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, 3, 4, 5, 6]}

Bacterial infection

Most cases of bacterial pericarditis require percutaneous or surgical pericardial drainage for cure.^[7]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: Nafcillinor 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

Echinocandin therapy (micafungin, anidulafungin, caspofungin) as per Pericarditis Empiric Therapy
Fluconazole 6-12 mg/kg IV/PO q24h once susceptibility results available
Duration of therapy: 2-6 weeks

Non -albicans Candida species

Echinocandin therapy (micafungin, anidulafungin, caspofungin) as per Pericarditis Empiric Therapy
Once stabilized, switch to voriconazole 400 mg PO q12h × 2 doses, then 200 mg PO q12h
Duration of therapy: 2-6 weeks

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