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]
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: Nafcillinoroxacillin 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
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
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); orposaconazole 200 mg q6h initially, then 400 mg PO q12h once clinically stable
Duration of therapy: 2-6 weeks
Second-line treatment
Caspofungin 70-mg loading dose, then 50 mg IV q24h; or micafungin 100-150 mg IV daily
Duration of therapy: 2-6 weeks
Third-line treatment
Liposomal amphotericin B 3-5 mg/kg IV daily
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
Itraconazole 200 mg q8h × 3d, then q12h × 6-12wk
Prednisone 0.5-1.0 mg/kg IV daily (maximum, 80 mg daily), taper dose over 1-2wk
See Pericarditis Empiric Therapy, Mycobacterial.
Mycoplasma pneumoniae
First-line treatment
Doxycycline 100 mg IV/PO q12h
Duration of therapy: 2-6 weeks
Second-line treatment
Azithromycin 500 mg IV/PO q24h
Duration of therapy: 2-6 weeks
Third-line treatment
Erythromycin 500 mg IV/PO q6h
Duration of therapy: 2-6 weeks