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}}; '''Associate Editors-in-Chief:''' {{CZ}}; {{AZ}}
+{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}
 ==Overview==
-[[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.
+[[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.
-==Timing of Initiation of Antibiotics==
+==Medical Therapy==
-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.
+===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>
-==Duration of Antibiotic Therapy==
+===Timing of Initiation of Antibiotics===
-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.
-==Empirical Antibiotic Therapy==
+* [[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.
-*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.<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>
+===Duration of Antibiotic Therapy===
-*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.
+* 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 therapy is needed for all likely pathogens, certain antibiotic agents, including aminoglycosides, is preferably avoided for its toxic effects.
+===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>
-*Clinical course of infection beside the epidemiological features should be considered upon selecting empirical treatment regimen.
+:*'''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
-*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>
+::*'''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
-==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>==
+::*'''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
-==Streptococci==
+::*'''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 {{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
-===Native Valve Endocarditis Caused by Viridans Group Streptococci and Streptococcus bovis===
+:::* '''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
-<div class="mw-collapsible mw-collapsed">
+::*'''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
-===== Viridans Group Streptococci and Streptococcus bovis Highly Penicillin-Susceptible =====
+:::* '''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
-<div class="mw-collapsible-content">
+:::* '''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
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: center; width:48em" cellpadding="0" cellspacing="0";
+:::* '''2.3.4. Endocarditis caused by enterococcal strains resistant to penicillin, gentamicin, and vancomycin'''
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Native Valve Endocarditis Caused by Highly Penicillin-Susceptible <br> Viridans Group Streptococci and Streptococcus bovis}}''
+::::* 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
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''<u>Preferred Regimen</u>''''' ( 4 wks )
+::::* 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
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
+:::::* 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
-|-
-| 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.
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-===== Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin Resistant (MIC >0.12 μg/mL- ≤ 0.5 μg/mL)=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|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: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
-|-
-| 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 per 24 h IV/IM in 1 dose'''''
-|-
-!style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
-|-
-| 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="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 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'''''
-|-
-|}
-|}
-</div></div>
-===Prosthetic Valves Endocarditis or Other Prosthetic Material Caused by Viridans Group Streptococci and Streptococcus Bovis===
+::* '''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
-<div class="mw-collapsible mw-collapsed">
+::* '''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
+::::* 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
+::::* 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
-===== Viridans Group Streptococci and Streptococcus bovis Penicillin-susceptible strain (MIC ≤ 0.12 μg/mL)=====
+:::* '''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
-<div class="mw-collapsible-content">
+:::* '''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
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|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''
-|-
+:::* '''2.5.4 Prosthetic valve endocarditis caused by oxacillin-resistant staphylococci'''
-| 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'''''
+::::* 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
-!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.
+::* '''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
-:† 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.
+:::* '''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
-:‡ 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.
+:::* '''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
-</div></div>
+:::* '''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
-<div class="mw-collapsible mw-collapsed">
+==Antithrombotic Therapy==
-===== Viridans Group Streptococci and Streptococcus bovis Penicillin relatively or fully resistant strain (MIC >0.12 μg/mL)=====
+*[[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.
-<div class="mw-collapsible-content">
-{|
+{| class="wikitable"
 |-
-| valign=top |
+| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
+| bgcolor="LightGreen" |
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|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>'''''
+| bgcolor="LightGreen" |"'''1.'''  Penicillin G or Amoxicilline or Ceftriaxonef''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  A]])''"
+| bgcolor="LightGreen" |
 |-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
+| bgcolor="LightGreen" |”'''2.'''  (Paste guideline here) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
+| bgcolor="LightGreen" |
 |-
-| 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'''''
+| bgcolor="LightGreen" |”'''3.'''  (Paste guideline here) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
-|-
+| bgcolor="LightGreen" |
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
-|-
-| 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="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'''''
-|-
-!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 | ▸ '''''[[Vancomycin|Vancomycin hydrochloride]] 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses'''''
-|-
-|}
 |}
-</div></div>
+==References==
-<div class="mw-collapsible mw-collapsed">
-===== Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin-Resistant Streptococci, MIC 0.2–0.5 µg/ml=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|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'''''
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====Relatively Penicillin-Resistant Streptococci, (MIC > 0.5 µg/ml)=====
-<div class="mw-collapsible-content">
-{|
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Relatively Penicillin-Resistant Streptococci,<br> MIC > 0.5 µg/ml, consider Enterococcal regimen}}''
-|-
-!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 '''''
-|-
-| 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  '''''
-|-
-! 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]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks '''''
-|-
-| 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  '''''
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====Unable to tolerate Penicillin or Ceftriaxone=====
-<div class="mw-collapsible-content">
-{|
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Unable to tolerate [[Penicillin G potassium|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 '''''
-|-
-|}
-|}
-</div></div>
-==Enterococci==
-'''Native valve or prosthetic valve''' enterococcal endocarditis requires combination therapy with two antibiotics as the following:
-<div class="mw-collapsible mw-collapsed">
-=====Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin=====
-<div class="mw-collapsible-content">
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: center; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin}}''
-|-
-!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 | ▸ '''''[[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'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''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'''''
-|-
-!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]] 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'''''
-|-
-! 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]] 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'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''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'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR (in penicillin hypersensitivity)''
-|-
-| 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'''''
-|-
-|-
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin=====
-<div class="mw-collapsible-content">
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: center; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin}}''
-|-
-!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 | ▸ '''''[[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'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
-|-
-| 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'''''
-|-
-!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]] 30 mg/kg I.V. daily in 2 equally divided doses x 6 Wks'''''<br> ''PLUS'' <br> ▸'''[[Streptomycin sulfate]] 15 mg/kg per 24 h IV/IM in 2 equally divided doses x 4-6 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]] 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'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''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'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR (in penicillin hypersensitivity)''
-|-
-| 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'''''
-|-
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====Enterococci Strains Resistant to Penicillin and Susceptible to Aminoglycoside and Vancomycin=====
-<div class="mw-collapsible-content">
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: center; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| β-Lactamase–producing strain}}''
-|-
-!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 | ▸ '''''[[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="margin: 0 0 0em 0em; border: 1px solid #696969; float: center; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| 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'''''
-|-
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====Enterococci Strains Resistant to Penicillin, Aminoglycoside, and Vancomycin=====
-<div class="mw-collapsible-content">
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: center; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| 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="margin: 0 0 0em 0em; border: 1px solid #696969; float: center; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| 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'''''
-|
-|}
-|}
-</div></div>
-==Staphylococci==
-===Native Valve Endocarditis caused by Staphylococci in the Absence of Prosthetic Material===
-<div class="mw-collapsible mw-collapsed">
-=====Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material}}''
-|-
-!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.
-:‡ Gentamicin should be administered in close temporal proximity to vancomycin, nafcillin, or oxacillin dosing.
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====Staphylococci (Methicillin-resistant) with Penicillin G Anaphylactoid Hypersensitivity in the Absence of Prosthetic Material =====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococci (Methicillin-resistant) in the Absence of Prosthetic Material <br> (in anaphylactoid [[Penicillin G potassium adverse reactions|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 '''''
-|-
-|}
-|}
-</div></div>
+{{reflist|2}}
-===Prosthetic Valves Endocarditis or Other Prosthetic Material Caused by Staphylococci===
-<div class="mw-collapsible mw-collapsed">
-=====Oxacillin-susceptible strains in the Presence of Prosthetic Material=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|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'''''
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-=====Oxacillin-resistant strains in the Presence of Prosthetic Material=====
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|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'''''
-|-
-|}
-|}
-</div></div>
-==HACEK Organisms==
-<div class="mw-collapsible mw-collapsed">
-[[HACEK organism]]s are more indolent and the infection is less complicated.
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|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.
-</div></div>
-==Culture Negative Endocarditis==
-*Clinical course of infection beside the epidemiological features should be considered upon selecting treatment regimen.
-*Patients should be divided into 2 groups:
-====Patients Who Received Antibiotic Therapy Before the Blood Culture====
-*Patients with acute clinical presentations with native valve infection: coverage of S. aureus should be followed as detailed in proven staphylococcal disease.
-*Patients with subacute presentation: antibiotic coverage for S. aureus, viridians group streptococci, and enterococci should be considered.
-*Antibiotics for HACEK group of organism also should be considered.
-*Symptomatic patients with prosthetic valve and culture negative infection within 1 year of valve replacement should receive vancomycin to cover the oxacillin-resistant staphylococci.
-*Symptomatic patients with prosthetic valve and culture negative infection within 2 months of valve replacement should also receive cefepime for gram negative bacilli coverage.
-*Symptomatic patients with prosthetic valve more than 1 year, the most likely causing organisms are oxacillin-susceptible staphylococci, viridians group streptococci, and enterococci.   Antibiotic coverage for those organisms should be continued for at least 6 weeks.
-====Patients with Culture-Negative Endocarditis and Suspected Infection with Uncommon Endocarditis Pathogens====
-*Examples of these pathogens include Bartonella species, Chlamydia species, Coxiella burnetii, Brucella species, Legionella species, Tropheryma whippleii, and non-Candida fungi.
-*The most common pathogens that have been reported with culture-negative endocarditis are [[Bartonella|Bartonella species]], [[Coxiella burnetii]], and [[Brucella|Brucella species]].
-*Antibiotic therapy for these pathogens should include aminoglycosides for at least 2 weeks.
-*Therapeutic regimens for Bartonella endocarditis based on the [[Endocarditis causes|epidemiological risk]] and high index of suspicion.<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 mw-collapsed">
-===Native Valve Culture Negative Endocarditis===
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Native valve}}''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 3 g q6h IV x 4–6 wks'''''<BR>''PLUS''<BR> ▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 wks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Vancomycin]] 15 mg per kg q12h IV x 4–6 wks''''' <BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 wks''''' <BR>''PLUS''<BR>'''''[[Ciprofloxacin]] 500 mg q12h PO or 320 mg q12h IV x 4–6 wks'''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 90%; 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'''''<BR>''PLUS''<BR> ▸'''''[[Gentamicin]] 1 mg per kg q8h IV/IM x 4–6 wks'''''
-|-
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Vancomycin]] 32 mg per kg per 24 h in 2 or 3 equally divided doses x 4–6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 wks'''''<BR>''PLUS''<BR> ▸'''''[[Ciprofloxacin]] 10-15 mg per kg q12h IV/PO x 4–6 wks'''''
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-===Prosthetic Valve Culture Negative Endocarditis===
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float:left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Prosthetic valve (early, ≤ 1y)}}''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg per kg q12h IV x 4-6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 2wks'''''<BR>''PLUS''<BR>▸'''''[[Cefepime]] 2 g q8h IV x 6 wks''''' <BR>''PLUS''<BR>▸ '''''[[Rifampin]] 300 mg q8h PO/IV x 6 wks'''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Vancomycin]] 15 mg per kg q12h IV x 4-6 wks'''''<BR>''PLUS''<BR> ▸'''''[[Gentamicin]] 1 mg per kg q8h IV/IM x 2 wks'''''<BR>''PLUS''<BR> ▸'''''[[Cefepime]] 50 mg q8h IV x 6 wks '''''<BR>''PLUS''<BR> ▸'''''[[Rifampin]] 20 mg per kg per 24 h PO/IV in 3 equally divided doses x 6 wks'''''
-|-
-! 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="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 3 g q6h IV x 4–6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Rifampin]] 300 mg q8h PO/IV x 6 wks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg per kg q12h IV x 4–6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Ciprofloxacin]] 500 mg q12h PO or 320 mg q12h IV x 4–6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Rifampin]] 300 mg q8h PO/IV x 6 wks'''''
-|-
-|}
-|}
-</div></div>
-<div class="mw-collapsible mw-collapsed">
-===Bartonella Culture Negative Endocarditis===
-<div class="mw-collapsible-content">
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float:left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Suspected Bartonella, (culture negative)}}''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone sodium]] 2 g per 24 h IV/IM in 1 dose x 6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 2 wks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |''WITH / WITHOUT''
-|-
-|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg per kg q12h IV/PO x 6 wks'''''
-|-
-! 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: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg q12h IV or PO x 6 wks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 2 wks'''''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatrics dose}}''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Doxycycline]] 2–4 mg per kg per 24 h IV/PO in 2 equally divided doses'''''<BR>''PLUS''<BR>▸'''''[[Gentamicin]] 1 mg per kg q8h IV/IM'''''
-|-
-|}
-|}
-</div></div>
-==References==
-{{Reflist|2}}
 [[Category:Emergency medicine]]
 [[Category:Cardiology]]
-[[Category:Infectious disease]]
 [[Category:Intensive care medicine]]
 [[Category:Up-To-Date]]
+[[Category: Infectious Disease Project]]
-{{WH}}
-{{WS}}