Sandbox endocarditis2

Meningitis Main Page
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Medical Therapy

Pharmacotherapy

Empiric Treatment

• Do not wait for the results of the CT scan and the lumbar puncture; empiric treatment should be started as soon as possible.
• Blood cultures should be drawn before starting the antibiotic therapy, and then the antibiotic treatment should be changed once the blood culture results are out.

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

Age <1 Week Preferred Regimen ▸ Ampicillin 50 mg/kg IV q8h AND ▸ Cefotaxime 100—150 mg/kg/day IV q8—12h Alternative Regimen ▸ Ampicillin 50 mg/kg IV q8h AND ▸ Gentamicin 2.5 mg/kg IV q12h Age <1 Week Preferred Regimen ▸ Ampicillin 50 mg/kg IV q8h AND ▸ Cefotaxime 100—150 mg/kg/day IV q8—12h Alternative Regimen ▸ Ampicillin 50 mg/kg IV q8h AND ▸ Gentamicin 2.5 mg/kg IV q12h

Age 1—4 Weeks Preferred Regimen ▸ Ampicillin 200 mg/kg/day IV q6—8h AND ▸ Cefotaxime 150—200 mg/kg/day IV q6—8h Alternative Regimen ▸ Ampicillin 200 mg/kg/day IV q6—8h AND ▸ Gentamicin 2.5 mg/kg IV q8h OR ▸Tobramycin 2.5 mg/kg IV q8h OR ▸ Amikacin 10 mg/kg IV q8h

Age 1—23 Months Preferred Regimen ▸ Ampicillin 200 mg/kg/day IV q6—8h AND ▸ Cefotaxime 150—200 mg/kg/day IV q6—8h Alternative Regimen ▸ Ampicillin 200 mg/kg/day IV q6—8h AND ▸ Gentamicin 2.5 mg/kg IV q8h OR ▸Tobramycin 2.5 mg/kg IV q8h OR ▸ Amikacin 10 mg/kg IV q8h

Age 1—4 Weeks Preferred Regimen ▸ Ampicillin 200 mg/kg/day IV q6—8h AND ▸ Cefotaxime 150—200 mg/kg/day IV q6—8h Alternative Regimen ▸ Ampicillin 200 mg/kg/day IV q6—8h AND ▸ Gentamicin 2.5 mg/kg IV q8h OR ▸Tobramycin 2.5 mg/kg IV q8h OR ▸ Amikacin 10 mg/kg IV q8h Empirical Antibiotic Therapy Although antibiotic therapy for subacute disease can be delayed till the result of blood culture, the rapid progression of acute cases necessitate the start of empirical treatment antibiotic therapy once the blood cultures have been collected. Empirical therapy is needed for all likely pathogens, certain antibiotic agents, including aminoglycosides, is preferably avoided for its toxic effects. Clinical course of infection beside the epidemiological features should be considered upon selecting empirical treatment regimen. Regimen Dosage and Route Duration(weeks) Native valve Ampicillin sulbactam 12 g per 24 h IV in 4 equally divided doses 4–6 weeks plus Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 4–6 weeks or Vancomycin 30 mg per kg per 24 h IV in 2 equally divided doses 4–6 weeks plus Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 4–6 weeks plus Ciprofloxacin 1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses 4–6 weeks →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, , mostly Oxacillin resistent) Vancomycin 30 mg per kg per 24 h IV in 2 equally divided doses 6 weeks plus Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 2 weeks plus Cefepime 6 g per 24 h IV in 3 equally divided doses 6 weeks plus Rifampin 900 mg per 24 h PO/IV in 3 equally divided doses 6 weeks →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, mostly Oxacillin sensitive) 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 weeks plus Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 2 weeks with/without Doxycycline 200 mg per kg per 24 h IV/PO in 2 equally divided doses 6 weeks Documented Bartonella, culture positive Doxycycline 200 mg per 24 h IV or PO in 2 equally divided doses 6 weeks plus Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 2 weeks →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 Epidemiological features Common Microorganism(s) Injection drug use S aureus, including community-acquired oxacillin-resistant strains Coagulase-negative staphylococci β-Hemolytic streptococci Fungi Aerobic Gram-negative bacilli, including Pseudomonas aeruginosa Treatment Based Upon Infectious Agent 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