Pericarditis Organism-Specific Therapy 

Updated: Jan 16, 2015
  • Author: Ryan C Maves, MD, FACP, FCCP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Specific Organisms and Therapeutic Regimens

Organism-specific therapeutic regimens for infectious pericarditis are provided below, including those for bacterial infections, viral infections, fungal infections, and mycobacterial infections. [1, 2]

Bacterial infection

Most cases of bacterial pericarditis require percutaneous or surgical pericardial drainage for cure. Early cardiology and cardiothoracic surgery consultation is strongly recommended.

Streptococcus pneumoniae

Penicillin-sensitive

  • First-line treatment: Penicillin G 4 million units IV q4h (penicillin MIC ≤2 µg/mL)
  • Second-line treatment: Ceftriaxone 2 g IV q24h (penicillin MIC >2 µg/mL and susceptible to ceftriaxone)
  • Duration of therapy: 2-6 weeks

Penicillin-resistant or patient with penicillin allergy

  • First-line treatment: Vancomycin 15 mg/kg IV q12h
  • Second-line treatment: Levofloxacin 750 mg IV/PO daily or moxifloxacin 400 mg IV/PO daily
  • Duration of therapy: 2-6 weeks

Staphylococcus aureus

Methicillin-sensitive (MSSA)

  • First-line treatment: Nafcillin or  oxacillin 2 g IV q4h or  cefazolin 2 g IV q8h or ceftriaxone 2 g IV q24h
  • Second-line treatment: see agents listed for MRSA below
  • Duration of therapy: 2-6 weeks

Methicillin-resistant (MRSA)

  • First-line treatment: Vancomycin 15 mg/kg IV q12h
  • Second-line treatment: Linezolid 600 mg IV/PO q24h
  • Duration of therapy: 2-6 weeks

Neisseria meningitidis

  • First-line treatment: Ceftriaxone 2 g IV/IM q12h (may reduce to 2 g IV q24h only if concomitant meningitis is ruled out)
  • Second-line treatment: Ampicillin 2 g IV q4h
  • Third-line treatment: Penicillin G 4 million units IV q4h
  • Duration of therapy: 2-6 weeks

Pseudomonas aeruginosa

  • First-line treatments: Cefepime 2 g IV q8h or  piperacillin-tazobactam 4.5 g IV q6h or meropenem 2 g IV q8h
  • Second-line treatments: ciprofloxacin 400 mg IV q8h or  ciprofloxacin 750 mg PO bid or levofloxacin 750 mg IV/PO q24h
  • Duration of therapy: 2-6 weeks

Enteric gram-negative bacilli (community-acquired)

  • First-line treatment: Ceftriaxone 2 g IV q24h
  • Duration of first-line therapy: 2-6 weeks
  • Second-line treatment: Ciprofloxacin 400 mg IV q12 or ciprofloxacin 500 mg PO q12h or levofloxacin 500 mg IV/PO q24h
  • Duration of second-line therapy: 2-6 weeks

Legionella pneumophila

  • First-line treatment: Azithromycin 500 mg IV/PO q24h
  • Second-line treatment: Levofloxacin 500 mg IV/PO q24h
  • Duration of therapy: 2-6 weeks

Anaerobes (Prevotella, Peptostreptococcus, Bacteroides)

  • First-line treatment: Clindamycin 600 mg IV/PO q6h
  • Second-line treatment: Metronidazole 500 mg IV/PO q12h
  • Duration of therapy: 2-6 weeks

Viral infection

See Pericarditis Empiric Therapy

  • If associated with human immunodeficiency virus (HIV) infection, treat with antiretroviral therapy, monitor for immune reconstitution inflammatory syndrome, and screen for opportunistic infections according to CD4 count
  • If associated with hepatitis B or C, treat with antiviral therapy as dictated by specific virus and genotype.
  • If associated with influenza A or B, treat with oseltamivir 75 mg PO BID × 10 doses

Fungal infection

Most cases of fungal pericarditis require percutaneous or surgical pericardial drainage for cure. Early cardiology and cardiothoracic surgery consultation is strongly recommended.

Candida albicans

Non -albicans Candida species

Aspergillus

First-line treatment

  • Voriconazole 6 mg/kg IV q12h × 1d, then 4 mg/kg IV q12h (oral dosage is 200 mg q12h); or  posaconazole 200 mg q6h initially, then 400 mg PO q12h once clinically stable
  • Duration of therapy: 2-6 weeks

Second-line treatment

  • Caspofungin 70-mg loading dose, then 50 mg IV q24h; or micafungin 100-150 mg IV daily
  • Duration of therapy: 2-6 weeks

Third-line treatment

Histoplasmosis

Immunocompetent with mild illness: NSAIDs as per Pericarditis Empiric Therapy, Viral

Immunocompromised illness not responsive to NSAIDs, or hemodynamically unstable

  • Itraconazole 200 mg q8h × 3d, then q12h × 6-12wk
  • Prednisone 0.5-1.0 mg/kg IV daily (maximum, 80 mg daily), taper dose over 1-2wk

Mycobacterial infection

See Pericarditis Empiric Therapy, Mycobacterial.

Other organisms

Mycoplasma pneumoniae

First-line treatment

  • Doxycycline 100 mg IV/PO q12h
  • Duration of therapy: 2-6 weeks

Second-line treatment

  • Azithromycin 500 mg IV/PO q24h
  • Duration of therapy: 2-6 weeks

Third-line treatment

  • Erythromycin 500 mg IV/PO q6h
  • Duration of therapy: 2-6 weeks