eMedicine Specialties > Emergency Medicine > Infectious Diseases
Endocarditis: Treatment & Medication
Updated: Nov 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
- Focus ED care on making the correct diagnosis and stabilizing the patient with acute disease and cardiovascular instability.
- In most cases, the etiologic microbial agent is not known while the patient is in the ED.
- General recommendations include drawing 3 sets of blood cultures over a few hours, and then empiric antibiotic therapy may be administered. The choice of empiric therapy can be tailored to the patient's history and circumstances.
- General measures
- Treatment of congestive heart failure
- Oxygen
- Hemodialysis (may be required in patients with renal failure)
Consultations
Admit all patients with suspected infectious endocarditis to the hospital for IV antibiotics while blood cultures are pending. Appropriate consultations could include cardiology, cardiothoracic surgery, and infectious disease services.
Medication
Empiric antibiotic therapy is chosen based on the most likely infecting organisms. Native valve disease has often traditionally been treated with penicillin G and gentamicin for synergistic coverage of streptococci. Patients with a history of IV drug use have been treated with nafcillin and gentamicin to cover for methicillin-sensitive staphylococci. The emergence of methicillin-resistant Staphylococcus aureus and penicillin-resistant streptococci has led to a change in empiric treatment with liberal substitution of vancomycin in lieu of a penicillin antibiotic.
Infection of a prosthetic valve may include methicillin-resistant Staphylococcus aureus or coagulase-negative staphylococci7 ; thus, vancomycin and gentamicin may be used, despite the risk of renal insufficiency. Rifampin also may be helpful in patients with prosthetic valves or other foreign bodies; however, it should be used in addition to vancomycin or gentamicin.
Linezolid or daptomycin are options for patients with intolerance to vancomycin or resistant organisms.14 Appropriate regimens should be devised in consultation with a specialist in infectious disease.
Antibiotics
Therapy must cover all likely pathogens in the context of this clinical setting.
Penicillin G (Pfizerpen)
DOC for streptococcal infection. Interferes with cell-wall mucopeptide synthesis of the microorganism.
Adult
12-18 million U/d IV divided q4h
Pediatric
200,000-400,000 U/kg/d IV divided q4-6h
Probenecid can increase penicillin effectiveness by decreasing clearance; coadministration with tetracyclines can decrease effectiveness of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Nafcillin (Unipen)
Provides coverage for penicillinase-producing staphylococci. Use to initiate therapy in any patient in whom a penicillin G–resistant staphylococcal infection is suspected. Do not use for the treatment of penicillin G-susceptible staphylococci.
Use parenteral therapy initially in severe infections. Very severe infections may require very high doses. Change to oral therapy as condition improves.
Because of occasional occurrence of thrombophlebitis associated with parenteral route, particularly in elderly patients, administer parenterally only for a short term (24-48 h), and change to oral route if clinically possible.
Adult
2 g IV q4h
Pediatric
100-200 mg/kg/d IV divided q4-6h
Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
To optimize therapy, determine causative organisms and susceptibility; >10 d treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); obtain cultures after treatment to confirm that infection is eradicated
Gentamicin (Gentacidin, Garamycin)
Offers synergistic benefit with penicillins in the treatment of gram-positive cocci. Use of high-dose, once-daily aminoglycosides has not been evaluated in endocarditis.
Adult
1.5 mg/kg IV loading dose, followed by 1 mg/kg IV tid
Pediatric
7.5 mg/kg/d IV divided tid
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents thus prolonged respiratory depression may, occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity, non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Vancomycin (Vancocin)
Used for penicillin-resistant streptococci, methicillin-resistant staphylococci (eg, S epidermidis), and enterococci.
Potent antibiotic directed against gram-positive organisms and is active against enterococci. Also useful in the treatment of septicemia and skin structure infections.
To avoid toxicity, the current recommendation is to assay vancomycin trough levels after the third dose drawn, 0.5 h prior to next dosing. Use CrCl to adjust the dose in patients with renal impairment.
Adult
30 mg/kg/d IV divided bid
Pediatric
40-60 mg/kg/d IV divided q6-8h
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; "red man" syndrome is caused by too-rapid IV infusion (dose given over a few minutes) but rarely happens when dose given as 2-h administration or as PO or IP administration; "red man" syndrome is not an allergic reaction
Rifampin (Rifadin, Rimactane)
Used synergistically in the treatment of staphylococcal infections associated with a foreign body, such as a prosthetic heart valve.
Inhibits DNA-dependent RNA polymerase activity in susceptible cells. Specifically, it interacts with bacterial RNA polymerase but does not inhibit the mammalian enzyme. Cross-resistance has been shown only with other rifamycins.
Adult
300 mg PO q8h
Pediatric
20 mg/kg/d PO qd; not to exceed 600 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin
Blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Rifampin and isoniazid when given after halothane anesthesia have been associated with hepatotoxicity and hepatic encephalopathy
Combination of isoniazid and rifampin may result in a higher rate of hepatotoxicity than when either agent is given alone; thus, discontinue one or both agents if alterations in LFTs occur
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBCs and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Linezolid (Zyvox)
Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against enterococci and staphylococci and bactericidal against most strains of streptococci. Used as alternative in patients allergic to vancomycin and for treatment of vancomycin-resistant enterococci. Effective against methicillin-resistant Staphylococcus aureus
Adult
600 mg PO/IV q12h for 14-28 d
Pediatric
Not established
May cause hypertension when used concomitantly with adrenergic agents, including pseudoepinephrine, sympathomimetic agents, and vasopressor or dopaminergic agents (reduce dose of dopamine or epinephrine if concurrent use required); serotonin syndrome may occur if used concomitantly with serotonergic agents, including tricyclic antidepressants, meperidine, dextromethorphan, trazodone, venlafaxine, and selective serotonin reuptake inhibitors
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Has mild MAOI properties and has potential to have same interactions as other MAOIs; caution in uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, or untreated hyperthyroidism, and patients who are at increased risk for bleeding, have preexisting thrombocytopenia, receive concomitant medications that may decrease platelet count or function, or who may require > 2 wk of therapy (monitor platelet counts); unnecessary use may lead to development of resistance to drug
More on Endocarditis |
| Overview: Endocarditis |
| Differential Diagnoses & Workup: Endocarditis |
 Treatment & Medication: Endocarditis |
| Follow-up: Endocarditis |
| Multimedia: Endocarditis |
| References |
| Further Reading |
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References
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Keywords
endocarditis, endocarditis symptoms, endocarditis causes, endocarditis treatment, inflammation of the endocardium, infective endocarditis, native valve endocarditis, native valve acute endocarditis, prosthetic valve endocarditis, valve infection, heart disease, nonbacterial thrombotic endocarditis
