Streptococci
▸ Click on the following categories to expand treatment regimens.
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 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
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| Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis
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| Preferred Regimen ( 4 wks )
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| Adult dose
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▸ Penicillin G sodium † 12–18 million U/24 h IV either continuously or in 4-6 equally divided doses x 4 Wks
OR
▸ Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 4 Wks
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| Pediatric dose ₳
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▸ Penicillin G sodium 200 000 U/kg q24h IV either continuously or in 4-6 equally divided doses x 4 Wks
OR
▸Ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose x 4 Wks
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| Alternative Regimen ( 2 wks )
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| Adult dose
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▸ Penicillin G sodium‡ 12–18 million U/24 h IV either continuously or in 6 equally divided doses x 2 Wks
OR
▸ Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 2 Wks
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| PLUS
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| ▸ Gentamicin sulfate ฿ 3 mg/Kg per 24h 1 dose x 2 Wks
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| Pediatric dose
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▸ Penicillin G sodium 200 000 U/kg q24h IV in 4-6 equally divided doses x 2 Wks
OR
▸Ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose x 2 Wks
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| PLUS
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| ▸ Gentamicin sulfate 3 mg/Kg per 24h 1 dose or 3 equally divided doses x 2 Wks
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| Alternative Regimen
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| Adult dose
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▸ Vancomycin hydrochloride ¶ 15 mg/kg q12h IV x 4 Wks
Doses should not to exceed 2 g/24 h unless concentrations in serum are inappropriately low
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| Pediatric dose
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| ▸Vancomycin hydrochloride 40 mg/kg per 24 h IV in 2–3 equally divided doses
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Minimum inhibitory concentration ≤ 0.12 μg/mL.
- † Preferred in most patients >65 y or patients with impairment of 8th cranial nerve function or renal function.
- ₳ Pediatric dose should not exceed that of a normal adult.
- ‡ 2-wk regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of <20 mL/min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella spp infection; gentamicin dosage should be adjusted to achieve peak serum concentration of 3-4 μg/mL and trough serum concentration of >1 μg/mL when 3 divided doses are used; nomogram used for single daily dosing.
- ¶ 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
- ฿ Other potentially nephrotoxic drugs (eg, nonsteroidal antiinflammatory drugs) should be used with caution in patients receiving gentamicin therapy. Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.
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| Native Valve Endocarditis Caused by Strains of Viridans Group Streptococci and Streptococcus bovis Relatively Resistant to Penicillin (MIC >0.12 μg/mL- ≤ 0.5 μg/mL))
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| Preferred Regimen
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| Adult dose
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▸ Penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 wks
OR
▸ Ceftriaxone 2 g/24 h IV/IM in 1 dose x 4 wks
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| PLUS
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| ▸ Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks
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| Pediatric dose
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▸ Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
OR
▸ Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose
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| PLUS
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| ▸ Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose or equally divided doses
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| Alternative Regimen
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| Adult dose
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| ▸ Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 4 wks
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| Pediatric dose
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| ▸ Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
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| Penicillin-susceptible strain (MIC ≤ 0.12 g/mL)
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| Preferred Regimen
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| Adult dose
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▸ Penicillin G sodium † 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks
OR
▸ Ceftriaxone 2 g/24 h IV/IM in 1 dose x 6 wks
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| WITH OR WITHOUT
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| ▸ Gentamicin sulfate ‡ 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks
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| Pediatric dose
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▸ Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
OR
▸ Ceftriaxone 100 mg/kg IV/IM once daily
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| WITH OR WITHOUT
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| ▸Gentamicin 3 mg/kg per 24 h IV/IM, in 1 dose or 3 equally divided doses
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| Alternative Regimen
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| Adult dose
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| ▸ Vancomycin
hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
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| Pediatric dose
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| ▸ 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
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*Dosages recommended are for patients with normal renal function.
- † Penicillin or ceftriaxone together with gentamicin has not demonstrated superior cure rates compared with monotherapy with penicillin or ceftriaxone for patients with highly susceptible strain; gentamicin therapy should not be administered to patients with creatinine clearance of <30 mL/min.
- ‡ Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.
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| Penicillin relatively or fully resistant strain (MIC >0.12 >μg/mL))
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| Preferred Regimen
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| Adult dose
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▸ Penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks
OR
▸ Ceftriaxone 2 g/24 h IV/IM in 1 dose x 6 wks
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| PLUS
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| ▸ Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 6 wks
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| Pediatric dose
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| ▸ Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
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| Alternative Regimen
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| Adult dose
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| ▸ Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
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| Pediatric dose
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| ▸ Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
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| Relatively Penicillin-Resistant Streptococci (MIC 0.2–0.5 µg/ml
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| Preferred Regimen
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| Adult dose
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▸ Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks
OR
▸Ceftriaxone 2 g/24 h IV/IM in 1 dose
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| AND
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| ▸ Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks
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| Pediatric dose
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▸ Penicillin G potassium 300 000 U/24 h IV in 4–6 equally divided doses X 4 Wks
OR
▸ Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose
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| AND
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| ▸ Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose or 3 equally divided doses X 2 Wks
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| Relatively Penicillin-Resistant Streptococci(MIC > 0.5 µg/ml, consider Enterococcal regimen
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| Preferred Regimen
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| Adult dose
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| ▸ Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks
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| PLUS
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| ▸ Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks
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| Pediatric dose
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| ▸ Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks
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| PLUS
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| ▸ Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks
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| Unable to Tolerate Aqueous crystalline penicillin G sodium or Ceftriaxone
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| Preferred Regimen
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| Adult dose
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| ▸ Vancomycin 30 mg/kg per 24 h IV in 2 equally divided doses not to exceed 2 g/24 h, unless serum concentrations are inappropriately low
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| Pediatric dose
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| ▸ Vancomycin 40 mg/kg 24 h in 2 or 3 equally divided doses X 4 Wks
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Enterococci
Endocarditis Caused by Enterococci
▸ Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin
▸ Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin
▸ Enterococci Strains Resistant to Penicillin and Susceptible to Aminoglycoside and Vancomycin
▸ Enterococci Strains Resistant to Penicillin, Aminoglycoside, and Vancomycin
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| Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin
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| Preferred Regimen
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| Adult dose
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▸ Ampicillin 12 g/24 h I.V.in 6 equally divided doses x 4–6 Wks
OR
▸Penicillin G sodium 18–30 million U. I.V. daily in 6 equally divided doses x 4–6 Wks
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| PLUS
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| ▸Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 4-6 Wks
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| Pediatric dose
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▸ Ampicillin 300 mg/kg per 24 h IV in 4–6 equally divided doses; X 4–6 Wks
OR
▸Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses X 4–6 Wks
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| PLUS
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| ▸Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks
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| Alternative Regimen
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▸ Vancomycin 30 mg/kg I.V. daily in 2 equally divided doses x 6 Wks
PLUS
▸Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
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| Pediatric dose
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▸ Vancomycin 30 mg/kg I.V. daily in divided doses q. 12 hour X 4–6 Wks
PLUS
▸Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks
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*Native valve: 4-wk therapy recommended for patients with symptoms of illness < 3 months.
- 6-wk therapy recommended for patients with symptoms >3 months.
- Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
- Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin.
- 6 wk of vancomycin therapy recommended because of decreased activity against enterococci.
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| Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin
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| Preferred Regimen
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| Adult dose
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▸ Ampicillin 12 g/24 h I.V.in 6 equally divided doses x 4–6 Wks
OR
▸Penicillin G sodium 24 million U. I.V. continuously or in 6 equally divided doses x 4–6 Wks
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| PLUS
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| ▸Streptomycin sulfate 15 mg/kg per 24 h IV/IM in 2 equally divided doses x 4-6 Wks
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| Pediatric dose
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▸ Ampicillin 300 mg/kg per 24 h IV in 4–6 equally divided doses; x 4–6 Wks
OR
▸Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses x 4–6 Wks
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| PLUS
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| ▸Streptomycin sulfate 20–30 mg/kg per 24 h IV/IM in 2 equally divided doses
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| Alternative Regimen
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| Adult dose
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▸ Vancomycin 30 mg/kg I.V. daily in 2 equally divided doses x 6 Wks
PLUS
▸Streptomycin sulfate 15 mg/kg per 24 h IV/IM in 2 equally divided doses x 4-6 Wks
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| Pediatric dose
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▸ Vancomycin 40 mg/kg per 24 h IV in 2 or 3 equally divided doses X 4–6 Wks
PLUS
▸Streptomycin sulfate 20–30 mg/kg per 24 h IV/IM in 2 equally divided doses
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- Native valve: 4-wk therapy recommended for patients with symptoms of illness < 3 months.
- 6-wk therapy recommended for patients with symptoms >3 months.
- Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
- Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin.
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| E faecium
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| Adult dose
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▸ Linezolid 1200 mg/24 h IV/PO in 2 equally divided doses x ≥8 Wks
OR
▸Quinupristin-dalfopristin 22.5 mg/kg per 24 h IV in 3 equally divided doses x ≥ 8 Wks
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| Pediatric dose
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▸ Linezolid 30 mg/kg per 24 h IV/PO in 3 equally divided doses ≥8 Wks
OR
▸Quinupristin-dalfopristin 22.5 mg/kg per 24 h IV in 3 equally divided doses ≥8 Wks
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| E faecalis
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| Adult dose
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| Preferred Regimen
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▸ Imipenem/cilastatin 2 g/24 h IV in 4 equally divided doses x ≥8 Wks
PLUS
▸Ampicillin sodium 12 g/24 h IV in 6 equally divided doses x ≥ 8 Wks
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| Pediatric dose
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▸ Imipenem/cilastatin 60–100 mg/kg per 24 h IV in 4 equally divided doses x ≥8 Wks
PLUS
▸Ampicillin sodium 300 mg/kg per 24
h IV in 4–6 equally divided doses x ≥ 8 Wks
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| Alternative Regimen
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| Adult dose
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▸ Ceftriaxone sodium 4 g/24 h IV/IM in 2 equally divided doses x ≥8 Wks
PLUS
▸Ampicillin sodium 12 g/24 h IV in 6 equally divided doses x ≥ 8 Wks
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| Pediatric dose
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▸ Ceftriaxone sodium 100 mg/kg per 24 h IV/IM in 2 equally divided doses x ≥8 Wks
PLUS
▸Ampicillin sodium 300 mg/kg per 24 h IV in 4–6 equally divided doses x ≥ 8 Wks
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- Patients with endocarditis caused by these strains should be treated in consultation with an infectious diseases specialist.
- Cardiac valve replacement may be necessary for bacteriologic cure.
- Cure with antimicrobial therapy alone may be < 50%
- Severe, usually reversible thrombocytopenia may occur with use of linezolid, especially after 2 wk of therapy.
- Quinupristin-dalfopristin only effective against E faecium and can cause severe myalgias, which may require discontinuation of therapy
- Only small no. of patients have reportedly been treated with imipenem/cilastatin-ampicillin or ceftriaxone + ampicillin.
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Staphylococci
Native Valve Endocarditis caused by Staphylococci in the Absence of Prosthetic Material
▸ Staphylococci (Methicillin Susceptible)
▸ Staphylococci (Methicillin-resistant) with Penicillin G Anaphylactoid Hypersensitivity
Prosthetic Valves Endocarditis or Other Prosthetic Material Caused by Staphylococci
▸ Oxacillin-susceptible strains
▸ Oxacillin-resistant strains
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| Staphylococci (Methicillin Susceptible)
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| Preferred Regimen
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| Adult dose
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| ▸ Nafcillin or Oxacillin † 12 g I.V. daily in equally divided doses x 6 Wks
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| PLUS (optional)
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| ▸ Gentamicin sulfate ‡ 3 mg/kg per 24 h IV/IM in 2-3 equally divided doses x 3-5 days
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| Altenative Regimen( in non anaphylactoid Penicillin hypersensitivity)
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| ▸ Cefazolin 6 g/ 24 h I.V. in 3 divided doses x 6 wks
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| PLUS (optional)
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| ▸ Gentamicin 3 mg/kg per 24 h IV/IM in 2-3 equally divided doses x 3-5 days
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| Pediatrics dose
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▸ Nafcillin or oxacillin 200 mg/kg per 24 h IV in 4–6 equally divided doses x 4-6 wks
OR ( in non anaphylactoid Penicillin hypersensitivity)
▸Cefazolin 100 mg/kg per 24 h IV in 3 equally divided doses x 4-6 wks
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| AND (optional)
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| ▸ Gentamicin 3 mg/kg per 24 h IV/IM in 3 equally divided doses
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- † Penicillin G 24 million U/24 h IV in 4 to 6 equally divided doses may be used in place of nafcillin or oxacillin if strain is penicillin susceptible (MIC ≤ 0.1 μg/mL) and does not produce β-lactamase.
- ‡ Gentamicin should be administered in close temporal proximity to vancomycin, nafcillin, or oxacillin dosing.
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Staphylococci (Methicillin-resistant)
(in anaphylactoid Penicillin hypersensitivity)
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| Preferred Regimen
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| Adult dose
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▸ Vancomycin 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
Adjust vancomycin dosage to achieve 1-h serum concentration of 30–45 > g/mL and trough concentration of 10–15 >g/mL
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| Pediatrics dose
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| ▸ Vancomycin 40 mg/kg per 24 h IV in 2 or 3 equally divided doses x 6 wks
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| Oxacillin-susceptible strains
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| Adult dose
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▸ Nafcillin or oxacillin 2 g q4h IV x ≥6 weeks
PLUS
▸ Rifampin 300 mg q8h IV/PO x ≥6 weeks
PLUS
▸ Gentamicin 3 mg/kg per 24 h IV/IM in 2 or 3 equally divided doses x 2 weeks
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| Pediatric dose
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▸Nafcillin or oxacillin 200 mg/kg per 24 h IV in 4–6 equally divided doses
PLUS
▸Rifampin 20 mg/kg per 24 h IV/PO in 3 equally divided doses
PLUS
▸Gentamicin 1 mg/kg q8h IV/IM
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| Oxacillin-resistant strains
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| Adult dose
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▸ Vancomycin 15 mg/kg q12h x ≥6 Wks
PLUS
▸ Rifampin 300 mg q8h IV/PO x ≥6 Wks
PLUS
▸ Gentamicin 3 mg/kg per 24 h IV/IM in 2 or 3 equally divided doses x 2 wks
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| Pediatric dose
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▸ Vancomycin 40 mg/kg per 24 h IV in 2-3 equally divided doses x ≥6 wks
PLUS
▸Rifampin 20 mg/kg per 24 h IV/PO in 3 equally divided doses x ≥6 wks
PLUS
▸ Gentamicin 1 mg/kg q8h IV/IM x 2 Wks
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