Infective endocarditis
From IDWiki
Background
- Infection of heart valves, either prosthetic or native
Organisms
- Bacteria
- Staphylococcus aureus (most common)
- Viridans group streptococci
- Coagulase-negative staphylococci
- Other streptococci
- Enterococci
- HACEK group
- Coxiella
- Brucella
- Fungi
Clinical Presentation
- 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
Management
- Varies by causative organism and prosthetic vs. native valve
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 | ≥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 μg/mL |
NVE | daptomycin | ≥8 mg/kg/dose | 6 weeks | |
PVE | vancomycin | 15 mg/kg IV q12h | ≥6 weeks | target vancomycin trough of 10-20 μg/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 μg/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 μg/mL |
PVE | crystalline penicillin G | 6 MU IV q4h | 6 weeks | |
± gentamicin | 3 mg/kg IV/IM q24h | 2 weeks | ||
PVE | ceftriaxone | 2 g IV/IM q24h | 6 weeks | |
± 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 μg/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 μ/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 | ||
± gentamicin | 2 weeks | |||
NVE | ceftriaxone | 4 weeks | ||
± gentamicin | 2 weeks | |||
PVE | crystalline penicillin G | 6 weeks | ||
± gentamicin | 2 weeks | |||
PVE | ceftriaxone | 6 weeks | ||
± 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 |