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Endocarditis, Bacterial: Treatment & Medication
Updated: Nov 13, 2009
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Treatment
Medical Care
Bacterial endocarditis is a disease in which complete eradication of the organism is required. Bacteria involved in endocarditis are relatively protected from phagocytic activity by the vegetation, which contains high concentrations of bacteria with relatively low metabolic rates. Prolonged parenteral therapy is the only way to achieve bactericidal serum levels for the time needed to kill all the bacteria present in a vegetation of endocarditis. Treatment ranges from 4-8 weeks.
Therapy is tailored according to the etiologic agent.2 Recommended antibiotic regimens for uncomplicated bacterial endocarditis are listed below. Because of the high risk for morbidity and mortality associated with this disease, individual therapy should be discussed between all consultants with the available antibiotic sensitivity testing.
- Penicillin-susceptible streptococcal endocarditis (PSSE) on native cardiac valves is treated with penicillin G for 4 weeks or penicillin or ceftriaxone combined with gentamicin for 2 weeks. Penicillin-resistant streptococcal endocarditis (PRSE) on native cardiac valves is treated with penicillin, ampicillin, or ceftriaxone for 4 weeks combined with gentamicin for the first 2 weeks.
- PSSE on prosthetic valve or other prosthetic material should be treated with penicillin, ampicillin, or ceftriaxone for 6 weeks combined with gentamicin for the first 2 weeks. PRSE on prosthetic valve or other prosthetic material is treated with penicillin, ampicillin, or ceftriaxone for 6 weeks combined with gentamicin.
- Susceptible enterococcal infection on native valves is treated with penicillin or ampicillin combined with gentamicin for 4-6 weeks. Infection on prosthetic material should be for at least 6 weeks.
- Methicillin-susceptible S aureus (MSSA) infection on native valves is treated with nafcillin or oxacillin for at least 6 weeks. The addition of gentamicin for 3-5 days is optional. Methicillin-resistant S aureus (MRSA) infection on native valves is treated with vancomycin for at least 6 weeks, with or without 3-5 days of gentamicin.
- MSSA infection on prosthetic tissue is treated with nafcillin or oxacillin plus rifampin for at least 6 weeks, in combination with gentamicin for 2 weeks. MRSA infection on prosthetic tissue is treated with vancomycin plus rifampin for at least 6 weeks, in combination with gentamicin for 2 weeks.
- Gram negative endocarditis caused by HACEK organisms is treated with ceftriaxone or ampicillin plus gentamicin for 4 weeks.
Surgical Care
Absolute indications for surgery include progressive cardiac failure, valve obstruction, definitive perivalvular abscess, noncandidal fungal infection, and pseudomonal infection. Relative indications include persistent bacteremia despite appropriate antibiotic therapy, candidal endocarditis, and vegetations larger than 10 mm.
Surgery should be performed without delay in patients with severe congestive heart failure (CHF) secondary to valvular regurgitation. Surgery for patients who have had a recent neurologic injury should be evaluated and possibly delayed to make modifications to avoid intracranial hemorrhage.
Consultations
Initial consultants for the patient suspected to have bacterial endocarditis should include an infectious disease specialist, a cardiologist, and a cardiac surgeon.
Diet
No specific dietary restrictions are recommended in the literature for the patient with bacterial endocarditis.
Activity
Patients may be as active as they can tolerate. Patients may be ill and should remain hospitalized until they are hemodynamically stable, afebrile, with negative blood cultures, and not at high risk for complications.
Medication
Antimicrobial agents
Treatment with antibiotics is specific to the etiologic agent and its characteristics. Therapy for penicillin-susceptible streptococcal endocarditis (PSSE), penicillin-resistant streptococcal endocarditis (PRSE), enterococcal endocarditis, methicillin-susceptible S aureus (MSSA), methicillin-resistant S aureus (MRSA), endocarditis caused by HACEK organisms (ie, Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella species), and fungal endocarditis are aimed at total eradication of the organism. After antibiotic treatment, antibiotic prophylaxis is required before procedures that may cause bacteremia are performed. For more information, see Antibiotic Prophylactic Regimens for Endocarditis.
Penicillin G (Pfizerpen)
First-line agent that interferes with synthesis of cell-wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
10-20 million U/d IV divided q4-6h for 4 wk
Pediatric
200,000-400,000 U/kg/d IV divided q4-6h for 4 wk
Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, decreasing effectiveness of concurrent penicillins
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 (adjust dose)
Ceftriaxone (Rocephin)
Alternative to penicillin. Third-generation cephalosporin with broad-spectrum gram-negative activity; decreased efficacy against gram-positive organisms; and increased efficacy against resistant organisms. Arrests bacterial growth by binding >1 penicillin-binding proteins.
Adult
PSSE or HACEK: 2 g/d IV/IM for 4 wk
Pediatric
PSSE or HACEK:
<45 kg: 50 mg/kg/d IV/IM divided q12h for 4 wk; not to exceed 2 g/d
>45 kg: Administer as in adults
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Decrease dose in combined hepatic and renal impairment; caution in breastfeeding women and penicillin allergy
Gentamicin (Garamycin)
Aminoglycoside antibiotic for gram-negative coverage. Not DOC. Consider if penicillins or other, less toxic drugs contraindicated; if clinically indicated; or if mixed infections are caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; adjust dose on basis of CrCl and changes in volume of distribution. Follow up each regimen by measuring trough level drawn 30 min before the third or fourth dose. Peak levels may be drawn 30 min after 30-min infusion.
Adult
PSSE: 1 mg/kg IV q8h for 2 wk; use in combination with ceftriaxone
Enterococcal: 1 mg/kg IV q8h for 4 wk; use in combination with ampicillin
MSSA: 1 mg/kg IV q8h for 3-5 d; use in combination with nafcillin
Pediatric
Administer as in adults
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity risk; may 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 (patient not receiving dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Vancomycin (Vancocin)
DOC in patients who cannot receive or whose condition fails to respond to penicillins and cephalosporins or who have infections with resistant staphylococci. Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. To avoid toxicity, current recommendation is to assay trough levels 0.5 h before fourth dose. Adjust dose according to CrCl in renal impairment.
Adult
PRSE or MRSA: 15 mg/kg IV q12h for 4 wk; not to exceed 2 g/d (unless serum levels measured)
Pediatric
Administer as in adults
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 and neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over few min) but rare when dose given over 2 h; red man syndrome is not an allergic reaction
Ampicillin (Omnipen, Principen)
Bactericidal activity against susceptible organisms. Alternative to amoxicillin when patient cannot take PO medication.
Adult
Enterococcal or HACEK: 2 g IV q4h for 4 wk
Pediatric
Enterococcal or HACEK: 100-200 mg/kg/d IV divided q4h for 4 wk; not to exceed 12 g/d
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Nafcillin (Unipen, Nafcil)
Initial therapy for suspected penicillin G–resistant (methicillin-susceptible) staphylococcal infections. Because of thrombophlebitis, particularly in elderly patients, administer parenterally only for short term (1-2 d); change to PO as clinically indicated.
Adult
MSSA: 2 g IV q4h for 4-6 wk
Pediatric
MSSA: 100-200 mg/kg/d IV divided q4h for 4-6 wk; not to exceed 12 g/d
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); obtain cultures after treatment to confirm that infection is eradicated
Oxacillin (Bactocill, Prostaphlin)
Bactericidal antibiotic that inhibits cell-wall synthesis; used to treat infections caused by penicillinase-producing staphylococci. May be used to start therapy when staphylococcal infection suspected.
Adult
MSSA: 2 g IV q4h for 4-6 wk
Pediatric
MSSA: 150-200 mg/kg/d IV divided q4h for 4-6 wk; not to exceed 12 g/d
Decreases effects of contraceptives and tetracycline; administered concomitantly with disulfiram and probenecid may increase levels; effect of anticoagulants increase when large IV doses given
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 (adjust dose)
Amphotericin B (Amphocil, Fungizone)
Produced by strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols (eg, ergosterol) in fungal cell membrane, causing intracellular components to leak with subsequent cell death.
Adult
1 mg/kg/d IV for 4-6 wk
Pediatric
Administer as in adults
Other nephrotoxins (eg, antineoplastic agents, aminoglycosides, radiocontrast) may enhance potential for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia; risk of renal toxicity increased with cyclosporine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor renal function, levels of serum electrolytes (eg, magnesium, potassium), liver function, CBC count, and hemoglobin concentrations; resume therapy at lowest level (eg, 0.25 mg/kg) when interrupted >7 d; hypoxemia, acute dyspnea, and interstitial infiltrates may occur in neutropenic patients receiving leukocyte transfusions (separate infusion from time of leukocyte transfusion)
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| Overview: Endocarditis, Bacterial |
| Differential Diagnoses & Workup: Endocarditis, Bacterial |
 Treatment & Medication: Endocarditis, Bacterial |
| Follow-up: Endocarditis, Bacterial |
| Multimedia: Endocarditis, Bacterial |
| References |
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References
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[Guideline] Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].
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Further Reading
Keywords
bacterial endocarditis, infective endocarditis, acute bacterial endocarditis, subacute bacterial endocarditis, fulminant endocarditis, rheumatic heart disease, congestive heart failure, CHF, left-sided endocarditis, , treatment, diagnosis, symptoms
