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] 200 000 U/kg q24h IV in 4-6 equally divided doses x 2 Wks'''''<BR>''OR''<BR> ▸'''''[[Ceftriaxone]] 100 mg/kg q24 h IV/IM in 1 dose x 2 Wks'''''
|-
!style="padding: 0 5px; font-size: 80%; background: #F8F8FF" align=left | '''''PLUS'''''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin| Gentamicin sulfate]] 3 mg/Kg per 24h 1 dose or 3 equally divided doses x 2 Wks'''''
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Alternative Regimen</u>'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Vancomycin|Vancomycin hydrochloride]] ¶ 15 mg/kg q12h IV x 4 Wks''''' <br> Doses should not to exceed 2 g/24 h unless concentrations in serum are inappropriately low
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |▸'''''[[Vancomycin|Vancomycin hydrochloride]] 40 mg/kg per 24 h IV in 2–3 equally divided doses'''''
|-
|
Minimum inhibitory concentration ≤ 0.12 μg/mL.
:† Preferred in most patients >65 y or patients with impairment of 8th cranial nerve function or renal function.
:₳ Pediatric dose should not exceed that of a normal adult.
:‡ 2-wk regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of <20 mL/min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella spp infection; gentamicin dosage should be adjusted to achieve peak serum concentration of 3-4 μg/mL and trough serum concentration of >1 μg/mL when 3 divided doses are used; nomogram used for single daily dosing.
:¶ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ceftriaxone; vancomycin 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
:฿ Other potentially nephrotoxic drugs (eg, nonsteroidal antiinflammatory drugs) should be used with caution in patients receiving gentamicin therapy. Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.
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{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table12" style="background: #FFFFFF;"
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{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:22em" cellpadding="0" cellspacing="0";
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Native valve}}''
! style="height: 50px; 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|Native Valve Endocarditis Caused by Strains of Viridans Group Streptococci and Streptococcus Bovis Relatively Resistant to Penicillin (MIC >0.12 μg/mL- ≤ 0.5 μg/mL))}}
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 wks'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 2 g/24 h IV/IM in 1 dose x 4 wks'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 3 g q6h IV x 4–6 weeks'''''<BR>''PLUS''<BR> ▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 weeks'''''
!style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Vancomycin]] 15 mg per kg q12h IV x 4–6 weeks''''' <BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 week''''' <BR>''PLUS''<BR>'''''[[Ciprofloxacin]] 500 mg q12h PO or 400 mg q12h IV x 4–6 weeks'''''
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Native valve pediatric dose}}''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] 300 000 U/kg per 24 h IV in 4–6 equally divided doses'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg per 24 h IV/IM in 1 dose'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]]300 mg per kg per 24 h IV in 4–6 equally divided doses'''''
!style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Gentamicin]] 1 mg per kg q8h IV/IM'''''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 1 dose or equally divided doses'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Vancomycin]] 40 mg per kg per 24 h in 2 or 3 equally divided doses '''''
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Alternative Regimen</u>'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ciprofloxacin]] 10-15 mg per kg q12h IV/PO'''''
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin|Vancomycin hydrochloride]] 30 mg/kg per 24 h IV in 2 equally divided doses x 4 wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin|Vancomycin hydrochloride]] 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses'''''
|-
|-
|}
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|valign=top |
{| 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: 50px; 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|Penicillin-susceptible strain (MIC ≤ 0.12 g/mL)}}
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] † 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 2 g/24 h IV/IM in 1 dose x 6 wks'''''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''WITH OR WITHOUT''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin|Gentamicin sulfate]] ‡ 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] 300 000 U/kg per 24 h IV in 4–6 equally divided doses'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM once daily'''''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''WITH OR WITHOUT''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM, in 1 dose or 3 equally divided doses'''''
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Alternative Regimen</u>'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin|Vancomycin
hydrochloride]] 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''40 mg/kg per 24 h IV or in 2 or 3 equally divided doses'''''
|-
|
*Dosages recommended are for patients with normal renal function.


{|
:† Penicillin or ceftriaxone together with gentamicin has not demonstrated superior cure rates compared with monotherapy with penicillin or ceftriaxone for patients with highly susceptible strain; gentamicin therapy should not be administered to patients with creatinine clearance of <30 mL/min.
 
:‡ Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.
|-
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{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table14" style="background: #FFFFFF;"
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| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float:left; width:22em" cellpadding="0" cellspacing="0";
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Prosthetic valve (early, ≤ 1y)}}''
! style="height: 50px; 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|Penicillin Relatively or Fully Resistant Strain (MIC >0.12 >μg/mL)}}
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Vancomycin]] 15 mg per kg q12h IV x 6'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 2weeks'''''<BR>''PLUS''<BR>▸'''''[[Cefepime]] 2 g q8h IV x 6 weeks''''' <BR>''PLUS''<BR>▸ '''''[[Rifampin]] 300 mg q8h PO/IV x 6 weeks'''''
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Prosthetic valve pediatric dose}}''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 2 g/24 h IV/IM in 1 dose x 6 wks'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Vancomycin]] 40 mg per kg per 24 h IV in 2 or 3 equally divided doses'''''
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Gentamicin]] 1 mg per kg q8h IV/IM '''''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 1 dose x 6 wks'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Cefepime]] 50 mg q8h IV '''''
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Rifampin]] 20 mg per kg per 24 h PO/IV in 3 equally divided doses'''''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] 300 000 U/kg per 24 h IV in 4–6 equally divided doses'''''
|-
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Prosthetic valve (late—greater than 1 y) (same regimens as for native valve endocarditis with addition of [[rifampin]])}}''
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Alternative Regimen</u>'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 3 g q6h IV x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Rifampin]] 300 mg q8h PO/IV x 6 weeks'''''
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin|Vancomycin hydrochloride]] 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks'''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg per kg q12h IV x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Ciprofloxacin]] 500 mg q12h PO or 400 mg q12h IV x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Rifampin]] 300 mg q8h PO/IV x 6 weeks'''''
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin|Vancomycin hydrochloride]] 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses'''''
|-
|-
|}
|}
|}


{|
|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: 50px; 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|Relatively Penicillin-Resistant Streptococci (MIC 0.2–0.5 µg/ml)}}
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G potassium]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks '''''<BR>''OR'' <BR>▸'''''[[Ceftriaxone]] 2 g/24 h IV/IM in 1 dose'''''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks  '''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G potassium]] 300 000 U/24 h IV in 4–6 equally divided doses X 4 Wks '''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg per 24 h IV/IM in 1 dose'''''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 1 dose or 3 equally divided doses X 2 Wks'''''
|-
|-
|}
|}
|valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table16" style="background: #FFFFFF;"
| valign=top |
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float:left; width:22em" cellpadding="0" cellspacing="0";
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Suspected Bartonella, culture negative}}''
! style="height: 50px; 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|Relatively Penicillin-Resistant Streptococci(MIC > 0.5 µg/ml, consider Enterococcal regimen)}}
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone sodium]] 2 g per 24 h IV/IM in 1 dose x 6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 2 weeks
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
<BR>''with/without''<BR>▸ '''''[[Doxycycline]] 100 mg per kg q12h IV/PO x 6 weeks'''''
|-
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Documented Bartonella, culture positive}}''
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg q12h IV or PO x 6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 2 weeks'''''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G potassium]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks '''''
|-
|-
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Documented Bartonella, culture positive pediatric dose}}''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ceftriaxone]] 100 mg per kg per 24 h IV/IM once daily'''''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks  '''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Gentamicin]] 1 mg per kg q8h IV/IM'''''
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Doxycycline]] 2–4 mg per kg per 24 h IV/PO in 2 equally divided doses'''''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G potassium]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks '''''
|-
|-
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Rifampin]] 10 mg per kg q12h PO/IV'''''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks  '''''
|-
|-
|}
|}
|valign=top |
{| 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: 50px; 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|Unable to Tolerate Aqueous crystalline penicillin G sodium or Ceftriaxone}}
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30 mg/kg per 24 h IV in 2 equally divided doses not to exceed 2 g/24 h, unless serum concentrations are inappropriately low  '''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg 24 h in 2 or 3 equally divided doses X 4 Wks '''''
|-
|}
|}
|}
|}


==Enterococci==


{| class="wikitable" style="margin: 1em auto 1em auto"
{|
|+
| valign=top |
! Regimen || Dosage and Route || Duration(wk)
<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: 40px; line-height: 30px; width: 250px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Endocarditis Caused by Enterococci'''
</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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin'''
</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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin'''
</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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Enterococci Strains Resistant to Penicillin and Susceptible to Aminoglycoside and Vancomycin'''
</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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Enterococci Strains Resistant to Penicillin, Aminoglycoside, and Vancomycin'''
</font>
</div>
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table18" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 500px;"
! style="height: 50px; 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|Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin}}
|-
|-
| ||'''''<u>Native valve</u>'''''||
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
|-
|-
| '''[[Ampicillin sulbactam|Ampicillin-Sulbactam]]'''||12 g per 24 h IV in 4 equally divided doses||4–6
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
|-
| || ''''PLUS'''' ||
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 12 g/24 h I.V.in 6 equally divided doses x 4–6 Wks'''''<br> ''OR'' <br> ▸'''''[[Penicillin G sodium]] 18–30 million U. I.V. daily in 6 equally divided doses x 4–6 Wks'''''
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''|| 3 mg per kg per 24 h IV/IM in 3 equally divided doses||4–6
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
|-
|-
| || ''OR'' ||
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 4-6 Wks'''''
|-
|-
| '''[[Vancomycin]]'''||30 mg per kg per 24 h IV in 2 equally divided doses||4–6
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
|-
| || ''''PLUS'''' ||
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 300 mg/kg per 24 h IV in 4–6 equally divided doses; X 4–6 Wks''''' <br>''OR''<br> ▸'''''[[Penicillin G sodium]] 300 000 U/kg per 24 h IV in 4–6 equally divided doses X 4–6 Wks'''''
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''||3 mg per kg per 24 h IV/IM in 3 equally divided doses||4–6
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
|-
|-
| || ''''PLUS'''' ||
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks'''''
|-
|-
| '''[[Ciprofloxacin]]'''||1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses||4–6
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Alternative Regimen</u>'''''
|-
|-
| ||→'''Pediatric dose''':
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | '''''[[Vancomycin]] 30 mg/kg I.V. daily in 2 equally divided doses x 6 Wks'''''<br> ''PLUS'' <br> ▸'''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks'''''
*'''[[Ampicillin sulbactam|Ampicillin-Sulbactam]]''' 300 mg per kg per 24 h IV in 4–6 equally divided doses
*'''[[Gentamicin]]''' 3 mg per kg per 24 h IV/IM in 3 equally divided doses
*'''[[Vancomycin]]''' 40 mg per kg per 24 h in 2 or 3 equally divided doses
*'''[[Ciprofloxacin]]''' 20–30 mg per kg per 24 h IV/PO in 2 equally divided doses
|-
|-
| ||'''''<u>Prosthetic valve (early, ≤ 1y)</u>'''''||
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
|-
| '''[[Vancomycin]]'''||30 mg per kg per 24 h IV in 2 equally divided doses||6
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30 mg/kg I.V. daily in divided doses q. 12 hour X 4–6 Wks'''''<br> ''PLUS'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks'''''
|-
|-
| ||''''PLUS''''||
|
*Native valve: 4-wk therapy recommended for patients with symptoms of illness < 3 months.
*6-wk therapy recommended for patients with symptoms >3 months.
*Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
*Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin.
*6 wk of vancomycin therapy recommended because of decreased activity against enterococci.
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''||3 mg per kg per 24 h IV/IM in 3 equally divided doses||2
|}
|}
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table19" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 500px;"
! style="height: 50px; 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|Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin}}
|-
|-
| ||''''PLUS''''||
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
|-
|-
|'''[[Cefepime]]'''||6 g per 24 h IV in 3 equally divided doses||6
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
|-
| ||''''PLUS''''||
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 12 g/24 h I.V.in 6 equally divided doses x 4–6 Wks'''''<br> ''OR'' <br> ▸'''''[[Penicillin G sodium]] 24 million U. I.V. continuously or in 6 equally divided doses x 4–6 Wks'''''
|-
|-
| '''[[Rifampin]]'''||900 mg per 24 h PO/IV in 3 equally divided doses||6
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
|-
|-
| ||→'''Pediatric dose''':
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |'''''[[Streptomycin|Streptomycin sulfate]] 15 mg/kg per 24 h IV/IM in 2 equally divided doses x 4-6 Wks'''''
*'''[[Vancomycin]]''' 40 mg per kg per 24 h IV in 2 or 3equally divided doses
*'''[[Gentamicin]]''' 3 mg per kg per 24 h IV/IM in 3 equally divided doses
*'''[[Cefepime]]''' 150 mg per kg per 24 h IV in 3 equally divided doses
*'''[[Rifampin]]''' 20 mg per kg per 24 h PO/IV in 3 equally divided doses
|-
|-
| ||'''''<u>Prosthetic valve (late—greater than 1 y)</u>'''''||'''Same regimens as listed above for native valve endocarditis'''
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
|-
| ||'''''<u>Suspected Bartonella, culture negative</u>'''''
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 300 mg/kg per 24 h IV in 4–6 equally divided doses; x 4–6 Wks''''' <br>''OR''<br> ▸'''''[[Penicillin G sodium]] 300 000 U/kg per 24 h IV in 4–6 equally divided doses x 4–6 Wks'''''
|-
|-
|'''[[Ceftriaxone sodium]]'''||2 g per 24 h IV/IM in 1 dose||6
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
|-
|-
| ||''''PLUS''''||
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |▸'''''[[Streptomycin|Streptomycin sulfate]] 20–30 mg/kg per 24 h IV/IM in 2 equally divided doses'''''
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''||3 mg per kg per 24 h IV/IM in 3 equally divided doses||2
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Alternative Regimen</u>'''''
|-
|-
| ||'''''with/without'''''||
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
|-
| '''[[Doxycycline]]'''||200 mg per kg per 24 h IV/PO in 2 equally divided doses||6
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30 mg/kg I.V. daily in 2 equally divided doses x 6 Wks'''''<br> ''PLUS'' <br> ▸'''[[Streptomycin|Streptomycin sulfate]] 15 mg/kg per 24 h IV/IM in 2 equally divided doses x 4-6 Wks'''''
|-
|-
| ||'''''<u>Documented Bartonella, culture positive</u>'''''||
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
|-
| '''[[Doxycycline]]'''||200 mg per 24 h IV or PO in 2 equally divided doses||6
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg per 24 h IV in 2 or 3 equally divided doses X 4–6 Wks'''''<br>''PLUS''<br>▸'''''[[Streptomycin|Streptomycin sulfate]] 20–30 mg/kg per 24 h IV/IM in 2 equally divided doses'''''
|-
|-
| ||''''PLUS''''||
|
*Native valve: 4-wk therapy recommended for patients with symptoms of illness < 3 months.
*6-wk therapy recommended for patients with symptoms >3 months.
*Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
*Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin.
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''||3 mg per kg per 24 h IV/IM in 3 equally divided doses||2
|}
|}
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table20" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 500px;"
! style="height: 50px; 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|β-Lactamase–producing strain}}
|-
|-
| ||→'''Pediatric dose''':
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
*'''[[Ceftriaxone]]''' 100 mg per kg per 24 h IV/IM once daily
*'''[[Gentamicin]]''' 3 mg per kg per 24 h IV/IM in 3 equally divided doses
*'''[[Doxycycline]]''' 2–4 mg per kg per 24 h IV/PO in 2 equally divided doses
*'''[[Rifampin]]''' 20 mg per kg per 24 h PO/IV in 2 equally divided doses
|-
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-sulbactam]] 12 g/24 h IV in 4 equally divided doses x 6 Wks'''''<br> ''PLUS'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-sulbactam]] 300 mg/kg per 24 h IV in 4 equally divided doses x 6 Wks''''' <br> ''PLUS'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks'''''
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Alternative Regimen</u>'''''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |▸'''''[[Vancomycin|Vancomycin hydrochloride]] 30 mg/kg per 24 h IV in 2 equally divided doses x 6 Wks'''''<br> ''PLUS'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin|Vancomycin hydrochloride]] 40 mg/kg per 24 h in 2 or 3 equally divided doses''''' <br> ''PLUS'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks'''''
|-
! style="height: 50px; 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|Intrinsic penicillin resistance}}
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |▸'''''[[Vancomycin|Vancomycin hydrochloride]] 30 mg/kg per 24 h IV in 2 equally divided doses x 6 Wks'''''<br> ''PLUS'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin|Vancomycin hydrochloride]] 40 mg/kg per 24 h in 2 or 3 equally divided doses''''' <br> ''PLUS'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks'''''
|-
|}
|}
|}


==Treatment Based Upon Infectious Agent<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>==
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table21" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 500px;"
! style="height: 50px; 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|E faecium}}
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 1200 mg/24 h IV/PO in 2 equally divided doses x ≥8 Wks'''''<br> ''OR'' <br> ▸'''''[[Quinupristin dalfopristin|Quinupristin-dalfopristin]] 22.5 mg/kg per 24 h IV in 3 equally divided doses x ≥ 8 Wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 30 mg/kg per 24 h IV/PO in 3 equally divided doses ≥8 Wks''''' <br> ''OR'' <br> ▸'''''[[Quinupristin dalfopristin|Quinupristin-dalfopristin]] 22.5 mg/kg per 24 h IV in 3 equally divided doses ≥8 Wks'''''
|-
! style="height: 50px; 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| E faecalis}}''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Imipenem/cilastatin]] 2 g/24 h IV in 4 equally divided doses x ≥8 Wks'''''<br> ''PLUS'' <br> ▸'''''[[Ampicillin|Ampicillin sodium]] 12 g/24 h IV in 6 equally divided doses x ≥ 8 Wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Imipenem/cilastatin]] 60–100 mg/kg per 24 h IV in 4 equally divided doses x ≥8 Wks'''''<br> ''PLUS'' <br> ▸'''''[[Ampicillin|Ampicillin sodium]] 300 mg/kg per 24
h IV in 4–6 equally divided doses x ≥ 8 Wks'''''
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Alternative Regimen</u>'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone|Ceftriaxone sodium]] 4 g/24 h IV/IM in 2 equally divided doses x ≥8 Wks'''''<br> ''PLUS'' <br> ▸'''''[[Ampicillin|Ampicillin sodium]] 12 g/24 h IV in 6 equally divided doses x ≥ 8 Wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone|Ceftriaxone sodium]] 100 mg/kg per 24 h IV/IM in 2 equally divided doses x ≥8 Wks'''''<br>''PLUS''<br> ▸'''''[[Ampicillin|Ampicillin sodium]] 300 mg/kg per 24 h IV in 4–6 equally divided doses x ≥ 8 Wks'''''
|-
|
*Patients with endocarditis caused by these strains should be treated in consultation with an infectious diseases specialist.
*Cardiac valve replacement may be necessary for bacteriologic cure.
*Cure with antimicrobial therapy alone may be < 50%
*Severe, usually reversible thrombocytopenia may occur with use of linezolid, especially after 2 wk of therapy.
*Quinupristin-dalfopristin only effective against E faecium and can cause severe myalgias, which may require discontinuation of therapy
*Only small no. of patients have reportedly been treated with imipenem/cilastatin-ampicillin or ceftriaxone + ampicillin.
|-
|}
|}
|}


===<u>Penicillin-Susceptible Strep Viridans and Other Nonenterococcal Streptococci</u>===
==Staphylococci==


====Penicillin G====
{|
*If Minimum inhibitory concentration [MIC] <0.2 µg/ml.
| valign=top |
*Dose: 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks.
<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: 70px; line-height: 30px; width: 250px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Native Valve Endocarditis caused by Staphylococci in the Absence of Prosthetic Material'''
</font>
</div>


====Penicillin G + Gentamicin====
<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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
*Dose: Penicillin G, 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks plus gentamicin, 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Staphylococci (Methicillin Susceptible)'''
</font>
</div>


====Ceftriaxone====
<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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
*Dose: 2 g I.V. daily as a single dose for 2 weeks.
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Staphylococci (Methicillin-resistant) with Penicillin G Anaphylactoid Hypersensitivity '''
</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: 70px; line-height: 30px; width: 250px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Prosthetic Valves Endocarditis or Other Prosthetic Material Caused by Staphylococci'''
</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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin-Susceptible Strains '''
</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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxacillin-Resistant Strains'''
</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: 50px; 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|Staphylococci (Methicillin Susceptible)}}
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] or [[Oxacillin]] † 12 g I.V. daily in equally divided doses x 6 Wks '''''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | PLUS (optional)
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin|Gentamicin sulfate]] ‡ 3 mg/kg per 24 h IV/IM in 2-3 equally divided doses x 3-5 days '''''
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Altenative Regimen</u>'''''( in non anaphylactoid [[Penicillin]] hypersensitivity)
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefazolin]] 6 g/ 24 h I.V. in 3 divided doses x 6 wks '''''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | PLUS (optional)
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 2-3 equally divided doses x 3-5 days '''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatrics dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] or [[oxacillin]] 200 mg/kg per 24 h IV in 4–6 equally divided doses x 4-6 wks'''''<BR>''OR ( in non anaphylactoid [[Penicillin]] hypersensitivity)'' <BR> ▸'''''[[Cefazolin]] 100 mg/kg per 24 h IV in 3 equally divided doses x 4-6 wks'''''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | AND (optional)
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses'''''
|-
|
:† 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 (MIC ≤ 0.1 μg/mL) and does not produce β-lactamase.


==References==
:‡ Gentamicin should be administered in close temporal proximity to vancomycin, nafcillin, or oxacillin dosing.
{{Reflist|2}}
|-
|}
|}
 
|valign=top |
{| 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: 50px; 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|Staphylococci (Methicillin-resistant) <BR>(in anaphylactoid Penicillin hypersensitivity)}}
|-
!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
! style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks''''' <br> Adjust vancomycin dosage to achieve 1-h serum concentration of 30–45 > g/mL and trough concentration of 10–15 >g/mL
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatrics dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg per 24 h IV in 2 or 3 equally divided doses x 6 wks '''''
|-
|}
|}
 
|valign=top |
{| 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: 50px; 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|Oxacillin-susceptible strains}}
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] or [[oxacillin]] 2 g q4h IV x  ≥6 weeks'''''<BR>''PLUS''<BR> ▸ '''''[[Rifampin]] 300 mg q8h IV/PO x ≥6 weeks''''' <BR>''PLUS''<BR> ▸ '''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 2 or 3 equally divided doses x 2 weeks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Nafcillin]] or [[oxacillin]] 200 mg/kg per 24 h IV in 4–6 equally divided doses'''''<BR>''PLUS''<BR> ▸'''''[[Rifampin]] 20 mg/kg per 24 h IV/PO in 3 equally divided doses'''''<BR>''PLUS''<BR>▸'''''[[Gentamicin]] 1 mg/kg q8h IV/IM'''''
|-
|}
|}
|valign=top |
{| 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: 50px; 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|Oxacillin-resistant strains}}
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg q12h x ≥6 Wks'''''<BR>''PLUS''<BR> ▸ '''''[[Rifampin]] 300 mg q8h IV/PO x ≥6 Wks''''' <BR>''PLUS''<BR> ▸ '''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 2 or 3 equally divided doses x 2 wks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg per 24 h IV in 2-3 equally divided doses x  ≥6 wks'''''<BR>''PLUS''<BR> ▸'''''[[Rifampin]] 20 mg/kg per 24 h IV/PO in 3 equally divided doses x  ≥6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin]] 1 mg/kg q8h IV/IM x 2 Wks'''''
|-
|}
|}
|}
 
==HACEK Organisms==
[[HACEK organism]]s are more indolent and the infection is less complicated.
<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>
<div class="mw-collapsible-content">
 
{|
| valign=top |
<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: 70px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Therapy for Both Native and Prosthetic Valve Endocarditis Caused by HACEK Microorganisms'''
</font>
</div>
 
|valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table27" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="height: 50px; 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|Therapy for Both Native and Prosthetic Valve Endocarditis Caused by HACEK Microorganisms}}
 
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone|Ceftriaxone sodium]] † 2 g/24 h IV/IM in 1 dose x 4 weeks'''''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin- sulbactam]] ‡ 12 g/24 h IV in 4 equally divided doses x 4 weeks'''''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] ‡¶ 500 mg q12h PO or 400 mg q12h IV x 4 weeks'''''
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
|-
| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 100 mg/kg per 24 h IV/IM once daily'''''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ampicillin sulbactam|Ampicillin- sulbactam]]  300 mg/kg per 24 h IV divided into 4 or 6 equally divided doses'''''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
|-
|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ciprofloxacin]] 10-15 mg/kg q12h IV/PO '''''
|-
|
*HACEK: Haemophilus parainfluenzae, H aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae.
 
:† Patients should be informed that IM injection of ceftriaxone is painful.
:‡ Dosage recommended for patients with normal renal function.
:¶ Fluoroquinolones are highly active in vitro against HACEK microorganisms. Published data on use of fluoroquinolone therapy for endocarditis caused by HACEK are minimal.
|-
|}
|}
|}

Latest revision as of 21:12, 5 March 2014

Streptococci

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis Caused by Viridans Group Streptococci and Streptococcus Bovis

  ▸  Viridans Group Streptococci and Streptococcus Bovis Highly Penicillin-Susceptible

  ▸  Viridans Group Streptococci and Streptococcus Bovis Relatively Penicillin Resistant (MIC >0.12 μg/mL- ≤ 0.5 μg/mL)

Prosthetic Valves Endocarditis Caused by Viridans Group Streptococci and Streptococcus Bovis

  ▸  Viridans Group Streptococci and Streptococcus Bovis Penicillin-Susceptible Strain (MIC ≤ 0.12 μg/mL)

  ▸  Viridans Group Streptococci and Streptococcus Bovis Penicillin Relatively or Fully Resistant Strain (MIC >0.12 μg/mL)

  ▸  Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin-Resistant Streptococci (MIC 0.2–0.5 µg/ml)

  ▸  Relatively Penicillin-Resistant Streptococci (MIC > 0.5 µg/ml)

  ▸  Unable to tolerate Penicillin or Ceftriaxone

Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis
Preferred Regimen ( 4 wks )
Adult dose
Penicillin G sodium † 12–18 million U/24 h IV either continuously or in 4-6 equally divided doses x 4 Wks
OR
Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 4 Wks
Pediatric dose ₳
Penicillin G sodium 200 000 U/kg q24h IV either continuously or in 4-6 equally divided doses x 4 Wks
OR
Ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose x 4 Wks
Alternative Regimen ( 2 wks )
Adult dose
Penicillin G sodium‡ 12–18 million U/24 h IV either continuously or in 6 equally divided doses x 2 Wks
OR
Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 2 Wks
PLUS
Gentamicin sulfate ฿ 3 mg/Kg per 24h 1 dose x 2 Wks
Pediatric dose
Penicillin G sodium 200 000 U/kg q24h IV in 4-6 equally divided doses x 2 Wks
OR
Ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose x 2 Wks
PLUS
Gentamicin sulfate 3 mg/Kg per 24h 1 dose or 3 equally divided doses x 2 Wks
Alternative Regimen
Adult dose
Vancomycin hydrochloride ¶ 15 mg/kg q12h IV x 4 Wks
Doses should not to exceed 2 g/24 h unless concentrations in serum are inappropriately low
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h IV in 2–3 equally divided doses

Minimum inhibitory concentration ≤ 0.12 μg/mL.

† Preferred in most patients >65 y or patients with impairment of 8th cranial nerve function or renal function.
₳ Pediatric dose should not exceed that of a normal adult.
‡ 2-wk regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of <20 mL/min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella spp infection; gentamicin dosage should be adjusted to achieve peak serum concentration of 3-4 μg/mL and trough serum concentration of >1 μg/mL when 3 divided doses are used; nomogram used for single daily dosing.
¶ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ceftriaxone; vancomycin 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
฿ Other potentially nephrotoxic drugs (eg, nonsteroidal antiinflammatory drugs) should be used with caution in patients receiving gentamicin therapy. Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.
Native Valve Endocarditis Caused by Strains of Viridans Group Streptococci and Streptococcus Bovis Relatively Resistant to Penicillin (MIC >0.12 μg/mL- ≤ 0.5 μg/mL))
Preferred Regimen
Adult dose
Penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 wks
OR
Ceftriaxone 2 g/24 h IV/IM in 1 dose x 4 wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks
Pediatric dose
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
OR
Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose or equally divided doses
Alternative Regimen
Adult dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 4 wks
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
Penicillin-susceptible strain (MIC ≤ 0.12 g/mL)
Preferred Regimen
Adult dose
Penicillin G sodium † 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks
OR
Ceftriaxone 2 g/24 h IV/IM in 1 dose x 6 wks
WITH OR WITHOUT
Gentamicin sulfate ‡ 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks
Pediatric dose
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
OR
Ceftriaxone 100 mg/kg IV/IM once daily
WITH OR WITHOUT
Gentamicin 3 mg/kg per 24 h IV/IM, in 1 dose or 3 equally divided doses
Alternative Regimen
Adult dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
Pediatric dose
40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
  • Dosages recommended are for patients with normal renal function.
† Penicillin or ceftriaxone together with gentamicin has not demonstrated superior cure rates compared with monotherapy with penicillin or ceftriaxone for patients with highly susceptible strain; gentamicin therapy should not be administered to patients with creatinine clearance of <30 mL/min.
‡ Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.
Penicillin Relatively or Fully Resistant Strain (MIC >0.12 >μg/mL)
Preferred Regimen
Adult dose
Penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks
OR
Ceftriaxone 2 g/24 h IV/IM in 1 dose x 6 wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 6 wks
Pediatric dose
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
Alternative Regimen
Adult dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
Relatively Penicillin-Resistant Streptococci (MIC 0.2–0.5 µg/ml)
Preferred Regimen
Adult dose
Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks
OR
Ceftriaxone 2 g/24 h IV/IM in 1 dose
AND
Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks
Pediatric dose
Penicillin G potassium 300 000 U/24 h IV in 4–6 equally divided doses X 4 Wks
OR
Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose
AND
Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose or 3 equally divided doses X 2 Wks
Relatively Penicillin-Resistant Streptococci(MIC > 0.5 µg/ml, consider Enterococcal regimen)
Preferred Regimen
Adult dose
Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks
PLUS
Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks
Pediatric dose
Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks
PLUS
Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks
Unable to Tolerate Aqueous crystalline penicillin G sodium or Ceftriaxone
Preferred Regimen
Adult dose
Vancomycin 30 mg/kg per 24 h IV in 2 equally divided doses not to exceed 2 g/24 h, unless serum concentrations are inappropriately low
Pediatric dose
Vancomycin 40 mg/kg 24 h in 2 or 3 equally divided doses X 4 Wks

Enterococci

Endocarditis Caused by Enterococci

  ▸  Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin

  ▸  Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin

  ▸  Enterococci Strains Resistant to Penicillin and Susceptible to Aminoglycoside and Vancomycin

  ▸  Enterococci Strains Resistant to Penicillin, Aminoglycoside, and Vancomycin

Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin
Preferred Regimen
Adult dose
Ampicillin 12 g/24 h I.V.in 6 equally divided doses x 4–6 Wks
OR
Penicillin G sodium 18–30 million U. I.V. daily in 6 equally divided doses x 4–6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 4-6 Wks
Pediatric dose
Ampicillin 300 mg/kg per 24 h IV in 4–6 equally divided doses; X 4–6 Wks
OR
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses X 4–6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks
Alternative Regimen
Vancomycin 30 mg/kg I.V. daily in 2 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Pediatric dose
Vancomycin 30 mg/kg I.V. daily in divided doses q. 12 hour X 4–6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks
  • Native valve: 4-wk therapy recommended for patients with symptoms of illness < 3 months.
  • 6-wk therapy recommended for patients with symptoms >3 months.
  • Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
  • Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin.
  • 6 wk of vancomycin therapy recommended because of decreased activity against enterococci.
Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin
Preferred Regimen
Adult dose
Ampicillin 12 g/24 h I.V.in 6 equally divided doses x 4–6 Wks
OR
Penicillin G sodium 24 million U. I.V. continuously or in 6 equally divided doses x 4–6 Wks
PLUS
Streptomycin sulfate 15 mg/kg per 24 h IV/IM in 2 equally divided doses x 4-6 Wks
Pediatric dose
Ampicillin 300 mg/kg per 24 h IV in 4–6 equally divided doses; x 4–6 Wks
OR
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses x 4–6 Wks
PLUS
Streptomycin sulfate 20–30 mg/kg per 24 h IV/IM in 2 equally divided doses
Alternative Regimen
Adult dose
Vancomycin 30 mg/kg I.V. daily in 2 equally divided doses x 6 Wks
PLUS
Streptomycin sulfate 15 mg/kg per 24 h IV/IM in 2 equally divided doses x 4-6 Wks
Pediatric dose
Vancomycin 40 mg/kg per 24 h IV in 2 or 3 equally divided doses X 4–6 Wks
PLUS
Streptomycin sulfate 20–30 mg/kg per 24 h IV/IM in 2 equally divided doses
  • Native valve: 4-wk therapy recommended for patients with symptoms of illness < 3 months.
  • 6-wk therapy recommended for patients with symptoms >3 months.
  • Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
  • Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin.
β-Lactamase–producing strain
Preferred Regimen
Adult dose
Ampicillin-sulbactam 12 g/24 h IV in 4 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Pediatric dose
Ampicillin-sulbactam 300 mg/kg per 24 h IV in 4 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Alternative Regimen
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h in 2 or 3 equally divided doses
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Intrinsic penicillin resistance
Adult dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h in 2 or 3 equally divided doses
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
E faecium
Adult dose
Linezolid 1200 mg/24 h IV/PO in 2 equally divided doses x ≥8 Wks
OR
Quinupristin-dalfopristin 22.5 mg/kg per 24 h IV in 3 equally divided doses x ≥ 8 Wks
Pediatric dose
Linezolid 30 mg/kg per 24 h IV/PO in 3 equally divided doses ≥8 Wks
OR
Quinupristin-dalfopristin 22.5 mg/kg per 24 h IV in 3 equally divided doses ≥8 Wks
E faecalis
Adult dose
Preferred Regimen
Imipenem/cilastatin 2 g/24 h IV in 4 equally divided doses x ≥8 Wks
PLUS
Ampicillin sodium 12 g/24 h IV in 6 equally divided doses x ≥ 8 Wks
Pediatric dose
Imipenem/cilastatin 60–100 mg/kg per 24 h IV in 4 equally divided doses x ≥8 Wks
PLUS
Ampicillin sodium 300 mg/kg per 24

h IV in 4–6 equally divided doses x ≥ 8 Wks

Alternative Regimen
Adult dose
Ceftriaxone sodium 4 g/24 h IV/IM in 2 equally divided doses x ≥8 Wks
PLUS
Ampicillin sodium 12 g/24 h IV in 6 equally divided doses x ≥ 8 Wks
Pediatric dose
Ceftriaxone sodium 100 mg/kg per 24 h IV/IM in 2 equally divided doses x ≥8 Wks
PLUS
Ampicillin sodium 300 mg/kg per 24 h IV in 4–6 equally divided doses x ≥ 8 Wks
  • Patients with endocarditis caused by these strains should be treated in consultation with an infectious diseases specialist.
  • Cardiac valve replacement may be necessary for bacteriologic cure.
  • Cure with antimicrobial therapy alone may be < 50%
  • Severe, usually reversible thrombocytopenia may occur with use of linezolid, especially after 2 wk of therapy.
  • Quinupristin-dalfopristin only effective against E faecium and can cause severe myalgias, which may require discontinuation of therapy
  • Only small no. of patients have reportedly been treated with imipenem/cilastatin-ampicillin or ceftriaxone + ampicillin.

Staphylococci

Native Valve Endocarditis caused by Staphylococci in the Absence of Prosthetic Material

  ▸  Staphylococci (Methicillin Susceptible)

  ▸  Staphylococci (Methicillin-resistant) with Penicillin G Anaphylactoid Hypersensitivity

Prosthetic Valves Endocarditis or Other Prosthetic Material Caused by Staphylococci

  ▸  Oxacillin-Susceptible Strains

  ▸  Oxacillin-Resistant Strains

Staphylococci (Methicillin Susceptible)
Preferred Regimen
Adult dose
Nafcillin or Oxacillin † 12 g I.V. daily in equally divided doses x 6 Wks
PLUS (optional)
Gentamicin sulfate ‡ 3 mg/kg per 24 h IV/IM in 2-3 equally divided doses x 3-5 days
Altenative Regimen( in non anaphylactoid Penicillin hypersensitivity)
Cefazolin 6 g/ 24 h I.V. in 3 divided doses x 6 wks
PLUS (optional)
Gentamicin 3 mg/kg per 24 h IV/IM in 2-3 equally divided doses x 3-5 days
Pediatrics dose
Nafcillin or oxacillin 200 mg/kg per 24 h IV in 4–6 equally divided doses x 4-6 wks
OR ( in non anaphylactoid Penicillin hypersensitivity)
Cefazolin 100 mg/kg per 24 h IV in 3 equally divided doses x 4-6 wks
AND (optional)
Gentamicin 3 mg/kg per 24 h IV/IM in 3 equally divided doses
† 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 (MIC ≤ 0.1 μg/mL) and does not produce β-lactamase.
‡ Gentamicin should be administered in close temporal proximity to vancomycin, nafcillin, or oxacillin dosing.
Staphylococci (Methicillin-resistant)
(in anaphylactoid Penicillin hypersensitivity)
Preferred Regimen
Adult dose
Vancomycin 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
Adjust vancomycin dosage to achieve 1-h serum concentration of 30–45 > g/mL and trough concentration of 10–15 >g/mL
Pediatrics dose
Vancomycin 40 mg/kg per 24 h IV in 2 or 3 equally divided doses x 6 wks
Oxacillin-susceptible strains
Adult dose
Nafcillin or oxacillin 2 g q4h IV x ≥6 weeks
PLUS
Rifampin 300 mg q8h IV/PO x ≥6 weeks
PLUS
Gentamicin 3 mg/kg per 24 h IV/IM in 2 or 3 equally divided doses x 2 weeks
Pediatric dose
Nafcillin or oxacillin 200 mg/kg per 24 h IV in 4–6 equally divided doses
PLUS
Rifampin 20 mg/kg per 24 h IV/PO in 3 equally divided doses
PLUS
Gentamicin 1 mg/kg q8h IV/IM
Oxacillin-resistant strains
Adult dose
Vancomycin 15 mg/kg q12h x ≥6 Wks
PLUS
Rifampin 300 mg q8h IV/PO x ≥6 Wks
PLUS
Gentamicin 3 mg/kg per 24 h IV/IM in 2 or 3 equally divided doses x 2 wks
Pediatric dose
Vancomycin 40 mg/kg per 24 h IV in 2-3 equally divided doses x ≥6 wks
PLUS
Rifampin 20 mg/kg per 24 h IV/PO in 3 equally divided doses x ≥6 wks
PLUS
Gentamicin 1 mg/kg q8h IV/IM x 2 Wks

HACEK Organisms

HACEK organisms are more indolent and the infection is less complicated. [1]

  ▸  Therapy for Both Native and Prosthetic Valve Endocarditis Caused by HACEK Microorganisms

Therapy for Both Native and Prosthetic Valve Endocarditis Caused by HACEK Microorganisms
Adult dose
Ceftriaxone sodium † 2 g/24 h IV/IM in 1 dose x 4 weeks
OR
Ampicillin- sulbactam ‡ 12 g/24 h IV in 4 equally divided doses x 4 weeks
OR
Ciprofloxacin ‡¶ 500 mg q12h PO or 400 mg q12h IV x 4 weeks
Pediatric dose
Ceftriaxone 100 mg/kg per 24 h IV/IM once daily
OR
Ampicillin- sulbactam 300 mg/kg per 24 h IV divided into 4 or 6 equally divided doses
OR
Ciprofloxacin 10-15 mg/kg q12h IV/PO
  • HACEK: Haemophilus parainfluenzae, H aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae.
† Patients should be informed that IM injection of ceftriaxone is painful.
‡ Dosage recommended for patients with normal renal function.
¶ Fluoroquinolones are highly active in vitro against HACEK microorganisms. Published data on use of fluoroquinolone therapy for endocarditis caused by HACEK are minimal.
  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)