Sandbox endocarditis2: Difference between revisions

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{| class="wikitable" style="margin: 1em auto 1em auto"
==Medical Therapy==
|+
! Epidemiological features || Common Microorganism(s)
|-
| <center>'''Injection drug use'''</center>||
*[[S aureus]], including community-acquired
*oxacillin-resistant strains
*Coagulase-negative [[staphylococci]]
*[[Streptococcus|β-Hemolytic streptococci]]
*[[Fungi]]
*Aerobic Gram-negative bacilli, including
:*Pseudomonas aeruginosa
|-
| <center>'''Indwelling cardiovascular medical devices'''</center> ||
*[[Staphylococcus aureus|S aureus]]
*Coagulase-negative staphylococci
*[[Fungi]]
*Aerobic Gram-negative bacilli
*[[Corynebacterium]] sp
|-
| <center>'''Genitourinary disorders'''</center>


<center>'''Genitourinary infection'''</center>
===Pharmacotherapy===
====Empiric Treatment====
* Do not wait for the results of the [[CT scan]] and the [[lumbar puncture]]; empiric treatment should be started as soon as possible.
* Blood cultures should be drawn before starting the [[antibiotic]] therapy, and then the antibiotic treatment should be changed once the blood culture results are out.


<center>'''Genitourinary manipulation'''</center>
* Empiric antibiotic treatment should be started within 30 minutes after the patient presentation.
* In case of high suspicion of pneumococcal meningitis in adult patients, 0.15 mg/kg IV Q6H dexomethasone should be administered for 2 to 4 days.
** The first dose of dexomethasone is given along with or 20 minutes prior to starting the antibiotics treatment.


<center>'''pregnancy'''</center>
{|
|-
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:19em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age <1 Week}}''
|-


<center>'''Delivery'''</center>


<center>'''Abortion'''</center>
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
||
*Enterococcus sp
*Group B [[streptococci]] (S agalactiae)
*[[Listeria]] monocytogenes
*Aerobic Gram-negative bacilli
*Neisseria [[gonorrhoeae]]
|-
|-
| <center>'''Chronic skin disorders''' </center>||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
*S aureus
*β-Hemolytic streptococci
|-
|-
| <center>'''Poor dental health, dental procedures''' </center>||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
*Viridans group streptococci
*“Nutritionally variant streptococci”
*Abiotrophia defectiva
*Granulicatella sp
*Gemella sp
*HACEK organisms
|-
|-
| <center>'''Alcoholism, cirrhosis''' </center>||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 100—150 mg/kg/day IV q8—12h'''''
*Bartonella sp
*Aeromonas sp
*[[Listeria]] sp
*[[Streptococcus pneumoniae|S pneumoniae]]
*β-Hemolytic streptococci
|-
|-
|  <center>'''Burn patients''' </center>||
*[[Staphylococcus aureus|S aureus]]
*Aerobic Gram-negative bacilli, including
:*[[Pseudomonas aeruginosa]]
*Fungi
|-
|  <center>'''Diabetes mellitus''' </center>||
*[[Staphylococcus aureus|S aureus]]
*β-Hemolytic streptococci
*[[Streptococcus pneumoniae|S pneumoniae]]
|-
| <center>'''Early (1 y) prosthetic valve placement''' </center>||
*Coagulase-negative staphylococci
*S aureus
*Aerobic Gram-negative bacilli
*Fungi
*Corynebacterium sp
*Legionella sp
|-
|  <center>'''Late (>1 y) prosthetic valve placement''' </center>|| Coagulase-negative staphylococci
*S aureus
*Viridans group streptococci
*Enterococcus species
*Fungi
*Corynebacterium sp
|-
| <center>'''Dog–cat exposure''' </center>||
*Bartonella sp
*Pasteurella sp
*Capnocytophaga sp
|-
| <center>'''Contact with contaminated milk'''</center>
<center>'''Contact with infected farm animals'''</center>
||
*Brucella sp
*Coxiella burnetii
*Erysipelothrix sp
|-
| <center>'''Homeless, body lice'''</center>||


*Bartonella sp
 
|-
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
| <center>'''AIDS'''</center> ||
*[[Salmonella|Salmonella sp]]
*[[Streptococcus pneumoniae|S pneumoniae]]
*[[Staphylococcus aureus|S aureus]]
|-
|-
| <center>'''Pneumonia, meningitis'''</center>||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
*S pneumoniae
|-
|-
| <center>'''Solid organ transplant'''</center>||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
*S aureus
*[[Aspergillus|Aspergillus fumigatus]]
*[[Enterococcus|Enterococcus sp]]
*[[Candida albicans|Candida sp]]
|-
|-
| <center>'''Gastrointestinal lesions'''</center>||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q12h'''''
*S bovis
*Enterococcus sp
*Clostridium septicum
|-
|-
|}
|}




==Empirical Antibiotic Therapy==
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:19em" cellpadding="0" cellspacing="0";
 
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age <1 Week}}''
*Although antibiotic therapy for subacute disease can be delayed till the result of blood culture, the rapid progression of acute cases necessitate the start of empirical treatment antibiotic therapy once the blood cultures have been collected.
|-
 
*Empirical therapy is needed for all likely pathogens, certain antibiotic agents, including aminoglycosides, is preferably avoided for its toxic effects.


*Clinical course of infection beside the epidemiological features should be considered upon selecting empirical treatment regimen.


{| class="wikitable"  style="margin: 1em auto 1em auto"
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|+
! Regimen || Dosage and Route || Duration(weeks)
|-
|-
| ||'''''<u>Native valve</u>'''''||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
|-
|-
| '''[[Ampicillin sulbactam]]'''||12 g per 24 h IV in 4 equally divided doses||4–6 weeks
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
|-
| || '''''plus''''' ||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 100—150 mg/kg/day IV q8—12h'''''
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''|| 3 mg per kg per 24 h IV/IM in 3 equally divided doses||4–6 weeks
 
 
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
|-
| || '''or''' ||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 50 mg/kg IV q8h'''''
|-
|-
| '''[[Vancomycin]]'''||30 mg per kg per 24 h IV in 2 equally divided doses||4–6 weeks
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
|-
| || '''''plus''''' ||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q12h'''''
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''||3 mg per kg per 24 h IV/IM in 3 equally divided doses||4–6 weeks
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:19em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age 1—4 Weeks}}''
|-
|-
| || '''''plus''''' ||
 
 
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
|-
| '''[[Ciprofloxacin]]'''||1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses||4–6 weeks
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
|-
|-
| ||→'''Pediatric dose''':
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
*'''[[Ampicillin sulbactam]]''' 300 mg per kg per 24 h IV in 4–6 equally divided doses
*'''[[Gentamicin]]''' 3 mg per kg per 24 h IV/IM in 3 equally divided doses
*'''[[Vancomycin]]''' 40 mg per kg per 24 h in 2 or 3 equally divided doses
*'''[[Ciprofloxacin]]''' 20–30 mg per kg per 24 h IV/PO in 2 equally divided doses
||
|-
|-
| ||'''''<u>Prosthetic valve (early, ≤ 1y, , mostly Oxacillin resistent)</u>''''' ||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 150—200 mg/kg/day IV q6—8h'''''
|-
|-
| '''[[Vancomycin]]'''||30 mg per kg per 24 h IV in 2 equally divided doses||6 weeks
 
 
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
|-
| ||'''''plus'''''||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''||3 mg per kg per 24 h IV/IM in 3 equally divided doses||2 weeks
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
|-
| ||'''''plus'''''||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸'''''[[Tobramycin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Amikacin]] 10 mg/kg IV q8h'''''
|-
|-
|'''[[Cefepime]]'''||6 g per 24 h IV in 3 equally divided doses||6 weeks
 
 
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:19em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age 1—23 Months}}''
|-
|-
| ||'''''plus'''''||
 
 
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
|-
| '''[[Rifampin]]'''||900 mg per 24 h PO/IV in 3 equally divided doses||6 weeks
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
|-
|-
| ||→'''Pediatric dose''':
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
*'''[[Vancomycin]]''' 40 mg per kg per 24 h IV in 2 or 3equally divided doses
*'''[[Gentamicin]]''' 3 mg per kg per 24 h IV/IM in 3 equally divided doses
*'''[[Cefepime]]''' 150 mg per kg per 24 h IV in 3 equally divided doses
*'''[[Rifampin]]''' 20 mg per kg per 24 h PO/IV in 3 equally divided doses
||
|-
|-
| ||'''''<u>Prosthetic valve (late—greater than 1 y, mostly Oxacillin sensitive)</u>'''''
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 150—200 mg/kg/day IV q6—8h'''''
'''Same regimens as listed above for native valve endocarditis'''
||
|-
|-
| ||'''''<u>Suspected Bartonella, culture negative</u>''''' ||
 
 
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
|-
|'''[[Ceftriaxone sodium]]'''||2 g per 24 h IV/IM in 1 dose||6 weeks
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
|-
|-
| ||'''''plus'''''||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''||3 mg per kg per 24 h IV/IM in 3 equally divided doses||2 weeks
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸'''''[[Tobramycin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Amikacin]] 10 mg/kg IV q8h'''''
|-
|-
| ||'''''with/without'''''||
 
 
|}
| valign=top |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:19em" cellpadding="0" cellspacing="0";
! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Age 1—4 Weeks}}''
|-
|-
| '''[[Doxycycline]]'''||200 mg per kg per 24 h IV/PO in 2 equally divided doses||6 weeks
 
 
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
|-
|-
| ||'''''<u>Documented Bartonella, culture positive</u>'''''||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
|-
|-
| '''[[Doxycycline]]'''||200 mg per 24 h IV or PO in 2 equally divided doses||6 weeks
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
|-
| ||'''''plus'''''||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefotaxime]] 150—200 mg/kg/day IV q6—8h'''''
|-
|-
| '''[[Gentamicin|Gentamicin sulfate]]'''||3 mg per kg per 24 h IV/IM in 3 equally divided doses||2 weeks
 
 
! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
|-
|-
| ||→'''Pediatric dose''':
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6—8h'''''
*'''[[Ceftriaxone]]''' 100 mg per kg per 24 h IV/IM once daily
*'''[[Gentamicin]]''' 3 mg per kg per 24 h IV/IM in 3 equally divided doses
*'''[[Doxycycline]]''' 2–4 mg per kg per 24 h IV/PO in 2 equally divided doses
*'''[[Rifampin]]''' 20 mg per kg per 24 h PO/IV in 2 equally divided doses
||
|-
|-
|}
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | AND
 
 
 
{| class="wikitable" style="margin: 1em auto 1em auto"
|+
! Epidemiological features || Common Microorganism(s)
|-
|-
| <center>'''Injection drug use'''</center>||
| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸'''''[[Tobramycin]] 2.5 mg/kg IV q8h''''' <BR> OR <BR> ▸ '''''[[Amikacin]] 10 mg/kg IV q8h'''''
*S aureus, including community-acquired
*oxacillin-resistant strains
*Coagulase-negative staphylococci
*β-Hemolytic streptococci
*Fungi
*Aerobic Gram-negative bacilli, including
:*Pseudomonas aeruginosa
|-
|-
|}




|}




==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>==
===<u>Penicillin-Susceptible Strep Viridans and Other Nonenterococcal Streptococci</u>===
====Penicillin G====
*If Minimum inhibitory concentration [MIC] <0.2 µg/ml.
*Dose: 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks.
====Penicillin G + Gentamicin====
*Dose: Penicillin G, 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks plus gentamicin, 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
====Ceftriaxone====
*Dose: 2 g I.V. daily as a single dose for 2 weeks.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 17:26, 14 January 2014

Medical Therapy

Pharmacotherapy

Empiric Treatment

  • Do not wait for the results of the CT scan and the lumbar puncture; empiric treatment should be started as soon as possible.
  • Blood cultures should be drawn before starting the antibiotic therapy, and then the antibiotic treatment should be changed once the blood culture results are out.
  • Empiric antibiotic treatment should be started within 30 minutes after the patient presentation.
  • In case of high suspicion of pneumococcal meningitis in adult patients, 0.15 mg/kg IV Q6H dexomethasone should be administered for 2 to 4 days.
    • The first dose of dexomethasone is given along with or 20 minutes prior to starting the antibiotics treatment.
Age <1 Week
Preferred Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Cefotaxime 100—150 mg/kg/day IV q8—12h
Alternative Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Gentamicin 2.5 mg/kg IV q12h


Age <1 Week
Preferred Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Cefotaxime 100—150 mg/kg/day IV q8—12h
Alternative Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Gentamicin 2.5 mg/kg IV q12h
Age 1—4 Weeks
Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Cefotaxime 150—200 mg/kg/day IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Gentamicin 2.5 mg/kg IV q8h
OR
▸Tobramycin 2.5 mg/kg IV q8h
OR
▸ Amikacin 10 mg/kg IV q8h
Age 1—23 Months
Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Cefotaxime 150—200 mg/kg/day IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Gentamicin 2.5 mg/kg IV q8h
OR
▸Tobramycin 2.5 mg/kg IV q8h
OR
▸ Amikacin 10 mg/kg IV q8h
Age 1—4 Weeks
Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Cefotaxime 150—200 mg/kg/day IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Gentamicin 2.5 mg/kg IV q8h
OR
▸Tobramycin 2.5 mg/kg IV q8h
OR
▸ Amikacin 10 mg/kg IV q8h


References
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