Endocarditis medical therapy
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2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Blood cultures should be drawn prior to instituting antibiotics to identify the etiologic agent and to determine its antimicrobial susceptibility. Older antibiotics such as penicillin G, ampicillin, nafcillin, cefazolin, gentamycin, ceftriaxone, rifampin and vancomycin are the mainstays of therapy.
Timing of Initiation of Antibiotics
Antibiotic therapy for subacute or indolent disease can be delayed until results of blood cultures are known; in fulminant infection or valvular dysfunction requiring urgent surgical intervention, begin empirical antibiotic therapy promptly after blood cultures have been obtained.
Duration of Antibiotic Therapy
The duration for native valve endocarditis is often 4 weeks. For prosthetic valve endocarditis (including the presence of a valve ring), treatment should be continued for 6 to 8 weeks. For each infective agent, the preferred antimicrobial agent, dose, and duration is listed below.
Empirical Antibiotic Therapy
- Antibiotic therapy for subacute hemodynamically stable disease, and in those who have received antibiotics recently can be delayed waiting the results of blood cultures, as this delay allows an additional blood cultures without the confounding effect of empiric treatment, which is very important in determining the causing pathogens.[1]
- On the other hand, the rapid progression of acute cases necessitate the start of empirical treatment antibiotic therapy once the blood cultures have been collected.
- Empirical therapy is needed for all likely pathogens, certain antibiotic agents, including aminoglycosides, is preferably avoided for its toxic effects.
- Clinical course of infection beside the epidemiological features should be considered upon selecting empirical treatment regimen.
- Consultation with an infectious disease specialist for the selection of one of the antibiotic regimens is recommended (see therapy for culture-negative endocarditis). [2]
Treatment Based Upon Infectious Agent[3]
Penicillin-Susceptible Strep Viridans and Other Nonenterococcal Streptococci
Penicillin G
- If Minimum inhibitory concentration [MIC] <0.2 µg/ml.
- Dose: 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks.
Penicillin G + Gentamicin
- Dose: Penicillin G, 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks plus gentamicin, 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
Ceftriaxone
- Dose: 2 g I.V. daily as a single dose for 2 weeks.
Vancomycin
- Vancomycin can be administered to patients with a history of penicillin hypersensitivity.
- Dose: 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks.
Relatively Penicillin-Resistant Streptococci
If MIC 0.2–0.5 µg/ml:
Penicillin G + Gentamicin
- Dose: Penicillin G, 20–30 million units I.V. daily in divided doses q. 4 hour for 4 weeks; gentamicin, 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr for 2 wk (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
If MIC > 0.5 µg/ml:
Penicillin G + Gentamicin
- Dose: penicillin G, 20–30 million units I.V. daily in divided doses q. 4 hour for 4 week; gentamicin, 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 4 week (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
Vancomycin
- Regimen for patients with history of penicillin hypersensitivity.
- Dose: 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks.
Enterococci
In general, treatment of enterococcal endocarditis requires combination therapy with two antibiotics:
Penicillin G + Gentamicin
- Dose is penicillin G, 20–30 million units I.V. daily in divided doses q. 4 hr for 4–6 weeks; gentamicin, 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 4–6 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
Ampicillin + Gentamicin
- Dose is ampicillin, 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; gentamicin, dose as above.
Vancomycin + Gentamicin
- This regimen is for patients with history of penicillin hypersensitivity.
- Dose: Vancomycin, 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks; gentamicin, dose as above.
Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material
Nafcillin or Oxacillin + Gentamicin (optional)
- Dose: Nafcillin or oxacillin, 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; gentamicin, 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr for 3–5 days (peak serum concentration should be ~ 3 µg/ml and trough concentrations <1 µg/ml).
Cefazolin + Gentamicin (optional)
- Alternative regimen for patients with history of penicillin hypersensitivity.
- Dose: Cefazolin, 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; gentamicin, dose as above.
Vancomycin
- Alternative regimen for patients with history of penicillin hypersensitivity.
- Dose: 30 mg/kg I.V. daily in divided doses q. 12 hr for 4–6 weeks.
Staphylococci (Methicillin Resistant) in the Absence of Prosthetic Material
Vancomycin
- Dose: 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks.
Staphylococci (Methicillin Susceptible) in the Presence of Prosthetic Material
Nafcillin or Oxacillin + Rifampin + Gentamicin
- Dose: Nafcillin or oxacillin, 12 g I.V. daily in divided doses q. 4 hour for 6–8 weeks plus rifampin, 300 mg p.o., q. 8 hour for 6–8 weeks plus gentamicin (administer during the initial 2 weeks), 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks.
Staphylococci (Methicillin Resistant) in the Presence of Prosthetic Material
Vancomycin + Rifampin + Gentamicin
- Dose: Vancomycin, 30 mg/kg I.V. daily in divided doses q. 12 hour for 6–8 weeks plus rifampin, 300 mg p.o., q. 8 hour for 6–8 weeks plus gentamicin (administer during the initial 2 weeks), 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks.
HACEK Organisms
HACEK organisms are more indolent and the infection is less complicated.
Ceftriaxone or another Third-Generation Cephalosporin
- Dose: 2 g I.V. daily as a single dose for 4 weeks.
Ampicillin-Sulbactam
Ciprofloxacin
- This is listed as an alternative, there is not a lot of data to support its regular use.
Culture Negative Endocarditis
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References
- ↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-2708-1.
- ↑ Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter
|month=ignored (help) - ↑ Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A. (2005). "Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): 3167–84. PMID 15956145.