Infective endocarditis: Difference between revisions

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βˆ’
== Background ==
 +
==Background==
⚫
* Infection of heart valves, either prosthetic or native
  
   
  ⚫
*Infection of endocardium, generally involving the heart valves, either prosthetic or native
βˆ’
=== Organisms ===
  
⚫
* '''Bacteria'''
  
⚫
** [[Staphylococcus aureus]] (most common)
  
⚫
** [[Viridans group streptococci]]
  
⚫
** [[Coagulase-negative staphylococci]]
  
⚫
** Other streptococci
  
⚫
** [[Enterococci]]
  
⚫
** [[HACEK group]]
  
⚫
** [[Coxiella]]
  
⚫
** [[Brucella]]
  
⚫
* [[Fungi]]
  
⚫
** ''[[Candidal endocarditis|Candida]]''
  
   
  +
===Microbiology===
⚫
== Clinical Manifestations ==
  
⚫
* Refer to [[Modified Duke criteria]]
  
⚫
* Specific organisms may be associated with specific risk factors
  
⚫
** Injection drug use: [[Viridans group streptococci]] and ''[[Pseudomonas aeruginosa]]''
  
⚫
** Colon cancer: ''[[Streptococcus bovis]]'' and ''[[Clostridium septicum]]''
  
   
  ⚫
*'''Bacteria'''
⚫
== Management ==
  
  ⚫
**[[Staphylococcus aureus]] (most common)
⚫
* Varies by causative organism and prosthetic vs. native valve
  
  ⚫
**[[Viridans group streptococci]]
⚫
* In patients who are in [[acute heart failure]], may need to consider [[antibiotics in sodium restriction|the sodium content of the antibiotics used]]
  
  ⚫
**[[Coagulase-negative staphylococci]]
  ⚫
**Other [[streptococci]]
  ⚫
**[[Enterococci]]
  ⚫
**[[HACEK group]]
  ⚫
**[[Coxiella]]
  ⚫
**[[Brucella]]
  ⚫
*'''[[Fungi]]'''
  ⚫
**''[[Candidal endocarditis|Candida]]''
  +
*[[Culture-negative endocarditis]]
  +
**[[Coxiella burnetii]]
  +
**[[Bartonella species]]
  +
**[[Brucella species]]
  +
**[[Legionella species]]
  +
**[[Mycoplasma species]]
  +
**[[Tropheryma whipplei]]
  +
**[[Abiotrophia species]]
  +
**[[Cutibacterium acnes]]
  +
  +
=== Risk Factors ===
  +
  +
* Cardiac
  +
** Prior endocarditis
  +
** Prosthetic heart valve or implanted device
  +
** Congenital heart disease, especially unrepaired cyanotic congenital heart disease
  +
** Valve abnormalities
  +
* Non-cardiac
  +
** Intravenous drug use
  +
** Indwelling intravenous lines
  +
** Immunosuppression
  +
** Recent dental work or surgical procedure associated with bacteremia
  +
  ⚫
==Clinical Manifestations==
  +
  +
*In general, symptoms are fever, chills, and malaise in a patient at risk for endocarditis
  +
*Tends to progress rapidly
  +
*May have a new murmur, stroke syndrome, pulmonary embolism, arthralgias
  ⚫
*Refer to [[Modified Duke criteria]]
  ⚫
*Specific organisms may be associated with specific risk factors
  ⚫
**Injection drug use: [[Viridans group streptococci]] and ''[[Pseudomonas aeruginosa]]''
  ⚫
**Colon cancer: [[Streptococcus gallolyticus subspecies gallolyticus|''Streptococcus gallolyticus'' subspecies ''gallolyticus'']] and ''[[Clostridium septicum]]''
  +
  +
=== Subacute Bacterial Endocarditis ===
  +
  +
* Insidious onset with more pronounced constitutional symptoms progressing over weeks to months
  +
  +
== Differential Diagnosis ==
  +
  +
* Non-infectious causes of endocarditis
  +
** [[Acute rheumatic fever]]
  +
** [[Libman-Sacks endocarditis]]
  +
** [[Rheumatoid arthritis]]
  +
** [[Marantic endocarditis]]
  +
** [[LΓΆeffler endocarditis]]
  +
* Any cause of fever or consitutional symptoms
  +
  ⚫
==Management==
  +
  ⚫
*Varies by causative organism and prosthetic vs. native valve
  ⚫
*In patients who are in [[acute heart failure]], may need to consider [[antibiotics in sodium restriction|the sodium content of the antibiotics used]]
   
 
{| class="wikitable"
  
{| class="wikitable"
βˆ’
! Valve
 +
!Valve
βˆ’
! Antibiotic
 +
!Antibiotic
βˆ’
! Dose
 +
!Dose
βˆ’
! Duration
 +
!Duration
βˆ’
! Notes
 +
!Notes
 
|-
  
|-
βˆ’
! colspan=5 | MSSA and other oxacillin-susceptible ''[[Staphylococcus]]''
 +
! colspan="5" |MSSA and other oxacillin-susceptible ''[[Staphylococcus]]''
 
|-
  
|-
βˆ’
| NVE
 +
|NVE
βˆ’
| [[oxacillin]] || 2 g IV q4h || 6 weeks
 +
|[[oxacillin]]||2 g IV q4h||6 weeks
βˆ’
| can treat for 2 weeks in uncomplicated right-sided NVE
 +
|can treat for 2 weeks in uncomplicated right-sided NVE
 
|-
  
|-
βˆ’
| NVE
 +
|NVE
βˆ’
| [[cefazolin]] || 2 g IV q8h || 6 weeks
 +
|[[cefazolin]]||2 g IV q8h||6 weeks
βˆ’
| in patients with non-anaphylactoid penicillin allergy
 +
|in patients with non-anaphylactoid penicillin allergy
 
|-
  
|-
βˆ’
| rowspan=3 | PVE
 +
| rowspan="3" |PVE
βˆ’
| [[oxacillin]]
 +
|[[oxacillin]]
βˆ’
| 2 g IV q4h
 +
|2 g IV q4h
βˆ’
| rowspan=2 | β‰₯6 weeks
 +
| rowspan="2" |β‰₯6 weeks
βˆ’
| rowspan=3 | use cefazolin or vancomycin if allergy
 +
| rowspan="3" |use cefazolin or vancomycin if allergy
 
|-
  
|-
 
| + [[rifampin]]
  
| + [[rifampin]]
βˆ’
| 300 mg IV/PO q8h
 +
|300 mg IV/PO q8h
 
|-
  
|-
 
| + [[gentamicin]]
  
| + [[gentamicin]]
βˆ’
| 1 mg/kg IV/IM q8h
 +
|1 mg/kg IV/IM q8h
βˆ’
| 2 weeks
 +
|2 weeks
 
|-
  
|-
βˆ’
! colspan=5 | MRSA and other oxacillin-resistant ''[[Staphylococcus]]''
 +
! colspan="5" |MRSA and other oxacillin-resistant ''[[Staphylococcus]]''
 
|-
  
|-
βˆ’
| NVE
 +
|NVE
βˆ’
| [[vancomycin]] || 15 mg/kg IV q12h || 6 weeks
 +
|[[vancomycin]]||15 mg/kg IV q12h||6 weeks
βˆ’
| target trough 10-20 ΞΌg/mL
 +
|target trough 10-20 ΞΌg/mL
 
|-
  
|-
βˆ’
| NVE
 +
|NVE
βˆ’
| [[daptomycin]] || β‰₯8 mg/kg/dose || 6 weeks
 +
|[[daptomycin]]||β‰₯8 mg/kg/dose||6 weeks
 
|
  
|
 
|-
  
|-
βˆ’
| rowspan=3 | PVE
 +
| rowspan="3" |PVE
βˆ’
| [[vancomycin]]
 +
|[[vancomycin]]
βˆ’
| 15 mg/kg IV q12h
 +
|15 mg/kg IV q12h
βˆ’
| rowspan=2 | β‰₯6 weeks
 +
| rowspan="2" |β‰₯6 weeks
βˆ’
| rowspan=3 | target vancomycin trough of 10-20 ΞΌg/mL
 +
| rowspan="3" |target vancomycin trough of 10-20 ΞΌg/mL
 
|-
  
|-
 
| + [[rifampin]]
  
| + [[rifampin]]
βˆ’
| 300 mg IV/PO q8h
 +
|300 mg IV/PO q8h
 
|-
  
|-
 
| + [[gentamicin]]
  
| + [[gentamicin]]
βˆ’
| 1 mg/kg IV/IM q8h
 +
|1 mg/kg IV/IM q8h
βˆ’
| 2 weeks
 +
|2 weeks
 
|-
  
|-
βˆ’
! colspan=5 | ''[[Enterococcus]]'' susceptible to [[penicillin]] and [[gentamicin]]
 +
! colspan="5" |''[[Enterococcus]]'' susceptible to [[penicillin]] and [[gentamicin]]
 
|-
  
|-
βˆ’
| rowspan=2 | NVE/PVE
 +
| rowspan="2" |NVE/PVE
βˆ’
| [[ampicillin]]
 +
|[[ampicillin]]
βˆ’
| 2 g IV q4h
 +
|2 g IV q4h
βˆ’
| rowspan=2 | 4-6 weeks
 +
| rowspan="2" |4-6 weeks
βˆ’
| rowspan=2 | 4 weeks if symptoms <3 months;<br/>6 weeks if symptoms >3 months or if PVE
 +
| rowspan="2" |4 weeks if symptoms <3 months;<br />6 weeks if symptoms >3 months or if PVE
 
|-
  
|-
 
| + [[gentamicin]]
  
| + [[gentamicin]]
βˆ’
| 1 mg/kg IV q8h
 +
|1 mg/kg IV q8h
 
|-
  
|-
βˆ’
| rowspan=2 | NVE/PVE
 +
| rowspan="2" |NVE/PVE
βˆ’
| [[ampicillin]]
 +
|[[ampicillin]]
βˆ’
| 2 g IV q4h
 +
|2 g IV q4h
βˆ’
| rowspan=2 | 6 weeks
 +
| rowspan="2" |6 weeks
βˆ’
| rowspan=2 | alternative regimen if CrCl <50
 +
| rowspan="2" |alternative regimen if CrCl <50
 
|-
  
|-
 
| + [[ceftriaxone]]
  
| + [[ceftriaxone]]
βˆ’
| 2 g IV q12h
 +
|2 g IV q12h
 
|-
  
|-
βˆ’
! colspan=5 | ''[[Enterococcus]]'' susceptible to [[penicillin]] and resistant to [[aminoglycosides]]
 +
! colspan="5" |''[[Enterococcus]]'' susceptible to [[penicillin]] and resistant to [[aminoglycosides]]
 
|-
  
|-
βˆ’
| rowspan=2 | NVE/PVE
 +
| rowspan="2" |NVE/PVE
βˆ’
| [[ampicillin]]
 +
|[[ampicillin]]
βˆ’
| 2 g IV q4h
 +
|2 g IV q4h
βˆ’
| rowspan=2 | 6 weeks
 +
| rowspan="2" |6 weeks
βˆ’
| rowspan=2 |
+
| rowspan="2" |
 
|-
  
|-
 
| + [[ceftriaxone]]
  
| + [[ceftriaxone]]
βˆ’
| 2 g IV q12h
 +
|2 g IV q12h
 
|-
  
|-
βˆ’
! colspan=5 | ''[[Enterococcus]]'' resistant to [[penicillin]] and susceptible to [[vancomycin]] and [[aminoglycosides]]
 +
! colspan="5" |''[[Enterococcus]]'' resistant to [[penicillin]] and susceptible to [[vancomycin]] and [[aminoglycosides]]
 
|-
  
|-
βˆ’
| rowspan=2 | NVE/PVE
 +
| rowspan="2" |NVE/PVE
βˆ’
| [[vancomycin]]
 +
|[[vancomycin]]
βˆ’
| 15 mg/kg IV q12h
 +
|15 mg/kg IV q12h
βˆ’
| rowspan=2 | 6 weeks
 +
| rowspan="2" |6 weeks
βˆ’
| rowspan=2 |
 +
| rowspan="2" |
 
|-
  
|-
 
| + [[gentamicin]]
  
| + [[gentamicin]]
βˆ’
| 1 mg/kg IV/IM q8h
 +
|1 mg/kg IV/IM q8h
 
|-
  
|-
βˆ’
! colspan=5 | ''[[Enterococcus]]'' resistant to [[penicillin]], [[aminoglycosides]], and [[vancomycin]]
 +
! colspan="5" |''[[Enterococcus]]'' resistant to [[penicillin]], [[aminoglycosides]], and [[vancomycin]]
 
|-
  
|-
βˆ’
| NVE/PVE
 +
|NVE/PVE
βˆ’
| [[linezolid]]
 +
|[[linezolid]]
βˆ’
| 600 mg IV/PO q12h
 +
|600 mg IV/PO q12h
βˆ’
| &gt;6 weeks
 +
|&gt;6 weeks
 
|
  
|
 
|-
  
|-
βˆ’
| NVE/PVE
 +
|NVE/PVE
βˆ’
| [[daptomycin]]
 +
|[[daptomycin]]
βˆ’
| 10-12 mg/kg IV q24h
 +
|10-12 mg/kg IV q24h
βˆ’
| &gt;6 weeks
 +
|&gt;6 weeks
 
|
  
|
 
|-
  
|-
βˆ’
! colspan=5 | Viridans ''Streptococcus'' or ''Streptococcus gallolyticus'' highly susceptible to [[penicillin]] (MIC ≀0.12 ΞΌg/mL)
 +
! colspan="5" |Viridans ''Streptococcus'' or ''Streptococcus gallolyticus'' highly susceptible to [[penicillin]] (MIC ≀0.12 ΞΌg/mL)
 
|-
  
|-
βˆ’
| NVE
 +
|NVE
βˆ’
| crystalline [[penicillin]] G
 +
|crystalline [[penicillin]] G
βˆ’
| 3-4 MU IV q4h
 +
|3-4 MU IV q4h
βˆ’
| 4 weeks
 +
|4 weeks
 
|
  
|
 
|-
  
|-
βˆ’
| NVE
 +
|NVE
βˆ’
| [[ceftriaxone]]
 +
|[[ceftriaxone]]
βˆ’
| 2 g IV/IM q24h
 +
|2 g IV/IM q24h
βˆ’
| 4 weeks
 +
|4 weeks
 
|
  
|
 
|-
  
|-
βˆ’
| rowspan=2 | NVE
 +
| rowspan="2" |NVE
βˆ’
| [[penicillin]] or [[ceftriaxone]]
 +
|[[penicillin]] or [[ceftriaxone]]
βˆ’
| as above
 +
|as above
βˆ’
| rowspan=2 | 2 weeks
 +
| rowspan="2" |2 weeks
βˆ’
| rowspan=2 |
+
| rowspan="2" |
 
|-
  
|-
 
| + [[gentamicin]]
  
| + [[gentamicin]]
βˆ’
| 3 mg/kg IV/IM q24h
 +
|3 mg/kg IV/IM q24h
 
|-
  
|-
βˆ’
| NVE
 +
|NVE
βˆ’
| [[vancomycin]]
 +
|[[vancomycin]]
βˆ’
| 15 mg/kg IV q12h
 +
|15 mg/kg IV q12h
βˆ’
| 4 weeks
 +
|4 weeks
βˆ’
| use if allergy, target 10-15 ΞΌg/mL
 +
|use if allergy, target 10-15 ΞΌg/mL
 
|-
  
|-
βˆ’
| rowspan=2 | PVE
 +
| rowspan="2" |PVE
βˆ’
| crystalline [[penicillin]] G
 +
|crystalline [[penicillin]] G
βˆ’
| 6 MU IV q4h
 +
|6 MU IV q4h
βˆ’
| 6 weeks
 +
|6 weeks
βˆ’
| rowspan=2 |
 +
| rowspan="2" |
 
|-
  
|-
βˆ’
| Β± [[gentamicin]]
 +
|Β± [[gentamicin]]
βˆ’
| 3 mg/kg IV/IM q24h
 +
|3 mg/kg IV/IM q24h
βˆ’
| 2 weeks
 +
|2 weeks
 
|-
  
|-
βˆ’
| rowspan=2 | PVE
 +
| rowspan="2" |PVE
βˆ’
| [[ceftriaxone]]
 +
|[[ceftriaxone]]
βˆ’
| 2 g IV/IM q24h
 +
|2 g IV/IM q24h
βˆ’
| 6 weeks
 +
|6 weeks
βˆ’
| rowspan=2 |
 +
| rowspan="2" |
 
|-
  
|-
βˆ’
| Β± [[gentamicin]]
 +
|Β± [[gentamicin]]
βˆ’
| 3 mg/kg IV/IM q24h
 +
|3 mg/kg IV/IM q24h
βˆ’
| 2 weeks
 +
|2 weeks
 
|-
  
|-
βˆ’
| PVE
 +
|PVE
βˆ’
| [[vancomycin]]
 +
|[[vancomycin]]
βˆ’
| 15 mg/kg IV q12h
 +
|15 mg/kg IV q12h
βˆ’
| 6 weeks
 +
|6 weeks
βˆ’
| use if allergy
 +
|use if allergy
 
|-
  
|-
βˆ’
! colspan=5 | Viridans ''Streptococcus'' or ''Streptococcus gallolyticus'' relatively resistant to [[penicillin]] (MIC &gt;0.12 ΞΌg/mL)
 +
! colspan="5" |Viridans ''Streptococcus'' or ''Streptococcus gallolyticus'' relatively resistant to [[penicillin]] (MIC &gt;0.12 ΞΌg/mL)
 
|-
  
|-
βˆ’
| rowspan=2 | NVE
 +
| rowspan="2" |NVE
βˆ’
| crystalline [[penicillin]] G
 +
|crystalline [[penicillin]] G
βˆ’
| 6 MU IV q4h
 +
|6 MU IV q4h
βˆ’
| 4 weeks
 +
|4 weeks
βˆ’
| rowspan=2 |
 +
| rowspan="2" |
 
|-
  
|-
 
| + [[gentamicin]]
  
| + [[gentamicin]]
βˆ’
| 3 mg/kg IV/IM q24h
 +
|3 mg/kg IV/IM q24h
βˆ’
| 2 weeks
 +
|2 weeks
 
|-
  
|-
βˆ’
| NVE
 +
|NVE
βˆ’
| [[vancomycin]]
 +
|[[vancomycin]]
βˆ’
| 15 mg/kg IV q12h
 +
|15 mg/kg IV q12h
βˆ’
| 4 weeks
 +
|4 weeks
βˆ’
| use if allergy, target 10-15 ΞΌ/mL
 +
|use if allergy, target 10-15 ΞΌ/mL
 
|-
  
|-
βˆ’
| rowspan=2 | PVE
 +
| rowspan="2" |PVE
βˆ’
| crystalline [[penicillin]] G
 +
|crystalline [[penicillin]] G
βˆ’
| 6 MU IV q4h
 +
|6 MU IV q4h
βˆ’
| rowspan=2 | 6 weeks
 +
| rowspan="2" |6 weeks
βˆ’
| rowspan=2 |
 +
| rowspan="2" |
 
|-
  
|-
 
| + [[gentamicin]]
  
| + [[gentamicin]]
βˆ’
| 3 mg/kg IV/IM q24h
 +
|3 mg/kg IV/IM q24h
 
|-
  
|-
βˆ’
| rowspan=2 | PVE
 +
| rowspan="2" |PVE
βˆ’
| [[ceftriaxone]]
 +
|[[ceftriaxone]]
βˆ’
| 2 g IV/IM q24h
 +
|2 g IV/IM q24h
βˆ’
| rowspan=2 | 6 weeks
 +
| rowspan="2" |6 weeks
βˆ’
| rowspan=2 |
 +
| rowspan="2" |
 
|-
  
|-
 
| + [[gentamicin]]
  
| + [[gentamicin]]
βˆ’
| 3 mg/kg IV/IM q24h
 +
|3 mg/kg IV/IM q24h
 
|-
  
|-
βˆ’
| PVE
 +
|PVE
βˆ’
| [[vancomycin]]
 +
|[[vancomycin]]
βˆ’
| 15 mg/kg IV q12h
 +
|15 mg/kg IV q12h
βˆ’
| 6 weeks
 +
|6 weeks
βˆ’
| use if allergy
 +
|use if allergy
 
|-
  
|-
βˆ’
! colspan=5 | ''Streptococcus pneumoniae''
 +
! colspan="5" |''Streptococcus pneumoniae''
 
|-
  
|-
βˆ’
| NVE || [[penicillin]] || || 4 weeks ||
 +
|NVE||[[penicillin]]|| ||4 weeks||
 
|-
  
|-
βˆ’
| NVE || [[cefazolin]] || || 4 weeks ||
 +
|NVE||[[cefazolin]]|| ||4 weeks||
 
|-
  
|-
βˆ’
| NVE || [[ceftriaxone]] || || 4 weeks ||
 +
|NVE||[[ceftriaxone]]|| ||4 weeks||
 
|-
  
|-
βˆ’
| PVE || [[penicillin]] || || 6 weeks ||
 +
|PVE||[[penicillin]]|| ||6 weeks||
 
|-
  
|-
βˆ’
| PVE || [[cefazolin]] || || 6 weeks ||
 +
|PVE||[[cefazolin]]|| ||6 weeks||
 
|-
  
|-
βˆ’
| PVE || [[ceftriaxone]] || || 6 weeks ||
 +
|PVE||[[ceftriaxone]]|| ||6 weeks||
 
|-
  
|-
βˆ’
! colspan=5 | ''Streptococcus pyogenes''
 +
! colspan="5" |''Streptococcus pyogenes''
 
|-
  
|-
βˆ’
| NVE || crystalline [[penicillin]] G || || 4 weeks ||
 +
|NVE||crystalline [[penicillin]] G|| ||4 weeks||
 
|-
  
|-
βˆ’
| NVE || [[ceftriaxone]] || || 4 weeks ||
 +
|NVE||[[ceftriaxone]]|| ||4 weeks||
 
|-
  
|-
βˆ’
| PVE || crystalline [[penicillin]] G || || 6 weeks ||
 +
|PVE||crystalline [[penicillin]] G|| ||6 weeks||
 
|-
  
|-
βˆ’
| PVE || [[ceftriaxone]] || || 6 weeks ||
 +
|PVE||[[ceftriaxone]]|| ||6 weeks||
 
|-
  
|-
βˆ’
! colspan=5 | Group B, C, or G ''Streptococcus''
 +
! colspan="5" |Group B, C, or G ''Streptococcus''
 
|-
  
|-
βˆ’
| rowspan=2 | NVE
 +
| rowspan="2" |NVE
βˆ’
| crystalline [[penicillin]] G
 +
|crystalline [[penicillin]] G
 
|
  
|
βˆ’
| 4 weeks
 +
|4 weeks
βˆ’
| rowspan=2 |
+
| rowspan="2" |
 
|-
  
|-
βˆ’
| Β± [[gentamicin]]
 +
|Β± [[gentamicin]]
βˆ’
|
+
|
βˆ’
| 2 weeks
 +
|2 weeks
 
|-
  
|-
βˆ’
| rowspan=2 | NVE
 +
| rowspan="2" |NVE
βˆ’
| [[ceftriaxone]]
 +
|[[ceftriaxone]]
βˆ’
|
+
|
βˆ’
| 4 weeks
 +
|4 weeks
βˆ’
| rowspan=2 |
 +
| rowspan="2" |
 
|-
  
|-
βˆ’
| Β± [[gentamicin]]
 +
|Β± [[gentamicin]]
βˆ’
|
+
|
βˆ’
| 2 weeks
 +
|2 weeks
 
|-
  
|-
βˆ’
| rowspan=2 | PVE
 +
| rowspan="2" |PVE
βˆ’
| crystalline [[penicillin]] G
 +
|crystalline [[penicillin]] G
βˆ’
|
+
|
βˆ’
| 6 weeks
 +
|6 weeks
βˆ’
| rowspan=2 |
 +
| rowspan="2" |
 
|-
  
|-
βˆ’
| Β± [[gentamicin]]
 +
|Β± [[gentamicin]]
βˆ’
|
+
|
βˆ’
| 2 weeks
 +
|2 weeks
 
|-
  
|-
βˆ’
| rowspan=2 | PVE
 +
| rowspan="2" |PVE
βˆ’
| [[ceftriaxone]]
 +
|[[ceftriaxone]]
βˆ’
|
+
|
βˆ’
| 6 weeks
 +
|6 weeks
βˆ’
| rowspan=2 |
 +
| rowspan="2" |
 
|-
  
|-
βˆ’
| Β± [[gentamicin]]
 +
|Β± [[gentamicin]]
βˆ’
|
+
|
βˆ’
| 2 weeks
 +
|2 weeks
 
|-
  
|-
βˆ’
! colspan=5 | HACEK bacterium
 +
! colspan="5" |HACEK bacterium
 
|-
  
|-
βˆ’
| NVE
 +
|NVE
βˆ’
| [[ceftriaxone]]
 +
|[[ceftriaxone]]
βˆ’
| 2 g IV/IM q24h
 +
|2 g IV/IM q24h
βˆ’
| 4 weeks
 +
|4 weeks
 
|
  
|
 
|-
  
|-
βˆ’
| PVE
 +
|PVE
βˆ’
| [[ceftriaxone]]
 +
|[[ceftriaxone]]
βˆ’
| 2 g IV/IM q24h
 +
|2 g IV/IM q24h
βˆ’
| 6 weeks
 +
|6 weeks
 
|
  
|
 
|-
  
|-
βˆ’
| NVE/PVE
 +
|NVE/PVE
βˆ’
| [[ciprofloxacin]]
 +
|[[ciprofloxacin]]
βˆ’
| 500 mg PO q12h
 +
|500 mg PO q12h
βˆ’
| 6 weeks
 +
|6 weeks
βˆ’
|
+
|
 
|}
  
|}
   

Revision as of 20:07, 18 August 2020

Background

  • Infection of endocardium, generally involving the heart valves, either prosthetic or native

Microbiology

Risk Factors

  • Cardiac
    • Prior endocarditis
    • Prosthetic heart valve or implanted device
    • Congenital heart disease, especially unrepaired cyanotic congenital heart disease
    • Valve abnormalities
  • Non-cardiac
    • Intravenous drug use
    • Indwelling intravenous lines
    • Immunosuppression
    • Recent dental work or surgical procedure associated with bacteremia

Clinical Manifestations

Subacute Bacterial Endocarditis

  • Insidious onset with more pronounced constitutional symptoms progressing over weeks to months

Differential Diagnosis

Management

Valve Antibiotic Dose Duration Notes
MSSA and other oxacillin-susceptible Staphylococcus
NVE oxacillin 2 g IV q4h 6 weeks can treat for 2 weeks in uncomplicated right-sided NVE
NVE cefazolin 2 g IV q8h 6 weeks in patients with non-anaphylactoid penicillin allergy
PVE oxacillin 2 g IV q4h β‰₯6 weeks use cefazolin or vancomycin if allergy
+ rifampin 300 mg IV/PO q8h
+ gentamicin 1 mg/kg IV/IM q8h 2 weeks
MRSA and other oxacillin-resistant Staphylococcus
NVE vancomycin 15 mg/kg IV q12h 6 weeks target trough 10-20 ΞΌg/mL
NVE daptomycin β‰₯8 mg/kg/dose 6 weeks
PVE vancomycin 15 mg/kg IV q12h β‰₯6 weeks target vancomycin trough of 10-20 ΞΌg/mL
+ rifampin 300 mg IV/PO q8h
+ gentamicin 1 mg/kg IV/IM q8h 2 weeks
Enterococcus susceptible to penicillin and gentamicin
NVE/PVE ampicillin 2 g IV q4h 4-6 weeks 4 weeks if symptoms <3 months;
6 weeks if symptoms >3 months or if PVE
+ gentamicin 1 mg/kg IV q8h
NVE/PVE ampicillin 2 g IV q4h 6 weeks alternative regimen if CrCl <50
+ ceftriaxone 2 g IV q12h
Enterococcus susceptible to penicillin and resistant to aminoglycosides
NVE/PVE ampicillin 2 g IV q4h 6 weeks
+ ceftriaxone 2 g IV q12h
Enterococcus resistant to penicillin and susceptible to vancomycin and aminoglycosides
NVE/PVE vancomycin 15 mg/kg IV q12h 6 weeks
+ gentamicin 1 mg/kg IV/IM q8h
Enterococcus resistant to penicillin, aminoglycosides, and vancomycin
NVE/PVE linezolid 600 mg IV/PO q12h >6 weeks
NVE/PVE daptomycin 10-12 mg/kg IV q24h >6 weeks
Viridans Streptococcus or Streptococcus gallolyticus highly susceptible to penicillin (MIC ≀0.12 ΞΌg/mL)
NVE crystalline penicillin G 3-4 MU IV q4h 4 weeks
NVE ceftriaxone 2 g IV/IM q24h 4 weeks
NVE penicillin or ceftriaxone as above 2 weeks
+ gentamicin 3 mg/kg IV/IM q24h
NVE vancomycin 15 mg/kg IV q12h 4 weeks use if allergy, target 10-15 ΞΌg/mL
PVE crystalline penicillin G 6 MU IV q4h 6 weeks
Β± gentamicin 3 mg/kg IV/IM q24h 2 weeks
PVE ceftriaxone 2 g IV/IM q24h 6 weeks
Β± gentamicin 3 mg/kg IV/IM q24h 2 weeks
PVE vancomycin 15 mg/kg IV q12h 6 weeks use if allergy
Viridans Streptococcus or Streptococcus gallolyticus relatively resistant to penicillin (MIC >0.12 ΞΌg/mL)
NVE crystalline penicillin G 6 MU IV q4h 4 weeks
+ gentamicin 3 mg/kg IV/IM q24h 2 weeks
NVE vancomycin 15 mg/kg IV q12h 4 weeks use if allergy, target 10-15 ΞΌ/mL
PVE crystalline penicillin G 6 MU IV q4h 6 weeks
+ gentamicin 3 mg/kg IV/IM q24h
PVE ceftriaxone 2 g IV/IM q24h 6 weeks
+ gentamicin 3 mg/kg IV/IM q24h
PVE vancomycin 15 mg/kg IV q12h 6 weeks use if allergy
Streptococcus pneumoniae
NVE penicillin 4 weeks
NVE cefazolin 4 weeks
NVE ceftriaxone 4 weeks
PVE penicillin 6 weeks
PVE cefazolin 6 weeks
PVE ceftriaxone 6 weeks
Streptococcus pyogenes
NVE crystalline penicillin G 4 weeks
NVE ceftriaxone 4 weeks
PVE crystalline penicillin G 6 weeks
PVE ceftriaxone 6 weeks
Group B, C, or G Streptococcus
NVE crystalline penicillin G 4 weeks
Β± gentamicin 2 weeks
NVE ceftriaxone 4 weeks
Β± gentamicin 2 weeks
PVE crystalline penicillin G 6 weeks
Β± gentamicin 2 weeks
PVE ceftriaxone 6 weeks
Β± gentamicin 2 weeks
HACEK bacterium
NVE ceftriaxone 2 g IV/IM q24h 4 weeks
PVE ceftriaxone 2 g IV/IM q24h 6 weeks
NVE/PVE ciprofloxacin 500 mg PO q12h 6 weeks

References

  1. ^  Kasper Iversen, Nikolaj Ihlemann, Sabine U. Gill, Trine Madsen, Hanne Elming, Kaare T. Jensen, Niels E. Bruun, Dan E. HΓΈfsten, Kurt Fursted, Jens J. Christensen, Martin Schultz, Christine F. Klein, Emil L. FosbΓΈll, Flemming Rosenvinge, Henrik C. SchΓΈnheyder, Lars KΓΈber, Christian Torp-Pedersen, Jannik Helweg-Larsen, Niels TΓΈnder, Claus Moser, Henning Bundgaard. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. New England Journal of Medicine. 2019;380(5):415-424. doi:10.1056/nejmoa1808312.
  2. ^  John A Wildenthal, Andrew Atkinson, Sophia Lewis, Sena Sayood, Nathanial S Nolan, Nicolo L Cabrera, Jonas Marschall, Michael J Durkin, Laura R Marks. Outcomes of Partial Oral Antibiotic Treatment for Complicated Staphylococcus aureus Bacteremia in People Who Inject Drugs. Clinical Infectious Diseases. 2022;76(3):487-496. doi:10.1093/cid/ciac714.
  3. ^  Sarah Freling, Noah Wald-Dickler, Josh Banerjee, Catherine P Canamar, Soodtida Tangpraphaphorn, Dara Bruce, Kusha Davar, Fernando Dominguez, Daniel Norwitz, Ganesh Krishnamurthi, Lilian Fung, Ashley Guanzon, Emi Minejima, Michael Spellberg, Catherine Spellberg, Rachel Baden, Paul Holtom, Brad Spellberg. Real-World Application of Oral Therapy for Infective Endocarditis: A Multicenter, Retrospective, Cohort Study. Clinical Infectious Diseases. 2023;77(5):672-679. doi:10.1093/cid/ciad119.

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