Sandbox endocarditis

Empirical Antibiotic Therapy

• Antibiotic therapy for subacute disease, and in those who have received antibiotics recently can be delayed waiting the results of blood cultures, as this delay allows an additional blood cultures without the confounding effect of empiric treatment, which is very important in determining the causing pathogens.

• 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.

• 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.

• Consultation with an infectious disease specialist for the selection of one of the antibiotic regimens is recommended(See therapy for culture-negative endocarditis).

Native valve ▸ Ampicillin-Sulbactam 3 g q6h IV x 4–6 weeks PLUS ▸ Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 weeks OR ▸ Vancomycin 15 mg per kg q12h IV x 4–6 weeks PLUS ▸ Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 week PLUS Ciprofloxacin 500 mg q12h PO or 400 mg q12h IV x 4–6 weeks Native valve pediatric dose ▸Ampicillin-Sulbactam300 mg per kg per 24 h IV in 4–6 equally divided doses ▸Gentamicin 1 mg per kg q8h IV/IM ▸Vancomycin 40 mg per kg per 24 h in 2 or 3 equally divided doses ▸Ciprofloxacin 10-15 mg per kg q12h IV/PO Prosthetic valve (early, ≤ 1y) ▸ Vancomycin 15 mg per kg q12h IV x 6 PLUS ▸ Gentamicin sulfate 1 mg per kg q8h IV/IM x 2weeks PLUS ▸Cefepime 2 g q8h IV x 6 weeks PLUS ▸ Rifampin 300 mg q8h PO/IV x 6 weeks Prosthetic valve pediatric dose ▸Vancomycin 40 mg per kg per 24 h IV in 2 or 3 equally divided doses ▸Gentamicin 1 mg per kg q8h IV/IM ▸Cefepime 50 mg q8h IV ▸Rifampin 20 mg per kg per 24 h PO/IV in 3 equally divided doses Prosthetic valve (late—greater than 1 y) (same regimens as for native valve endocarditis with addition of rifampin) ▸ Ampicillin-Sulbactam 3 g q6h IV x 4–6 weeks PLUS ▸ Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 weeks PLUS ▸ Rifampin 300 mg q8h PO/IV x 6 weeks OR ▸ Vancomycin 15 mg per kg q12h IV x 4–6 weeks PLUS ▸ Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 weeks PLUS ▸ Ciprofloxacin 500 mg q12h PO or 400 mg q12h IV x 4–6 weeks PLUS ▸ Rifampin 300 mg q8h PO/IV x 6 weeks Suspected Bartonella, culture negative ▸ Ceftriaxone sodium 2 g per 24 h IV/IM in 1 dose x 6 weeks PLUS ▸ Gentamicin sulfate 1 mg per kg q8h IV/IM x 2 weeks WITH/WITHOUT ▸ Doxycycline 100 mg per kg q12h IV/PO x 6 weeks Documented Bartonella, culture positive ▸ Doxycycline 100 mg q12h IV or PO x 6 weeks PLUS ▸ Gentamicin sulfate 1 mg per kg q8h IV/IM x 2 weeks Documented Bartonella, culture positive pediatric dose ▸Ceftriaxone 100 mg per kg per 24 h IV/IM once daily ▸Gentamicin 1 mg per kg q8h IV/IM ▸Doxycycline 2–4 mg per kg per 24 h IV/PO in 2 equally divided doses ▸Rifampin 10 mg per kg q12h PO/IV Regimen Dosage and Route Duration(wk) Native valve Ampicillin-Sulbactam 12 g per 24 h IV in 4 equally divided doses 4–6 'PLUS' Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 4–6 OR Vancomycin 30 mg per kg per 24 h IV in 2 equally divided doses 4–6 'PLUS' Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 4–6 'PLUS' Ciprofloxacin 1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses 4–6 →Pediatric dose: 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 Prosthetic valve (early, ≤ 1y) Vancomycin 30 mg per kg per 24 h IV in 2 equally divided doses 6 'PLUS' Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 2 'PLUS' Cefepime 6 g per 24 h IV in 3 equally divided doses 6 'PLUS' Rifampin 900 mg per 24 h PO/IV in 3 equally divided doses 6 →Pediatric dose: 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 Prosthetic valve (late—greater than 1 y) Same regimens as listed above for native valve endocarditis Suspected Bartonella, culture negative Ceftriaxone sodium 2 g per 24 h IV/IM in 1 dose 6 'PLUS' Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 2 with/without Doxycycline 200 mg per kg per 24 h IV/PO in 2 equally divided doses 6 Documented Bartonella, culture positive Doxycycline 200 mg per 24 h IV or PO in 2 equally divided doses 6 'PLUS' Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 2 →Pediatric dose: 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 Treatment Based Upon Infectious Agent Penicillin-Susceptible Strep Viridans and Other Nonenterococcal Streptococci 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