Endocarditis medical therapy: Difference between revisions

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Revision as of 16:05, 12 August 2015

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Ahmed Zaghw, M.D. [3]; Mohamed Moubarak, M.D. [4]

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. Empiric antiomicrobial therapy is started once the blood cultures have been collected.

Timing of Initiation of Antibiotics

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

Duration of Antibiotic Therapy

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

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.

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). ^[2]

Pathogen-Based Therapy Adapted from Circulation 2005;111(23):e394-434.^[2] and Circulation 2008;118(15):e523-661.^[3]

Endocarditis, treatment ⇧ Return to Top ⇧

Infective endocarditis^[4]

Culture-negative endocarditis

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/24h 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

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/24h 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/24h PO/IV q8h

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/24h 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

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/24h 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/24h PO or 800 mg/24h IV q12h for 4–6 weeks AND Rifampin 900 mg/24h 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/24h PO/IV q8h

Pathogen-directed antimicrobial therapy

Bartonella

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

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

Enterococcus

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 4–6weeks
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

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

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

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

HACEK organisms

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

Staphylococcus

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

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

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

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

Viridans group streptococci and Streptococcus bovis

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

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

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

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

Streptococcus pneumoniae, Streptococcus pyogenes, and Groups B, C, and G Streptococci

▸ Click on the following categories to expand treatment regimens.

Streptococcus pneumoniae

▸ PCN Susceptible

▸ PCN Resistant, Without Meningitis

▸ PCN Resistant, With Meningitis

Streptococcus pyogenes

▸ S. pyogenes Endocarditis

Group B, C, and G Streptococcus

▸ Group B, C, and G Streptococcus Endocarditis

S. pneumoniae Endocarditis, PCN Susceptible (MIC ≤0.1 μg/mL)
Preferred Regimen
▸ Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks OR ▸ Cefazolin 1—1.5 g IV q6h x 4 weeks OR ▸ Ceftriaxone 2 g IV q24h x 4 weeks
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q12h x 4 weeks^ǁ
^ǁ Recommended only for patients unable to tolerate β-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

S. pneumoniae Endocarditis, PCN Resistant (MIC >0.1 μg/mL), Without Meningitis
Preferred Regimen
▸ Penicillin G 24 MU/day IV continuously or q4—6h x 4 weeks OR ▸ Cefotaxime 2 g IV q6—8h x 4 weeks OR ▸ Ceftriaxone 2 g IV q24h x 4 weeks
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q12h x 4 weeks^ǁ
^ǁ Recommended only for patients unable to tolerate β-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

S. pneumoniae Endocarditis, PCN Resistant (MIC >0.1 μg/mL), With Meningitis
Preferred Regimen
▸ Cefotaxime 2 g IV q4—6h x 4 weeks OR ▸ Ceftriaxone 2 g IV q12h x 4 weeks
PLUS
▸ Vancomycin 15 mg/kg IV q6h x 4 weeks
PLUS
▸ Rifampin 600 mg IV q24h x 4 weeks

S. pyogenes Endocarditis
Preferred Regimen
▸ Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks OR ▸ Cefazolin 1—1.5 g IV q6h x 4 weeks OR ▸ Ceftriaxone 2 g IV q24h x 4 weeks
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q12h x 4 weeks^ǁ
^ǁ Recommended only for patients unable to tolerate β-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Group B, C, or G Streptococcus Endocarditis
Preferred Regimen
▸ Penicillin G 24 MU/day IV continuously or q4—6h x 4—6 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 4—6 weeks
PLUS
▸ Gentamicin 3 mg/kg IV/IM q24h (1 mg/kg IV/IM q8h) x 2 weeks^¶
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q12h x 4—6 weeks^ǁ
^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Staphylococcus

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis

▸ Oxacillin Susceptible, Adult

▸ Oxacillin Susceptible, Pediatric

▸ Oxacillin Resistant, Adult

▸ Oxacillin Resistant, Pediatric

Prosthetic Valve Endocarditis

▸ Oxacillin Susceptible, Adult

▸ Oxacillin Susceptible, Pediatric

▸ Oxacillin Resistant, Adult

▸ Oxacillin Resistant, Pediatric

Staphylococcal NVE, Oxacillin Susceptible, Adult
Preferred Regimen^†
▸ Nafcillin 12 g/day IV q4—6h x 6 weeks OR ▸ Oxacillin 12 g/day IV q4—6h x 6 weeks
WITH OR WITHOUT
▸ Gentamicin 3 mg/kg/day IV/IM q8—12h x 3—5 days^¶
Alternative Regimen^‡
▸ Cefazolin 2 g IV q8h x 6 weeks^§
WITH OR WITHOUT
▸ Gentamicin 3 mg/kg/day IV/IM q8—12h x 3—5 days^¶
^† For complicated right-sided IE and for left-sided IE; for uncomplicated right-sided IE, 2 weeks. ^¶ Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^‡ For penicillin-allergic (nonanaphylactoid type) patients; consider skin testing for oxacillin-susceptible staphylococci and questionable history of immediate-type hypersensitivity to penicillin. ^§ Cephalosporins should be avoided in patients with anaphylactoid-type hypersensitivity to β-lactams; vancomycin should be used in these cases.

Staphylococcal NVE, Oxacillin Susceptible, Pediatric
Preferred Regimen^†
▸ Nafcillin 200 mg/kg/day IV q4—6h x 6 weeks OR ▸ Oxacillin 200 mg/kg/day IV q4—6h x 6 weeks
WITH OR WITHOUT
▸ Gentamicin 1 mg/kg IV/IM q8h x 3—5 days^¶
Alternative Regimen^‡
▸ Cefazolin 100 mg/kg/day IV q8h x 6 weeks^§
WITH OR WITHOUT
▸ Gentamicin 1 mg/kg IV/IM q8h x 3—5 days^¶
^† For complicated right-sided IE and for left-sided IE; for uncomplicated right-sided IE, 2 weeks. ^¶ Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^‡ For penicillin-allergic (nonanaphylactoid type) patients; consider skin testing for oxacillin-susceptible staphylococci and questionable history of immediate-type hypersensitivity to penicillin. ^§ Cephalosporins should be avoided in patients with anaphylactoid-type hypersensitivity to β-lactams; vancomycin should be used in these cases.

Staphylococcal NVE, Oxacillin Resistant, Adult
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q12h x 6 weeks^ǁ
Alternative Regimen
▸ Linezolid 600 mg IV/PO q12h x 8 weeks OR ▸ Daptomycin 6 mg/kg IV q24h x 2—6 weeks
^ǁ Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Staphylococcal NVE, Oxacillin Resistant, Pediatric
Preferred Regimen
▸ Vancomycin 40 mg/kg/day IV q8—12h x 6 weeks^ǁ
Alternative Regimen
▸ Linezolid 10 mg/kg IV/PO q8h x 8 weeks
^ǁ Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Staphylococcal PVE, Oxacillin Susceptible, Adult
Preferred Regimen^†
▸ Nafcillin 2 g IV q4h x ≥6 weeks OR ▸ Oxacillin 2 g IV q4h x ≥6 weeks
PLUS
▸ Rifampin 300 mg IV/PO q8h x ≥6 weeks
PLUS
▸ Gentamicin 3 mg/kg/day IV/IM q8—12h x 2 weeks^¶
^† Penicillin G 24 million U/24 h IV in 4 to 6 equally divided doses may be used in place of nafcillin or oxacillin if strain is penicillin susceptible (minimum inhibitory concentration ≤0.1 μg/mL) and does not produce β-lactamase; vancomycin should be used in patients with immediate-type hypersensitivity reactions to β-lactam antibiotics; cefazolin may be substituted for nafcillin or oxacillin in patients with non–immediate-type hypersensitivity reactions to penicillins. ^¶ Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.

Staphylococcal PVE, Oxacillin Susceptible, Pediatric
Preferred Regimen^†
▸ Nafcillin 200 mg/kg/day IV q4—6h x ≥6 weeks OR ▸ Oxacillin 2 g IV q4h x ≥6 weeks
PLUS
▸ Rifampin 20 mg/kg/day IV/PO q8h x ≥6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 2 weeks^¶
^† Penicillin G 24 million U/24 h IV in 4 to 6 equally divided doses may be used in place of nafcillin or oxacillin if strain is penicillin susceptible (minimum inhibitory concentration ≤0.1 μg/mL) and does not produce β-lactamase; vancomycin should be used in patients with immediate-type hypersensitivity reactions to β-lactam antibiotics; cefazolin may be substituted for nafcillin or oxacillin in patients with non–immediate-type hypersensitivity reactions to penicillins. ^¶ Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.

Staphylococcal PVE, Oxacillin Resistant, Adult
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q12h x ≥6 weeks^ǁ
PLUS
▸ Rifampin 300 mg IV/PO q8h x ≥6 weeks
PLUS
▸ Gentamicin 3 mg/kg/day IV/IM q8—12h x 2 weeks^¶
^ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. ^¶ Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.

Staphylococcal PVE, Oxacillin Resistant, Pediatric
Preferred Regimen^†
▸ Vancomycin 40 mg/kg/day IV q8—12h x ≥6 weeks^ǁ
PLUS
▸ Rifampin 20 mg/kg/day IV/PO q8h x ≥6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 2 weeks^¶
^ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. ^¶ Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.

Enterococcus

▸ Click on the following categories to expand treatment regimens.

PCN/GM/VM Susceptible

▸ PCN/GM/VM Susceptible, Adult

▸ PCN/GM/VM Susceptible, Pediatric

PCN/VM Susceptible, GM Resistant

▸ PCN/VM Susceptible, GM Resistant, Adult

▸ PCN/VM Susceptible, GM Resistant, Pediatric

VM/AG Susceptible, PCN Resistant

▸ VM/AG Susceptible, PCN Resistant, Adult

▸ VM/AG Susceptible, PCN Resistant, Pediatric

PCN/VM/AG Resistant

▸ PCN/VM/AG Resistant, Adult

▸ PCN/VM/AG Resistant, Pediatric

Enterococcal Endocarditis, PCN/GM/VM Susceptible, Adult
Preferred Regimen^†
▸ Ampicillin 2 g IV q4h x 4—6 weeks OR ▸ Penicillin G 18—30 MU/day IV continuously or q4h x 4—6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks^¶
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q12h x 6 weeks^ǁ
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks^¶
^† Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended. ^¶ Gentamicin should be administered in close proximity to vancomycin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^ǁ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Enterococcal Endocarditis, PCN/GM/VM Susceptible, Pediatric
Preferred Regimen^†
▸ Ampicillin 300 mg/kg/day IV q4—6h x 4—6 weeks OR ▸ Penicillin G 0.3 MU/kg/day IV q4—6h x 4—6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks^¶
Alternative Regimen
▸ Vancomycin 40 mg/kg/day IV q8—12h x 6 weeks^ǁ
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks^¶
^† Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended. ^¶ Gentamicin should be administered in close proximity to vancomycin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^ǁ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Enterococcal Endocarditis, PCN/VM Susceptible, GM Resistant, Adult
Preferred Regimen^†
▸ Ampicillin 2 g IV q4h x 4—6 weeks OR ▸ Penicillin G 24 MU/day IV continuously or q4h x 4—6 weeks
PLUS
▸ Streptomycin 7.5 mg/kg IV/IM q12h x 4—6 weeks^¶
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q12h x 6 weeks^ǁ
PLUS
▸ Streptomycin 7.5 mg/kg IV/IM q12h x 6 weeks^¶
^† Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended. ^¶ Streptomycin dosage adjusted to achieve a 1-hour serum concentration of 20 to 35 μg/mL and a trough concentration of <10 μg/mL Patients with a creatinine clearance of <50 mL/min should be treated in consultation with an infectious diseases specialist. ^ǁ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Enterococcal Endocarditis, PCN/VM Susceptible, GM Resistant, Pediatric
Preferred Regimen^†
▸ Ampicillin 300 mg/kg/day IV q4—6h x 4—6 weeks OR ▸ Penicillin G 0.3 MU/kg/day IV q4—6h x 4—6 weeks
PLUS
▸ Streptomycin 40 mg/kg/day IV q8—12h x 6 weeks^¶
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q12h x 6 weeks^ǁ
PLUS
▸ Streptomycin 10—15 mg/kg IV/IM q12h x 6 weeks^¶
^† Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended. ^¶ Streptomycin dosage adjusted to achieve a 1-hour serum concentration of 20 to 35 μg/mL and a trough concentration of <10 μg/mL Patients with a creatinine clearance of <50 mL/min should be treated in consultation with an infectious diseases specialist. ^ǁ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Gram-Negative Bacteria

▸ Click on the following categories to expand treatment regimens.

Gram-Negative Bacteria

▸ Bartonella spp.

▸ Escherichia coli

▸ HACEK Microorganisms

▸ Klebsiella spp.

▸ Neisseria spp.

▸ Proteus mirabilis

▸ Pseudomonas aeruginosa

Suspected Bartonella Endocarditis, Culture Negative
Preferred Regimen^†
▸ Ceftriaxone 2 g IV/IM q24h x 6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 2 weeks^¶
WITH OR WITHOUT
▸ Doxycycline 100 mg IV/PO q12h x 6 weeks
Documented Bartonella Endocarditis, Culture Positive
Preferred Regimen
▸ Doxycycline 100 mg IV/PO q12h x 6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 2 weeks^¶
Alternative Regimen
▸ Doxycycline 100 mg IV/PO q12h x 6 weeks
PLUS
▸ Rifampin 300 mg PO/IV q12h x 6 weeks
^† Patients with Bartonella endocarditis should be treated in consultation with an infectious diseases specialist. ^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.

Escherichia coli Endocarditis
Preferred Regimen
▸ Ampicillin 2 g IV q4h x 4—6 weeks OR ▸ Penicillin G 20 MU/day IV continuously x 4—6 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 4—6 weeks
PLUS
▸ Gentamicin 1.7 mg/kg IV/IM q8h x 2 weeks^¶
^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.

HACEK Endocarditis, Adult^†
Preferred Regimen
▸ Ceftriaxone 2 g IV/IM q24h x 4 weeks^‡
Alternative Regimen
▸ Ampicillin-Sulbactam 1.5 g IV q6h x 4 weeks OR ▸ Ciprofloxacin 500 mg PO q12h (or 400 mg IV q12h) x 4 weeks^§
HACEK Endocarditis, Pediatric^†
Preferred Regimen
▸ Ceftriaxone 100 mg/kg IV/IM q24h x 4 weeks^‡
Alternative Regimen
▸ Ampicillin-Sulbactam 300 mg/kg/day IV q4—6h x 4 weeks OR ▸ Ciprofloxacin 10—15 mg/kg IV/PO q12h x 4 weeks^§
^† Prosthetic valve: patients with endocarditis involving prosthetic cardiac valve or other prosthetic cardiac material should be treated for 6 wk. ^‡ Cefotaxime or another third- or fourth-generation cephalosporin may be substituted. ^§ Fluoroquinolone therapy recommended only for patients unable to tolerate cephalosporin and ampicillin therapy; levofloxacin, gatifloxacin, or moxifloxacin may be substituted; fluoroquinolones generally not recommended for patients <18 y old.

Klebsiella Endocarditis
Preferred Regimen^†
▸ Ceftriaxone 2 g IV/IM q24h x 4 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 2 weeks^¶ OR ▸ Amikacin 15 mg/kg/day IV q8—12h x 2 weeks^§
Alternative Regimen
▸ Piperacillin/Tazobactam 3.375 g IV q6h x 4 weeks
^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^§ Peak concentrations (30 to 90 minutes after injection) above 35 μg/mL and trough concentrations (just prior to the next dose) above 10 μg/mL should be avoided. Dosage should be adjusted as indicated.

Neisseria Endocarditis
Preferred Regimen^†
▸ Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks OR ▸ Cefazolin 1—1.5 g IV q6h x 4 weeks OR ▸ Ceftriaxone 2 g IV q24h x 4 weeks
^† Infectious disease consultation should be obtained in cases in which Neisseria are resistant to penicillin.

Proteus mirabilis Endocarditis
Preferred Regimen
▸ Ampicillin 2 g IV q4h x 4—6 weeks OR ▸ Penicillin G 20 MU/day IV continuously x 4—6 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 4—6 weeks
PLUS
▸ Gentamicin 1.7 mg/kg IV/IM q8h x 2 weeks^¶
^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.

Pseudomonas aeruginosa Endocarditis
Preferred Regimen
▸ Ticarcillin 3 g IV q4h (or 4 g IV q6h) x ≥6 weeks OR ▸ Piperacillin/Tazobactam 3.375 gm IV q4h (or 4.5 g IV q6h) x ≥6 weeks OR ▸ Ceftazidime 2 g IV q8h x ≥6 weeks OR ▸ Cefepime 2 g IV q8h x ≥6 weeks
PLUS
▸ Tobramycin 8 mg/kg IV/IM q24h x ≥6 weeks^¶
^¶ Maintenance of peak and trough concentrations of 15—20 μg/mL and ≤2 μg/mL, respectively.

Culture-Negative Endocarditis Adapted from Circulation 2005;111(23):e394-434.^[2] and Circulation 2008;118(15):e523-661.^[3]

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis

▸ Culture-Negative NVE, Adult

▸ Culture-Negative NVE, Pediatric

Prosthetic Valve Endocarditis

▸ Culture-Negative PVE, Adult (Early, ≤1 year)

▸ Culture-Negative PVE, Pediatric (Early, ≤1 year)

▸ Culture-Negative PVE, Adult (Late, >1 year)

Culture-Negative Native Valve Endocarditis, Adult
Preferred Regimen
▸ Ampicillin-Sulbactam 3 g IV q6h x 4—6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks^¶
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q12h x 4—6 weeks^ǁ
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks^¶
PLUS
▸ Ciprofloxacin 500 mg PO q12h (or 400 mg IV q12h) x 4—6 weeks
^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Culture-Negative Native Valve Endocarditis, Pediatric
Preferred Regimen
▸ Ampicillin-Sulbactam 300 mg/kg/day IV q4—6h x 4—6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks^¶
Alternative Regimen
▸ Vancomycin 40 mg/kg/day IV q8—12h x 4—6 weeks^ǁ
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks^¶
PLUS
▸ Ciprofloxacin 10—15 mg/kg IV/PO q12h x 4—6 weeks
^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Culture-Negative Prosthetic Valve Endocarditis, Adult (Early, ≤1 year)
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q12h x 6 weeks^ǁ
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 2 weeks^¶
PLUS
▸ Cefepime 2 g IV q8h x 6 weeks
PLUS
▸ Rifampin 300 mg PO/IV q8h x 6 weeks
^ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. ^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.

Culture-Negative Prosthetic Valve Endocarditis, Pediatric (Early, ≤1 year)
Preferred Regimen
▸ Vancomycin 40 mg/kg/day IV q8—12h x 6 weeks^ǁ
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 2 weeks^¶
PLUS
▸ Cefepime 50 mg/kg IV q8h x 6 weeks
PLUS
▸ Rifampin 20 mg/kg/day PO/IV q8h x 6 weeks
^ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. ^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.

Culture-Negative Prosthetic Valve Endocarditis, Adult (Late, >1 year)
Preferred Regimen
▸ Ampicillin-Sulbactam 3 g IV q6h x 6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks^¶
PLUS
▸ Rifampin 300 mg PO/IV q8h x 6 weeks
Alternative Regimen
▸ Vancomycin 15 mg/kg IV q12h x 6 weeks^ǁ
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks^¶
PLUS
▸ Ciprofloxacin 500 mg PO q12h (or 400 mg IV q12h) x 6 weeks
PLUS
▸ Rifampin 300 mg PO/IV q8h x 6 weeks
^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Culture-Negative Prosthetic Valve Endocarditis, Pediatric (Late, >1 year)
Preferred Regimen
▸ Ampicillin-Sulbactam 300 mg/kg/day IV q4—6h x 6 weeks
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks^¶
PLUS
▸ Rifampin 20 mg/kg/day PO/IV q8h x 6 weeks
Alternative Regimen
▸ Vancomycin 40 mg/kg/day IV q8—12h x 6 weeks^ǁ
PLUS
▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks^¶
PLUS
▸ Ciprofloxacin 10—15 mg/kg IV/PO q12h x 6 weeks
PLUS
▸ Rifampin 20 mg/kg/day PO/IV q8h x 6 weeks
^¶ Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. ^ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

References

↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-2708-1.
↑ ^2.0 ^2.1 ^2.2 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)
↑ ^3.0 ^3.1 Bonow, RO.; Carabello, BA.; Chatterjee, K.; de Leon, AC.; Faxon, DP.; Freed, MD.; Gaasch, WH.; Lytle, BW.; Nishimura, RA. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134. 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.

[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] 2.0 ^2.1 ^2.2 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)

[Bonow-2008-3] 3.0 ^3.1 Bonow, RO.; Carabello, BA.; Chatterjee, K.; de Leon, AC.; Faxon, DP.; Freed, MD.; Gaasch, WH.; Lytle, BW.; Nishimura, RA. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134. Unknown parameter |month= ignored (help)

[4] 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.

[1]

[2]

[3]

[4]

@@ Line 30: / Line 30: @@
 ==Pathogen-Based Therapy <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''Circulation 2005;111(23):e394-434.''<ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref> and ''Circulation 2008;118(15):e523-661.''<ref name="Bonow-2008">{{Cite journal  | last1 = Bonow | first1 = RO. | last2 = Carabello | first2 = BA. | last3 = Chatterjee | first3 = K. | last4 = de Leon | first4 = AC. | last5 = Faxon | first5 = DP. | last6 = Freed | first6 = MD. | last7 = Gaasch | first7 = WH. | last8 = Lytle | first8 = BW. | last9 = Nishimura | first9 = RA. | title = 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal = J Am Coll Cardiol | volume = 52 | issue = 13 | pages = e1-142 | month = Sep | year = 2008 | doi = 10.1016/j.jacc.2008.05.007 | PMID = 18848134 }}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
-====Viridans Streptococci or ''Streptococcus bovis''====
+<h4>Endocarditis, treatment {{ID-returntotop-organ}}</h4>
-<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
+* 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>
+:* Culture-negative endocarditis
+::* '''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/24h 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
-{|
+::* '''Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)'''
-| valign=top |
+:::* 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/24h PO/IV q8h for 6 weeks
-<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
+:::* 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/24h PO/IV q8h
-<font color="#FFF">
-'''Native Valve Endocarditis'''
-</font>
-</div>
-<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Highly PCN Susceptible, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Highly PCN Susceptible, Pediatric'''
-</font>
-</div>
-<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Relatively PCN Resistant, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Relatively PCN Resistant, Pediatric'''
-</font>
-</div>
-<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Highly PCN Resistant'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #A1BCDD; text-align: center;">
-<font color="#FFF">
-'''Prosthetic Valve Endocarditis'''
-</font>
-</div>
-<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Susceptible, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table07" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Susceptible, Pediatric'''
-</font>
-</div>
-<div class="mw-customtoggle-table08" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Resistant, Adult'''
-</font>
-</div>
-<div class="mw-customtoggle-table09" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 320px; background: #4479BA;">
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''PCN Resistant, Pediatric'''
-</font>
-</div>
-| valign=top |
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC ≤0.12 μg/mL, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 12—18 MU/day IV continuously or q4—6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 4 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 1'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 12—18 MU/day IV continuously or q4—6h x 2 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 2 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 2'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function. <BR> <sup>‡</sup> Two-week regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of less than 20 ml per min, impaired 8th cranial nerve function, or ''Abiotrophia'', ''Granulicatella'', or ''Gemella'' infection. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC ≤0.12 μg/mL, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''<sup>†</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.2 MU/kg/day IV q4—6h x 4 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 4 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 1'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.2 MU/kg/day IV q4—6h x 2 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 2 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 2'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function. <BR> <sup>‡</sup> Two-week regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of less than 20 ml per min, impaired 8th cranial nerve function, or ''Abiotrophia'', ''Granulicatella'', or ''Gemella'' infection. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 24 MU/day IV continuously or q4—6h x 4 weeks'''''<sup>†</sup> <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 4 weeks'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Patients with endocarditis caused by Penicillin Resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis. <BR> <sup>‡</sup> Recommended for enterococcal endocarditis. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.3 MU/kg/day IV q4—6h x 4 weeks'''''<sup>†</sup> <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 4 weeks'''''<sup>‡</sup>
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg IV q8—12h x 4 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>†</sup> Patients with endocarditis caused by Penicillin Resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis. <BR> <sup>‡</sup> Recommended for enterococcal endocarditis. <BR> <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' NVE, Penicillin MIC >0.5 μg/ml}}
-|-
-| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=left | ▸ Endocarditis caused by highly penicillin resistant (MIC >0.5 μg/ml) strains of viridans streptococci, ''Abiotrophia defectiva'', ''Granulicatella'' species, and ''Gemella'' species should be treated with a regimen that is recommended for enterococcal endocarditis.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' PVE, Penicillin MIC ≤0.12 μg/ml, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 24 MU/day IV continuously or q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin therapy should not be administered to patients with creatinine clearance of <30 mL/min <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table07" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' PVE, Penicillin MIC ≤0.12 μg/ml, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.3 MU/kg/day IV q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | WITH OR WITHOUT
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table08" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' PVE, Penicillin MIC >0.12 μg/ml, Adult}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 24 MU/day IV continuously or q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV/IM q24h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table09" style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viridans Streptococci or ''S. bovis'' PVE, Penicillin MIC >0.12 μg/ml, Pediatric}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium|Penicillin G]] 0.3 MU/kg/day IV q4—6h x 6 weeks''''' <BR> OR <BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM q24h x 6 weeks'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 6 weeks'''''<sup>¶</sup>
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 40 mg/kg/day IV q8—12h x 6 weeks'''''<sup>ǁ</sup>
-|-
-| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" align=left | <sup>¶</sup> Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy. <BR> <sup>ǁ</sup> Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
-|}
-|}
-|}
+::* '''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/24h 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
+::* '''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/24h 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/24h PO or 800 mg/24h IV q12h for 4–6 weeks {{and}} [[Rifampin]] 900 mg/24h 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/24h PO/IV q8h
+:* Pathogen-directed antimicrobial therapy
+::* Bartonella
+:::* '''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
+:::* '''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
+::* Enterococcus
+:::* '''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 4–6weeks
+::::* 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
+:::* '''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
+:::* '''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
+:::* '''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
+::* HACEK organisms
+:::* '''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
+::* Staphylococcus
+:::* '''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
+:::* '''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
+:::* '''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
+:::* '''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
+::* Viridans group streptococci and Streptococcus bovis
+:::* '''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
+:::* '''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
+:::* '''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
+:::* '''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
 ====''Streptococcus pneumoniae'', ''Streptococcus pyogenes'', and Groups B, C, and G Streptococci====

Endocarditis medical therapy: Difference between revisions

Revision as of 16:05, 12 August 2015

Overview

Timing of Initiation of Antibiotics

Duration of Antibiotic Therapy

Empirical Antibiotic Therapy

Pathogen-Based Therapy Adapted from Circulation 2005;111(23):e394-434.[2] and Circulation 2008;118(15):e523-661.[3]

Endocarditis, treatment ⇧ Return to Top ⇧

Streptococcus pneumoniae, Streptococcus pyogenes, and Groups B, C, and G Streptococci

Staphylococcus

Enterococcus

Gram-Negative Bacteria

Culture-Negative Endocarditis Adapted from Circulation 2005;111(23):e394-434.[2] and Circulation 2008;118(15):e523-661.[3]

References

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Pathogen-Based Therapy Adapted from Circulation 2005;111(23):e394-434.^[2] and Circulation 2008;118(15):e523-661.^[3]

Culture-Negative Endocarditis Adapted from Circulation 2005;111(23):e394-434.^[2] and Circulation 2008;118(15):e523-661.^[3]