Sandbox endocarditis2

Medical Therapy

Relatively Penicillin-Resistant Streptococci, MIC 0.2–0.5 µg/ml
Preferred Regimen
▸ Adult:Aqueous crystalline penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks ▸ Pediatrics:Aqueous crystalline penicillin G sodium 300 000 U/24 h IV in 4–6 equally divided doses X 4 Wks OR ▸Adult:Ceftriaxone 2 g/24 h IV/IM in 1 dose ▸Pediatrics:Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose
AND
▸ Adult:Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks ▸ Pediatrics: 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, consider Enterococcal regimen
Preferred Regimen
▸ Adult:Aqueous crystalline penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks
AND
▸ Adult:Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks
Unable to tolerate Aqueous crystalline penicillin G sodium or Ceftriaxone
Preferred Regimen
▸ Adult: 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
▸ Pediatrics: Vancomycin 40 mg/kg 24 h in 2 or 3 equally divided doses X 4 Wks

Newborn, 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
Newborn, 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
Infant and Children^†
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q6h to achieve serum trough concentrations of 15–20 μg/mL
AND
▸ Cefotaxime 225—300 mg/kg/day IV q6–8h OR ▸Ceftriaxone 80—100 mg/kg/day IV q12–24h

Adult, Age <50 Years^†
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h to achieve serum trough concentrations of 15–20 μg/mL
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸Ceftriaxone 2 g IV q12h
Adult, Age >50 Years
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h
AND
▸ Ampicillin 2 g IV q4h
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸Ceftriaxone 2 g IV q12h
Immunocompromised
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h
AND
▸ Ampicillin 2 g IV q4h
AND
▸ Cefepime 2 g IV q8h OR ▸ Meropenem2 g IV q8h
Recurrent
Preferred Regimen
▸ Vancomycin 30—60 mg/kg/day IV q8–12h
AND
▸ Cefotaxime 8–12 g/day IV q4–6h OR ▸Ceftriaxone 2 g IV q12h

^†Add Ampicillin 2 g IV q4h (50 mg/kg IV q6h for children) if meningitis caused by Listeria monocytogenesis also suspected.

Adapted from Advances in treatment of bacterial meningitis. Lancet. 2012;380(9854):1693-702.^[1]

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—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

↑ van de Beek, D.; Brouwer, MC.; Thwaites, GE.; Tunkel, AR. (2012). "Advances in treatment of bacterial meningitis". Lancet. 380 (9854): 1693–702. doi:10.1016/S0140-6736(12)61186-6. PMID 23141618. Unknown parameter |month= ignored (help)