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Pathogen-Based Therapy Adapted from Circulation 2008;118(15):e523-661.

Viridans Streptococci or Streptococcus bovis

• Patients with endocarditis caused by highly penicillin resistant (MIC >0.5 μg/ml) strains of Abiotrophia defectiva, Granulicatella species, Gemella species, and viridans streptococci should be treated with a regimen that is recommended for enterococcal endocarditis.

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis   ▸  Highly PCN Susceptible, Adult   ▸  Highly PCN Susceptible, Pediatric   ▸  Relatively PCN Resistant, Adult   ▸  Relatively PCN Resistant, Pediatric Prosthetic Valve Endocarditis   ▸  Highly PCN Susceptible, Adult   ▸  Highly PCN Susceptible, Pediatric   ▸  Relatively PCN Resistant, Adult   ▸  Relatively PCN Resistant, Pediatric

Viridans Streptococci or S. bovis NVE, Penicillin MIC ≤0.12 μg/mL, Adult Preferred Regimen† ▸ Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 4 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 4 weeks Alternative Regimen 1‡ ▸ Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 2 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 2 weeks PLUS ▸ Gentamicin 3 mg/kg IV q24h x 2 weeks¶ Alternative Regimen 2 ▸ Vancomycin 15 mg/kg IV q12h x 4 weeksǁ † Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function. ‡ 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. ¶ 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 dosages should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. Viridans Streptococci or S. bovis NVE, Penicillin MIC ≤0.12 μg/mL, Pediatric Preferred Regimen† ▸ Penicillin G sodium 0.2 MU/kg/day IV q4—6h x 4 weeks OR ▸ Ceftriaxone 100 mg/kg IV/IM q24h x 4 weeks Alternative Regimen 1‡ ▸ Penicillin G sodium 0.2 MU/kg/day IV q4—6h x 2 weeks OR ▸ Ceftriaxone 100 mg/kg IV/IM q24h x 2 weeks PLUS ▸ Gentamicin 3 mg/kg IV q24h (or 1 mg/kg IV q8h) x 2 weeks¶ Alternative Regimen 2 ▸ Vancomycin 40 mg/kg/day IV q8—12h x 4 weeksǁ † Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function. ‡ 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. ¶ 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 dosages should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. Viridans Streptococci or S. bovis NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Adult Preferred Regimen ▸ Penicillin G sodium 24 MU/day IV continuously/q4—6h x 4 weeks† OR ▸ Ceftriaxone 2 g IV/IM q24h x 4 weeks‡ PLUS ▸ Gentamicin 3 mg/kg IV q24h x 2 weeks Alternative Regimen ▸ Vancomycin 40 mg/kg/day IV q8—12h x 4 weeksǁ † Patients with endocarditis caused by Penicillin Resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis. ‡ Recommended for enterococcal endocarditis. 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 dosages should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. Viridans Streptococci or S. bovis NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Pediatric Preferred Regimen ▸ Penicillin G sodium 0.3 MU/kg/day IV q4—6h x 4 weeks† OR ▸ Ceftriaxone 100 mg/kg IV/IM q24h x 4 weeks‡ PLUS ▸ Gentamicin 3 mg/kg IV q24h (or 1 mg/kg IV q8h) x 2 weeks Alternative Regimen ▸ Vancomycin 15 mg/kg IV q12h x 4 weeksǁ † Patients with endocarditis caused by Penicillin Resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis. ‡ Recommended for enterococcal endocarditis. 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 dosages should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. Viridans Streptococci or S. bovis NVE, Penicillin MIC ≤0.12 μg/ml, Adult Preferred Regimen ▸ Penicillin G sodium 24 MU/day IV continuously/q4—6h x 4 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 4 weeks PLUS ▸ Gentamicin 3 mg/kg IV q24h (or 1 mg/kg IV q8h) x 2 weeks Alternative Regimen ▸ Vancomycin 15 mg/kg IV q12h x 4 weeks ǁ Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low; 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; vancomycin dosages should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome. Viridans Streptococci or S. bovis NVE, Penicillin MIC ≤0.12 μg/ml, Pediatric Preferred Regimen ▸ Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 4 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 4 weeks Alternative Regimen 1 ▸ Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 2 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 2 weeks PLUS ▸ Gentamicin 3 mg/kg IV q24h x 2 weeks Alternative Regimen 2 ▸ Vancomycin 15 mg/kg IV q12h x 4 weeks Viridans Streptococci or S. bovis NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Adult Preferred Regimen ▸ Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 4 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 4 weeks Alternative Regimen 1 ▸ Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 2 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 2 weeks PLUS ▸ Gentamicin 3 mg/kg IV q24h x 2 weeks Alternative Regimen 2 ▸ Vancomycin 15 mg/kg IV q12h x 4 weeks Viridans Streptococci or S. bovis NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Pediatric Preferred Regimen ▸ Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 4 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 4 weeks Alternative Regimen 1 ▸ Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 2 weeks OR ▸ Ceftriaxone 2 g IV/IM q24h x 2 weeks PLUS ▸ Gentamicin 3 mg/kg IV q24h x 2 weeks Alternative Regimen 2 ▸ Vancomycin 15 mg/kg IV q12h x 4 weeks