eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Pericarditis, Bacterial: Treatment & Medication

Author: John Berger, MD, Departments of Critical Care Medicine and Pediatric Cardiology, Assistant Professor, George Washington University and Children's National Medical Center
Contributor Information and Disclosures

Updated: Jul 15, 2008

Treatment

Medical Care

Proper treatment of life-threatening illness requires proper antimicrobial therapy, pericardial decompression and drainage, and intensive supportive care.

• Antibiotics
  • Until a definitive agent is identified, empiric therapy includes antibiotics to treat both S aureus and gram-negative bacilli.
  • Initial antibiotics should include a combination of penicillinase-resistant penicillin and third-generation cephalosporin.
  • In areas of high antibiotic resistance, consider the use of vancomycin and a third-generation cephalosporin.
  • Include an aminoglycoside if the patient is postoperative from cardiac surgery, is immunocompromised, or has a genitourinary coinfection.
  • Duration of therapy is empiric but generally continues for 3-4 weeks with an antibiotic specific to the organism isolated.
• Pericardial drainage
  • Although needle pericardiocentesis may be life saving in tamponade and confirming the diagnosis, it rarely provides complete and long-lasting resolution of the effusion.
  • Avoid repeated attempts at needle pericardiocentesis because they are associated with increased morbidity rates.
  • Open surgical drainage has been used in most cases of purulent pericarditis.
  • Continuous drainage using specialized pericardial catheters and echographic monitoring has had reported success in treating bacterial pericarditis. However, the pericardial fluid may be too thick or loculated to be drained adequately by a catheter.
  • Delay in adequate pericardial drainage is associated with increased mortality rates.
• Supportive care
  • Almost all patients require intensive supportive care.
  • In patients with tamponade, supportive therapies are of little or no benefit until emergent pericardial drainage is performed.
  • Drugs that depress the heart rate, produce vasodilatation, or decrease intravascular volume are contraindicated because they further compromise cardiac output. Do not administer digoxin to an infant with purulent pericarditis who shows signs of congestive heart failure.
  • Application of positive pressure mechanical ventilation and positive end-expiratory pressure (PEEP) must be performed carefully because the increased intrathoracic pressure can lead to lethal falls in ventricular preload and worsened shock.
  • Although systolic function of the heart may not be depressed, inotropic agents may be required to treat hypotension that persists after pericardial drainage.
  • Plasma volume expansion is helpful in maintaining cardiac output.

Surgical Care

• Pericardial drainage
  • If pericardiocentesis is unsuccessful in resolving tamponade, emergent surgical drainage is indicated.
  • Surgical drainage is indicated in most patients after the acute emergency resolves.
  • Delay in adequate pericardial drainage is associated with increased mortality rates.
  • Various surgical procedures have been used to provide adequate pericardial drainage, and optimal approach is controversial. Techniques for drainage include placement of a large bore subxiphoid drainage tube (with or without irrigation), creation of a pericardial window and placement of a drain, or pericardiectomy.
  • Proponents of pericardiectomy argue that thick clots and fibrin are not removed through a tube and that it prevents the possibility of late pericardial constriction and recurrent tamponade.
• Pericardiectomy: Late pericardiectomy may be required in the rare patient who develops constrictive pericarditis as a complication of the infection.

Consultations

• Critical care specialist: Most patients with bacterial pericarditis present with severe hemodynamic compromise. Patients should be referred to specialists proficient in the use of vasoactive agents and mechanical ventilation.
• Cardiologist: Patients with cardiomegaly and cardiovascular compromise require cardiology consultation and echocardiography to rule out myocardial or pericardial disease.
• Cardiovascular surgeon: Emergent consultation with a cardiovascular surgeon is warranted in patients who have incomplete resolution of pericardial tamponade despite pericardiocentesis. Consultation should be considered in patients with recurrent effusions or constrictive pericarditis.

Activity

No activity restrictions are required in patients who have recovered from bacterial pericarditis.

Medication

Antibiotic agents

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Initial empiric coverage requires a combination of a penicillinase-resistant penicillin and third-generation cephalosporin. In areas of high antibiotic resistance, substitute vancomycin for the penicillin antibiotic.

Oxacillin

Bactericidal antibiotic that inhibits cell wall synthesis. Used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.

Nafcillin

Bactericidal antibiotic that inhibits cell wall synthesis. Used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.

Vancomycin (Vancocin, Vancoled)

Indicated for patients with suspected or known infection with resistant organisms. To avoid toxicity, assay vancomycin trough levels 30 min before fourth dose. Use CrCl to adjust dose in patients diagnosed with renal impairment.

Cefotaxime (Claforan)

Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin binding proteins.

Gentamicin (Garamycin)

Aminoglycoside antibiotic for gram-negative coverage. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. To avoid toxicity, assay trough levels 30 min before fourth dose and peak levels 30-60 min following.

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