▸ 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, Adult
▸ PCN/VM/AG Resistant, Pediatric
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Enterococcal Endocarditis, PCN/GM/VM Susceptible, Adult
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Preferred Regimen†
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▸ Ampicillin 2 g IV q4h x 4—6 weeks OR ▸ Penicillin G 18—30 MU/day IV continuously or q4h x 4—6 weeks
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks¶
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Alternative Regimen
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▸ Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks¶
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† 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.
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Enterococcal Endocarditis, PCN/GM/VM Susceptible, Pediatric
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Preferred Regimen†
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▸ 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
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks¶
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Alternative Regimen
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▸ Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks¶
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† 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.
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Enterococcal Endocarditis, PCN/VM Susceptible, GM Resistant, Adult
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Preferred Regimen†
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▸ Ampicillin 2 g IV q4h x 4—6 weeks OR ▸ Penicillin G 24 MU/day IV continuously or q4h x 4—6 weeks
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PLUS
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▸ Streptomycin 7.5 mg/kg IV/IM q12h x 4—6 weeks¶
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Alternative Regimen
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▸ Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
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PLUS
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▸ Streptomycin 7.5 mg/kg IV/IM q12h x 6 weeks¶
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† 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.
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Enterococcal Endocarditis, PCN/VM Susceptible, GM Resistant, Pediatric
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Preferred Regimen†
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▸ 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
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PLUS
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▸ Streptomycin 40 mg/kg/day IV q8—12h x 6 weeks¶
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Alternative Regimen
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▸ Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
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PLUS
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▸ Streptomycin 10—15 mg/kg IV/IM q12h x 6 weeks¶
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† 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.
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Enterococcal Endocarditis, VM/AG Susceptible, PCN Resistant, Adult
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Preferred Regimen β-Lactamase–Producing Strain†
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▸ Ampicillin/Sulbactam 3 g IV q6h x 6 weeks
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks¶
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Alternative Regimen β-Lactamase–Producing Strain
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▸ Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks¶
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Preferred Regimen Intrinsic Penicillin Resistance‡
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▸ Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks¶
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† Unlikely that the strain will be susceptible to gentamicin; if strain is gentamicin resistant, then >6 wk of ampicillin-sulbactam therapy will be needed. ¶ 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 ampicillin-sulbactam. 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. ‡ Consultation with a specialist in infectious diseases recommended.
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Enterococcal Endocarditis, VM/AG Susceptible, PCN Resistant, Pediatric
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Preferred Regimen β-Lactamase–Producing Strain†
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▸ Ampicillin/Sulbactam 75 mg/kg IV q6h x 6 weeks
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks¶
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Alternative Regimen β-Lactamase–Producing Strain
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▸ Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks¶
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Preferred Regimen Intrinsic Penicillin Resistance‡
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▸ Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
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PLUS
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▸ Gentamicin 1 mg/kg IV/IM q8h x 6 weeks¶
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† Unlikely that the strain will be susceptible to gentamicin; if strain is gentamicin resistant, then >6 wk of ampicillin-sulbactam therapy will be needed. ¶ 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 ampicillin-sulbactam. 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. ‡ Consultation with a specialist in infectious diseases recommended.
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Enterococcal Endocarditis, PCN/VM/AG Resistant, Adult
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Preferred Regimen Enterococcus faecium†
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▸ Linezolid 600 mg IV/PO q12h x ≥8 weeks OR ▸ Quinupristin-Dalfopristin 7.5 mg/kg IV q8h x ≥8 weeks
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Preferred Regimen Enterococcus faecalis
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▸ Imipenem/Cilastatin 500 mg IV q6h x ≥8 weeks
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PLUS
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▸ Ampicillin 2 g IV q4h x ≥8 weeks
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Alternative Regimen Enterococcus faecalis
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▸ Ceftriaxone 2 g IV/IM q12h x ≥8 weeks
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PLUS
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▸ Ampicillin 2 g IV q4h x ≥8 weeks
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† Patients with endocarditis caused by these strains should be treated in consultation with an infectious diseases specialist; cardiac valve replacement may be necessary for bacteriologic cure; cure with antimicrobial therapy alone may be <50%; severe, usually reversible thrombocytopenia may occur with use of linezolid, especially after 2 wk of therapy; quinupristin-dalfopristin only effective against E faecium and can cause severe myalgias, which may require discontinuation of therapy; only small no. of patients have reportedly been treated with imipenem/cilastatin-ampicillin or ceftriaxone + ampicillin.
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Enterococcal Endocarditis, PCN/VM/AG Resistant, Pediatric
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Preferred Regimen Enterococcus faecium†
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▸ Linezolid 10 mg/kg IV/PO q8h x ≥8 weeks OR ▸ Quinupristin-Dalfopristin 7.5 mg/kg IV q8h x ≥8 weeks
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Preferred Regimen Enterococcus faecalis
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▸ Imipenem/Cilastatin 15—25 mg/kg IV q6h x ≥8 weeks
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PLUS
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▸ Ampicillin 300 mg/kg/day IV q4—6h x ≥8 weeks
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Alternative Regimen Enterococcus faecalis
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▸ Ceftriaxone 50 mg/kg IV/IM q12h x ≥8 weeks
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PLUS
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▸ Ampicillin 2 g IV q4h x ≥8 weeks
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† Patients with endocarditis caused by these strains should be treated in consultation with an infectious diseases specialist; cardiac valve replacement may be necessary for bacteriologic cure; cure with antimicrobial therapy alone may be <50%; severe, usually reversible thrombocytopenia may occur with use of linezolid, especially after 2 wk of therapy; quinupristin-dalfopristin only effective against E faecium and can cause severe myalgias, which may require discontinuation of therapy; only small no. of patients have reportedly been treated with imipenem/cilastatin-ampicillin or ceftriaxone + ampicillin.
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