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
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First-line treatment: Penicillin G 4 million units IV q4h (penicillin MIC ≤2 µg/mL)
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Second-line treatment: Ceftriaxone 2 g IV q24h (penicillin MIC >2 µg/mL and susceptible to ceftriaxone)
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Duration of therapy: 2-6 weeks
Penicillin-resistant or patient with penicillin allergy
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First-line treatment: Vancomycin 15 mg/kg IV q12h
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Second-line treatment: Levofloxacin 750 mg IV/PO daily or moxifloxacin 400 mg IV/PO daily
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Duration of therapy: 2-6 weeks
Staphylococcus aureus
Methicillin-sensitive (MSSA)
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Second-line treatment: see agents listed for MRSA below
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Duration of therapy: 2-6 weeks
Methicillin-resistant (MRSA)
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First-line treatment: Vancomycin 15 mg/kg IV q12h
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Second-line treatment: Linezolid 600 mg IV/PO q24h
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Duration of therapy: 2-6 weeks
Neisseria meningitidis
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First-line treatment: Ceftriaxone 2 g IV/IM q12h (may reduce to 2 g IV q24h only if concomitant meningitis is ruled out)
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Second-line treatment: Ampicillin 2 g IV q4h
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Third-line treatment: Penicillin G 4 million units IV q4h
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Duration of therapy: 2-6 weeks
Pseudomonas aeruginosa
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First-line treatments: Cefepime 2 g IV q8h or piperacillin-tazobactam 4.5 g IV q6h or meropenem 2 g IV q8h
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Second-line treatments: ciprofloxacin 400 mg IV q8h or ciprofloxacin 750 mg PO bid or levofloxacin 750 mg IV/PO q24h
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Duration of therapy: 2-6 weeks
Enteric gram-negative bacilli (community-acquired)
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First-line treatment: Ceftriaxone 2 g IV q24h
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Duration of first-line therapy: 2-6 weeks
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Second-line treatment: Ciprofloxacin 400 mg IV q12 or ciprofloxacin 500 mg PO q12h or levofloxacin 500 mg IV/PO q24h
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Duration of second-line therapy: 2-6 weeks
Legionella pneumophila
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First-line treatment: Azithromycin 500 mg IV/PO q24h
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Second-line treatment: Levofloxacin 500 mg IV/PO q24h
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Duration of therapy: 2-6 weeks
Anaerobes (Prevotella, Peptostreptococcus, Bacteroides)
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First-line treatment: Clindamycin 600 mg IV/PO q6h
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Second-line treatment: Metronidazole 500 mg IV/PO q12h
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Duration of therapy: 2-6 weeks
Viral infection
See Pericarditis Empiric Therapy
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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
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If associated with hepatitis B or C, treat with antiviral therapy as dictated by specific virus and genotype.
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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
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Echinocandin therapy (micafungin, anidulafungin, caspofungin) as per Pericarditis Empiric Therapy
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Fluconazole 6-12 mg/kg IV/PO q24h once susceptibility results available
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Duration of therapy: 2-6 weeks
Non -albicans Candida species
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Echinocandin therapy (micafungin, anidulafungin, caspofungin) as per Pericarditis Empiric Therapy
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Once stabilized, switch to voriconazole 400 mg PO q12h × 2 doses, then 200 mg PO q12h
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Duration of therapy: 2-6 weeks
Aspergillus
First-line treatment
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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
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Duration of therapy: 2-6 weeks
Second-line treatment
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Caspofungin 70-mg loading dose, then 50 mg IV q24h; or micafungin 100-150 mg IV daily
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Duration of therapy: 2-6 weeks
Third-line treatment
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Liposomal amphotericin B 3-5 mg/kg IV daily
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Duration of therapy: 2-6 weeks
Histoplasmosis
Immunocompetent with mild illness: NSAIDs as per Pericarditis Empiric Therapy, Viral
Immunocompromised illness not responsive to NSAIDs, or hemodynamically unstable
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Itraconazole 200 mg q8h × 3d, then q12h × 6-12wk
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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
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Doxycycline 100 mg IV/PO q12h
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Duration of therapy: 2-6 weeks
Second-line treatment
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Azithromycin 500 mg IV/PO q24h
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Duration of therapy: 2-6 weeks
Third-line treatment
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Erythromycin 500 mg IV/PO q6h
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Duration of therapy: 2-6 weeks