Streptococci
▸ Click on the following categories to expand treatment regimens.
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
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| Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis
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| Preferred Regimen ( 4 wks )
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| Adult dose
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▸ 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
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| Pediatric dose ₳
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▸ 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
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| Alternative Regimen ( 2 wks )
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| Adult dose
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▸ 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
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| PLUS
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| ▸ Gentamicin sulfate ฿ 3 mg/Kg per 24h 1 dose x 2 Wks
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| Pediatric dose
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▸ 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
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| PLUS
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| ▸ Gentamicin sulfate 3 mg/Kg per 24h 1 dose or 3 equally divided doses x 2 Wks
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| Alternative Regimen
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| Adult dose
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▸ 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
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| Pediatric dose
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| ▸Vancomycin hydrochloride 40 mg/kg per 24 h IV in 2–3 equally divided doses
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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.
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| 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))
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| Preferred Regimen
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| Adult dose
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▸ 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
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| PLUS
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| ▸ Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks
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| Pediatric dose
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▸ 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
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| PLUS
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| ▸ Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose or equally divided doses
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| Alternative Regimen
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| Adult dose
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| ▸ Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 4 wks
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| Pediatric dose
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| ▸ Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
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| Penicillin-susceptible strain (MIC ≤ 0.12 g/mL)
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| Preferred Regimen
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| Adult dose
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▸ 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
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| WITH OR WITHOUT
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| ▸ Gentamicin sulfate ‡ 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks
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| Pediatric dose
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▸ 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
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| WITH OR WITHOUT
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| ▸Gentamicin 3 mg/kg per 24 h IV/IM, in 1 dose or 3 equally divided doses
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| Alternative Regimen
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| Adult dose
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| ▸ Vancomycin
hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
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| Pediatric dose
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| ▸ 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
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*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.
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| Penicillin relatively or fully resistant strain (MIC >0.12 >μg/mL))
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| Preferred Regimen
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| Adult dose
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▸ 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
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| PLUS
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| ▸ Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 6 wks
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| Pediatric dose
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| ▸ Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
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| Alternative Regimen
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| Adult dose
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| ▸ Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
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| Pediatric dose
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| ▸ Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
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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
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| Preferred Regimen
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| Adult dose
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▸ 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
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| AND
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| ▸ Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks
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| Pediatric dose
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▸ 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
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| AND
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| ▸ Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose or 3 equally divided doses X 2 Wks
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Relatively Penicillin-Resistant Streptococci, (MIC > 0.5 µg/ml)
Relatively Penicillin-Resistant Streptococci,
MIC > 0.5 µg/ml, consider Enterococcal regimen
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| Preferred Regimen
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| Adult dose
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| ▸ Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks
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| PLUS
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| ▸ Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks
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| Pediatric dose
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| ▸ Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks
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| PLUS
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| ▸ Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks
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Unable to tolerate Penicillin or Ceftriaxone
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