Endocarditis medical therapy

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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]; Ahmed Zaghw, M.D. [3]

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]

Streptococci

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 or Other Prosthetic Material 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

Enterococci

In general, treatment of enterococcal endocarditis requires combination therapy with two antibiotics:

Native Valve or Prosthetic Valve Enterococcal Endocarditis Caused by Strains Susceptible to Penicillin, Gentamicin, and Vancomycin

Staphylococci

Native Valve Endocarditis caused by Staphylococci in the Absence of Prosthetic Material

Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material
Staphylococci (Methicillin-resistant) with Penicillin G Anaphylactoid Hypersensitivity in the Absence of Prosthetic Material

Prosthetic Valves Endocarditis or Other Prosthetic Material Caused by Staphylococci

Oxacillin-susceptible strains in the Presence of Prosthetic Material
Oxacillin-resistant strains in the Presence of Prosthetic Material

HACEK Organisms

HACEK organisms are more indolent and the infection is less complicated.

Culture Negative Endocarditis

  • Clinical course of infection beside the epidemiological features should be considered upon selecting treatment regimen.
  • Patients should be divided into 2 groups:

Patients Who Received Antibiotic Therapy Before the Blood Culture

  • Patients with acute clinical presentations with native valve infection: coverage of S. aureus should be followed as detailed in proven staphylococcal disease.
  • Patients with subacute presentation: antibiotic coverage for S. aureus, viridians group streptococci, and enterococci should be considered.
  • Antibiotics for HACEK group of organism also should be considered.
  • Symptomatic patients with prosthetic valve and culture negative infection within 1 year of valve replacement should receive vancomycin to cover the oxacillin-resistant staphylococci.
  • Symptomatic patients with prosthetic valve and culture negative infection within 2 months of valve replacement should also receive cefepime for gram negative bacilli coverage.
  • Symptomatic patients with prosthetic valve more than 1 year, the most likely causing organisms are oxacillin-susceptible staphylococci, viridians group streptococci, and enterococci. Antibiotic coverage for those organisms should be continued for at least 6 weeks.

Patients with Culture-Negative Endocarditis and Suspected Infection with Uncommon Endocarditis Pathogens

  • Examples of these pathogens include Bartonella species, Chlamydia species, Coxiella burnetii, Brucella species, Legionella species, Tropheryma whippleii, and non-Candida fungi.
  • Antibiotic therapy for these pathogens should include aminoglycosides for at least 2 weeks.
  • Therapeutic regimens for Bartonella endocarditis based on the epidemiological risk and high in index of suspicion.[2]
Native valve
Ampicillin-Sulbactam 3 g q6h IV x 4–6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 weeks
OR
Vancomycin 15 mg per kg q12h IV x 4–6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 week
PLUS
Ciprofloxacin 500 mg q12h PO or 320 mg q12h IV x 4–6 weeks
Native valve pediatric dose
Ampicillin-Sulbactam300 mg per kg per 24 h IV in 4–6 equally divided doses
Gentamicin 1 mg per kg q8h IV/IM
Vancomycin 32 mg per kg per 24 h in 2 or 3 equally divided doses
Ciprofloxacin 10-15 mg per kg q12h IV/PO
Prosthetic valve (early, ≤ 1y)
Vancomycin 15 mg per kg q12h IV x 6
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 2weeks
PLUS
Cefepime 2 g q8h IV x 6 weeks
PLUS
Rifampin 300 mg q8h PO/IV x 6 weeks
Prosthetic valve pediatric dose
Vancomycin 32 mg per kg per 24 h IV in 2 or 3 equally divided doses
Gentamicin 1 mg per kg q8h IV/IM
Cefepime 50 mg q8h IV
Rifampin 20 mg per kg per 24 h PO/IV in 3 equally divided doses
Prosthetic valve (late—greater than 1 y) (same regimens as for native valve endocarditis with addition of rifampin)
Ampicillin-Sulbactam 3 g q6h IV x 4–6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 weeks
PLUS
Rifampin 300 mg q8h PO/IV x 6 weeks
OR
Vancomycin 15 mg per kg q12h IV x 4–6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 weeks
PLUS
Ciprofloxacin 500 mg q12h PO or 320 mg q12h IV x 4–6 weeks
PLUS
Rifampin 300 mg q8h PO/IV x 6 weeks
Suspected Bartonella, culture negative
Ceftriaxone sodium 2 g per 24 h IV/IM in 1 dose x 6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 2 weeks
WITH/WITHOUT
Doxycycline 100 mg per kg q12h IV/PO x 6 weeks
Documented Bartonella, culture positive
Doxycycline 100 mg q12h IV or PO x 6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 2 weeks
Documented Bartonella, culture positive pediatric dose
Ceftriaxone 100 mg per kg per 24 h IV/IM once daily
Gentamicin 1 mg per kg q8h IV/IM
Doxycycline 2–4 mg per kg per 24 h IV/PO in 2 equally divided doses
Rifampin 10 mg per kg q12h PO/IV

References

  1. Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-2708-1.
  2. Jump up to: 2.0 2.1 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)
  3. 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.

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