Sandbox/002

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Pathogen-Based Therapy Adapted from Circulation 2008;118(15):e523-661.[1]

Viridans Streptococci or Streptococcus bovis

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis

  ▸  Penicillin-Susceptible, Adult

  ▸  Penicillin-Susceptible, Pediatric

  ▸  Penicillin-Resistant, Adult

  ▸  Penicillin-Resistant, Pediatric

Prosthetic Valve Endocarditis

  ▸  Penicillin-Susceptible, Adult

  ▸  Penicillin-Susceptible, Pediatric

  ▸  Penicillin-Resistant, Adult

  ▸  Penicillin-Resistant, Pediatric

Viridans Streptococci or S. bovis NVE, PCN-Susceptible, Adult
Preferred Regimen
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
Alternative Regimen 1
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 2 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 2 weeks
PLUS
Gentamicin 3 mg/kg IV q24h x 2 weeks
Alternative Regimen 2
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function.
Two-week regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of less than 20 ml per min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella infection.
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 ceftriaxone; vancomycin 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 dosages should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis NVE, PCN-Susceptible, Pediatric
Preferred Regimen
Penicillin G sodium 0.2 MU/kg/day IV q4—6h x 4 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 4 weeks
Alternative Regimen 1
Penicillin G sodium 0.2 MU/kg/day IV q4—6h x 2 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 2 weeks
PLUS
Gentamicin 3 mg/kg IV q24h (or 1 mg/kg IV q8h) x 2 weeks
Alternative Regimen 2
Vancomycin 40 mg/kg/day IV q8—12h x 4 weeksǁ
Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function.
Two-week regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of less than 20 ml per min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella infection.
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 doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low; recommended only for patients unable to tolerate penicillin or ceftriaxone; vancomycin 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 dosages should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis NVE, PCN-Resistant, Adult
Preferred Regimen
Penicillin G sodium 24 MU/day IV continuously/q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
PLUS
Gentamicin 3 mg/kg IV q24h (or 1 mg/kg IV q8h) x 2 weeks
Alternative Regimen
Vancomycin 40 mg/kg/day IV q8—12h x 4 weeksǁ
Patients with endocarditis caused by penicillin-resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis.
Recommended for enterococcal endocarditis.
ǁ Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low; recommended only for patients unable to tolerate penicillin or ceftriaxone therapy.
Viridans Streptococci or S. bovis NVE, PCN-Resistant, Adult
Preferred Regimen
Penicillin G sodium 0.3 MU/kg/day IV q4—6h x 4 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 4 weeks
PLUS
Gentamicin 3 mg/kg IV q24h (ddd x 2 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
Patients with endocarditis caused by penicillin-resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis.
Recommended for enterococcal endocarditis.
ǁ Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low; recommended only for patients unable to tolerate penicillin or ceftriaxone therapy.
Viridans Streptococci or S. bovis NVE, PCN-Susceptible, Adult
Preferred Regimen
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
Alternative Regimen 1
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 2 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 2 weeks
PLUS
Gentamicin 3 mg/kg IV q24h x 2 weeks
Alternative Regimen 2
Vancomycin 15 mg/kg IV q12h x 4 weeks
Viridans Streptococci or S. bovis NVE, PCN-Susceptible, Adult
Preferred Regimen
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
Alternative Regimen 1
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 2 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 2 weeks
PLUS
Gentamicin 3 mg/kg IV q24h x 2 weeks
Alternative Regimen 2
Vancomycin 15 mg/kg IV q12h x 4 weeks
Viridans Streptococci or S. bovis NVE, PCN-Susceptible, Adult
Preferred Regimen
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
Alternative Regimen 1
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 2 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 2 weeks
PLUS
Gentamicin 3 mg/kg IV q24h x 2 weeks
Alternative Regimen 2
Vancomycin 15 mg/kg IV q12h x 4 weeks
Viridans Streptococci or S. bovis NVE, PCN-Susceptible, Adult
Preferred Regimen
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
Alternative Regimen 1
Penicillin G sodium 12—18 MU/day IV continuously/q4—6h x 2 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 2 weeks
PLUS
Gentamicin 3 mg/kg IV q24h x 2 weeks
Alternative Regimen 2
Vancomycin 15 mg/kg IV q12h x 4 weeks

References

  1. Bonow, RO.; Carabello, BA.; Chatterjee, K.; de Leon, AC.; Faxon, DP.; Freed, MD.; Gaasch, WH.; Lytle, BW.; Nishimura, RA. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134. Unknown parameter |month= ignored (help)