Sandbox endocarditis

Streptococci

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Native Valve Endocarditis Caused by Viridans Group Streptococci and Streptococcus bovis   ▸  Viridans Group Streptococci and Streptococcus bovis Highly Penicillin-Susceptible   ▸  Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin Resistant (MIC >0.12 μg/mL- ≤ 0.5 μg/mL) Prosthetic Valves Endocarditis Caused by Viridans Group Streptococci and Streptococcus Bovis   ▸  Viridans Group Streptococci and Streptococcus bovis Penicillin-susceptible strain (MIC ≤ 0.12 μg/mL)   ▸  Viridans Group Streptococci and Streptococcus bovis Penicillin relatively or fully resistant strain (MIC >0.12 μg/mL)   ▸  Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin-Resistant Streptococci, MIC 0.2–0.5 µg/ml   ▸  Relatively Penicillin-Resistant Streptococci, (MIC > 0.5 µg/ml)   ▸  Unable to tolerate Penicillin or Ceftriaxone Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis Preferred Regimen ( 4 wks ) Adult dose ▸ Penicillin G sodium † 12–18 million U/24 h IV either continuously or in 4-6 equally divided doses x 4 Wks OR ▸ Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 4 Wks Pediatric dose ₳ ▸ Penicillin G sodium 200 000 U/kg q24h IV either continuously or in 4-6 equally divided doses x 4 Wks OR ▸Ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose x 4 Wks Alternative Regimen ( 2 wks ) Adult dose ▸ Penicillin G sodium‡ 12–18 million U/24 h IV either continuously or in 6 equally divided doses x 2 Wks OR ▸ Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 2 Wks PLUS ▸ Gentamicin sulfate ฿ 3 mg/Kg per 24h 1 dose x 2 Wks\ Pediatric dose ▸ Penicillin G sodium 200 000 U/kg q24h IV in 4-6 equally divided doses x 2 Wks OR ▸Ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose x 2 Wks PLUS ▸ Gentamicin sulfate 3 mg/Kg per 24h 1 dose or 3 equally divided doses x 2 Wks Alternative Regimen Adult dose ▸ Vancomycin hydrochloride ¶ 15 mg/kg q12h IV x 4 Wks Doses should not to exceed 2 g/24 h unless concentrations in serum are inappropriately low Pediatric dose ▸Vancomycin hydrochloride 40 mg/kg per 24 h IV in 2–3 equally divided doses Minimum inhibitory concentration ≤ 0.12 μg/mL. † Preferred in most patients >65 y or patients with impairment of 8th cranial nerve function or renal function. ₳ Pediatric dose should not exceed that of a normal adult. ‡ 2-wk regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of <20 mL/min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella spp infection; gentamicin dosage should be adjusted to achieve peak serum concentration of 3-4 μg/mL and trough serum concentration of >1 μg/mL when 3 divided doses are used; nomogram used for single daily dosing. ¶ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ceftriaxone; vancomycin dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/mL and a trough concentration range of 10–15 μg/mL ฿ Other potentially nephrotoxic drugs (eg, nonsteroidal antiinflammatory drugs) should be used with caution in patients receiving gentamicin therapy. Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.

Native Valve Endocarditis Caused by Viridans Group Streptococci and Streptococcus bovis

Viridans Group Streptococci and Streptococcus bovis Highly Penicillin-Susceptible

Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin Resistant (MIC >0.12 μg/mL- ≤ 0.5 μg/mL)

Native Valve Endocarditis Caused by Strains of Viridans Group Streptococci and Streptococcus bovis Relatively Resistant to Penicillin (MIC >0.12 μg/mL- ≤ 0.5 μg/mL)) Preferred Regimen Adult dose ▸ Penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 wks OR ▸ Ceftriaxone 2 g/24 h IV/IM in 1 dose x 4 wks PLUS ▸ Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks Pediatric dose ▸ Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses OR ▸ Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose PLUS ▸ Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose or equally divided doses Alternative Regimen Adult dose ▸ Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 4 wks Pediatric dose ▸ Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses

Prosthetic Valves Endocarditis Caused by Viridans Group Streptococci and Streptococcus Bovis

Viridans Group Streptococci and Streptococcus bovis Penicillin-susceptible strain (MIC ≤ 0.12 μg/mL)

Penicillin-susceptible strain (MIC ≤ 0.12 g/mL) Preferred Regimen Adult dose ▸ Penicillin G sodium † 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks OR ▸ Ceftriaxone 2 g/24 h IV/IM in 1 dose x 6 wks WITH OR WITHOUT ▸ Gentamicin sulfate ‡ 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks Pediatric dose ▸ Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses OR ▸ Ceftriaxone 100 mg/kg IV/IM once daily WITH OR WITHOUT ▸Gentamicin 3 mg/kg per 24 h IV/IM, in 1 dose or 3 equally divided doses Alternative Regimen Adult dose ▸ Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks Pediatric dose ▸ 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses

• Dosages recommended are for patients with normal renal function.

† Penicillin or ceftriaxone together with gentamicin has not demonstrated superior cure rates compared with monotherapy with penicillin or ceftriaxone for patients with highly susceptible strain; gentamicin therapy should not be administered to patients with creatinine clearance of <30 mL/min.

‡ Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.

Viridans Group Streptococci and Streptococcus bovis Penicillin relatively or fully resistant strain (MIC >0.12 μg/mL)

Penicillin relatively or fully resistant strain (MIC >0.12 >μg/mL)) Preferred Regimen Adult dose ▸ Penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks OR ▸ Ceftriaxone 2 g/24 h IV/IM in 1 dose x 6 wks PLUS ▸ Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 6 wks Pediatric dose ▸ Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses Alternative Regimen Adult dose ▸ Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks Pediatric dose ▸ Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses

Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin-Resistant Streptococci, MIC 0.2–0.5 µg/ml

Relatively Penicillin-Resistant Streptococci, MIC 0.2–0.5 µg/ml Preferred Regimen Adult dose ▸ Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks OR ▸Ceftriaxone 2 g/24 h IV/IM in 1 dose AND ▸ Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks Pediatric dose ▸ Penicillin G potassium 300 000 U/24 h IV in 4–6 equally divided doses X 4 Wks OR ▸ Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose AND ▸ Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose or 3 equally divided doses X 2 Wks

Relatively Penicillin-Resistant Streptococci, (MIC > 0.5 µg/ml)

Relatively Penicillin-Resistant Streptococci, MIC > 0.5 µg/ml, consider Enterococcal regimen Preferred Regimen Adult dose ▸ Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks PLUS ▸ Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks Pediatric dose ▸ Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks PLUS ▸ Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks

Unable to tolerate Penicillin or Ceftriaxone

Unable to tolerate Aqueous crystalline penicillin G sodium or Ceftriaxone Preferred Regimen Adult dose ▸ Vancomycin 30 mg/kg per 24 h IV in 2 equally divided doses not to exceed 2 g/24 h, unless serum concentrations are inappropriately low Pediatric dose ▸ Vancomycin 40 mg/kg 24 h in 2 or 3 equally divided doses X 4 Wks