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Pathogen-Based Therapy Adapted from Circulation 2005;111(23):e394-434.[1] and Circulation 2008;118(15):e523-661.[2]

Viridans Streptococci or Streptococcus bovis

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis

  ▸  Highly PCN Susceptible, Adult

  ▸  Highly PCN Susceptible, Pediatric

  ▸  Relatively PCN Resistant, Adult

  ▸  Relatively PCN Resistant, Pediatric

  ▸  Highly PCN Resistant

Prosthetic Valve Endocarditis

  ▸  PCN Susceptible, Adult

  ▸  PCN Susceptible, Pediatric

  ▸  PCN Resistant, Adult

  ▸  PCN Resistant, Pediatric

Viridans Streptococci or S. bovis NVE, Penicillin MIC ≤0.12 μg/mL, Adult
Preferred Regimen
Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
Alternative Regimen 1
Penicillin G 12—18 MU/day IV continuously or q4—6h x 2 weeks
OR
Ceftriaxone 2 g 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 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 Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 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, Penicillin MIC ≤0.12 μg/mL, Pediatric
Preferred Regimen
Penicillin G 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 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 Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 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, Penicillin MIC >0.12 to ≤0.5 μg/ml, Adult
Preferred Regimen
Penicillin G 24 MU/day IV continuously or q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
PLUS
Gentamicin 3 mg/kg IV q24h (1 mg/kg IV q8h) x 2 weeks
Alternative Regimen
Vancomycin 15 mg/kg/day 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.
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 Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 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, Penicillin MIC >0.12 to ≤0.5 μg/ml, Pediatric
Preferred Regimen
Penicillin G 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 (or 1 mg/kg IV q8h) x 2 weeks
Alternative Regimen
Vancomycin 40 mg/kg 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.
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 Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 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, Penicillin MIC >0.5 μg/ml
▸ Endocarditis caused by highly penicillin resistant (MIC >0.5 μg/ml) strains of viridans streptococci, Abiotrophia defectiva, Granulicatella species, and Gemella species should be treated with a regimen that is recommended for enterococcal endocarditis.
Viridans Streptococci or S. bovis PVE, Penicillin MIC ≤0.12 μg/ml, Adult
Preferred Regimen
Penicillin G 24 MU/day IV continuously or q4—6h x 6 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 6 weeks
WITH OR WITHOUT
Gentamicin 3 mg/kg IV q24h (or 1 mg/kg IV q8h) x 2 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
Gentamicin therapy should not be administered to patients with creatinine clearance of <30 mL/min
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis PVE, Penicillin MIC ≤0.12 μg/ml, Pediatric
Preferred Regimen
Penicillin G 0.3 MU/kg/day IV q4—6h x 6 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 6 weeks
WITH OR WITHOUT
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 6 weeksǁ
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 Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis PVE, Penicillin MIC >0.12 μg/ml, Adult
Preferred Regimen
Penicillin G 24 MU/day IV continuously or q4—6h x 6 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 6 weeks
PLUS
Gentamicin 3 mg/kg IV q24h (or 1 mg/kg IV q8h) x 6 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
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 Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis PVE, Penicillin MIC >0.12 μg/ml, Pediatric
Preferred Regimen
Penicillin G 0.3 MU/kg/day IV q4—6h x 6 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 6 weeks
PLUS
Gentamicin 3 mg/kg IV q24h (or 1 mg/kg IV q8h) x 6 weeks
Alternative Regimen
Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
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 Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.



Streptococcus pneumoniae, Streptococcus pyogenes, and Groups B, C, and G Streptococci

▸ Click on the following categories to expand treatment regimens.

Streptococcus pneumoniae

  ▸  PCN Susceptible

  ▸  PCN Resistant, Without Meningitis

  ▸  PCN Resistant, With Meningitis

Streptococcus pyogenes

  ▸  IE Caused by S. pyogenes

Group B, C, and G Streptococcus

  ▸  IE Caused by Group B/C/G Streptococcus

S. pneumoniae Endocarditis, PCN Susceptible (MIC ≤0.1 μg/mL)
Preferred Regimen
Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks
OR
Cefazolin 1—1.5 g IV q6h x 4 weeks
OR
Ceftriaxone 2 g IV q24h x 4 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
ǁ Recommended only for patients unable to tolerate beta-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
S. pneumoniae Endocarditis, PCN Resistant (MIC >0.1 μg/mL), Without Meningitis
Preferred Regimen
Penicillin G 24 MU/day IV continuously or q4—6h x 4 weeks
OR
Cefotaxime 2 g IV q6—8h x 4 weeks
OR
Ceftriaxone 2 g IV q24h x 4 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
ǁ Recommended only for patients unable to tolerate beta-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
S. pneumoniae Endocarditis, PCN Resistant (MIC >0.1 μg/mL), With Meningitis
Preferred Regimen
Cefotaxime 2 g IV q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV q12h x 4 weeks
PLUS
Vancomycin 15 mg/kg IV q6h x 4 weeks
PLUS
Rifampin 600 mg IV q24h x 4 weeks
S. pneumoniae Endocarditis, PCN Resistant (MIC >0.1 μg/mL), With Meningitis
Preferred Regimen
Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks
OR
Cefazolin 1—1.5 g IV q6h x 4 weeks
OR
Ceftriaxone 2 g IV q24h x 4 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
ǁ Recommended only for patients unable to tolerate beta-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. 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 should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.



References

  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)
  2. 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)