Sandbox g09

• Bacterial pericarditis

• Empiric antimicrobial therapy

• Purulent pericarditis

• Preferred regimen: Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 28 days AND Ciprofloxacin 400 mg IV q12h for 28 days
• Alternative regimen (1): Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 28 days AND Cefepime 2 g IV q12h for 28 days
• Alternative regimen (2): Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 14–42 days AND Ceftriaxone 2 g IV q24h for 14–42 days

Note: Pericardiocentesis must be promptly performed. Pericardial drainage combined with effective systemic antibiotic therapy is mandatory (antistaphylococcal agent plus aminoglycoside, followed by tailored antibiotic therapy according to cultures). Frequent irrigation of the pericardial cavity with urokinase or streptokinase may be considered. Open surgical drainage through subxiphoid pericardiotomy is preferable. Pericardiectomy may be required in patients with dense adhesions, loculated and thick purulent effusion, recurrence of tamponade, persistent infection, and progression to constriction.

• Specific considerations

• Purulent pericarditis with contiguous pneumonia

• Preferred regimen: Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL AND (Ceftriaxone 1–2 g IV q12h OR Cefotaxime 2 g IV q6–8h) AND (Ciprofloxacin 400 mg IV q12h OR Levofloxacin 500–750 mg IV q24h)

• Purulent pericarditis with contiguous head and neck infection

• Preferred regimen: Imipenem 500 mg IV q6–8h OR Ampicillin-Sulbactam 3 g IV q6h

• Purulent pericarditis secondary to infective endocarditis

• Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h targeting trough levels of 15–20 μg/mL AND Gentamicin 3 mg/kg/day IV q8–12h

• Purulent pericarditis after cardiac surgery, pediatric

• Preferred regimen: Vancomycin 15 mg/kg IV q6h targeting trough levels of 15–20 μg/mL AND (Ceftriaxone 100 mg/kg/day IV q12–24h OR Cefotaxime 200–300 mg/kg/day IV q6–8h) AND Gentamicin 6–7.5 mg/kg/day IV q8h

• Purulent pericarditis in association with genitourinary infection, pediatric

• Preferred regimen: Vancomycin 15 mg/kg IV q6h targeting trough levels of 15–20 μg/mL AND (Ceftriaxone 100 mg/kg/day IV q12–24h OR Cefotaxime 200–300 mg/kg/day IV q6–8h) AND Gentamicin 6–7.5 mg/kg/day IV q8h

• Purulent pericarditis in immunocompromised host, pediatric

• Preferred regimen: Vancomycin 15 mg/kg IV q6h targeting trough levels of 15–20 μg/mL AND (Ceftriaxone 100 mg/kg/day IV q12–24h OR Cefotaxime 200–300 mg/kg/day IV q6–8h) AND Gentamicin 6–7.5 mg/kg/day IV q8h

• Culture-directed antimicrobial therapy

• Bacterial pericarditis caused by penicillin-susceptible Streptococcus pneumoniae

• Preferred regimen: Penicillin G 5–24 MU/day IM/IV q4–6h for 14–42 days OR Cefotaxime 2 g IV q6–8h for 14–42 days OR Ciprofloxacin 400 mg IV q12h for 14–42 days OR Levofloxacin 500–750 mg IV q24h for 14–42 days

• Bacterial pericarditis caused by penicillin-resistant Streptococcus pneumoniae

• Preferred regimen: Ciprofloxacin 400 mg IV q12h for 14–42 days OR Levofloxacin 500–750 mg IV q24h for 14–42 days OR Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 14–42 days

• Bacterial pericarditis caused by MSSA

• Preferred regimen: Nafcillin 1–2 g IV q4h for 14–42 days OR Oxacillin 1–2 g IV q4h for 14–42 days OR Cefazolin 1–2 g IV q48h for 14–42 days OR Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 14–42 days OR Clindamycin 600–900 mg IV q8h for 14–42 days

• Bacterial pericarditis caused by MRSA

• Preferred regimen: Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 14–42 days OR Linezolid 600 mg IV q12h for 14–42 days

• Bacterial pericarditis caused by Neisseria meningitidis

• Preferred regimen: Penicillin G 5–24 MU/day IM/IV q4–6h for 14–42 days OR Cefotaxime 2 g IV q6–8h for 14–42 days OR Ceftriaxone 2 g IV q24h for 14–42 days

• Bacterial pericarditis caused by Gram-negative bacilli

• Preferred regimen: Ciprofloxacin 400 mg IV q12h for 14–42 days OR Levofloxacin 500–750 mg IV q24h for 14–42 days OR Cefepime 2 g IV q12h for 14–42 days

• Bacterial pericarditis caused by anaerobes

• Preferred regimen: Clindamycin 600–900 mg IV q8h for 14–42 days OR Metronidazole 7.5 mg/kg IV q6h for 14–42 days OR Ampicillin-Sulbactam 3 g IV q6h for 14–42 days

• Bacterial pericarditis caused by Mycoplasma pneumoniae

• Preferred regimen: Doxycycline 100 mg IV q12h for 14–42 days OR Azithromycin 500 mg IV q24h for 14–42 days

• Bacterial pericarditis caused by Legionella pneumophila

• Preferred regimen: Ciprofloxacin 400 mg IV q12h for 14–42 days OR Levofloxacin 500–750 mg IV q24h for 14–42 days OR Azithromycin 500 mg IV q24h for 14–42 days

• Viral pericarditis

• CMV pericarditis

• Preferred regimen: immunoglobulin 1 time per day 4 ml/kg on day 0, 4, and 8; 2 ml/kg on day 12 and 16.

Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.

• Coxsackie B pericarditis

• Preferred regimen: Interferon alpha or beta 2,5 Mio. IU/m2 surface area s.c. 3×per week.

Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.

• Adenovirus and parvovirus B19 perimyocarditis

• Preferred regimen: Immunoglobulin 10 g intravenously at day 1 and 3 for 6–8 hours

Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.

• Fungal pericarditis