Bacterial Endocarditis Treatment

• Consult promptly with Infectious Diseases or Cardiology regarding treatment.
• Blood cultures (3 venepunctures) must be taken before antimicrobials are given. Take 6 blood cultures (6 venepunctures) if antimicrobials have been given within the last 2 weeks. Complete clinical details on request form.
• See investigation and treatment guidelines in Hospital HealthPathways.

Pathogens

• Native valves:
  • Common: Viridans streptococci, S. aureus, enterococci
  • Other: Gram-negative bacilli, HACEK (Haemophilus, Aggregatibacter (Actinobacillus), Cardiobacterium, Eikenella, Kingella)
• Prosthetic valves:
  • As above plus Coagulase-negative staphylococci

Drug treatment

• Gentamicin is used for synergy so doses and target concentrations are lower than for other indications.
• Treatment duration varies from 2 to 6 weeks.
• Rationalise treatment once organism is identified and susceptibilities are known.
• Consult with Infectious Diseases.

Empiric

Native valve

benzylpenicillin HMLSchedNZFPMLnoids Benzylpenicillin F: n/a Half life: 1 hour Elimination: hydrolysis fe: 0.9 (Penicillin G)

IV 2.4 g (4 megaunits) every four hours

• fe = 0.8. If CrCl < 30 mL/min, seek advice from infectious diseases/pharmacy.

AND

flucloxacillin HMLSchedNZFPMLnoids Flucloxacillin F: 0.9 Half life: 1 hour Elimination: renal fe: 0.7

IV 2 g every four hours

• fe = 0.7. If CrCl < 30 mL/min, seek advice from infectious diseases/pharmacy.
• Risk of hepatotoxicity is increased in females, patients > 55 years old, high doses, and courses longer than 14 days duration.

AND

gentamicin HMLSchedNZFPMLnoids Gentamicin F: n/a Half life: 3 hours Elimination: renal fe: 0.9 Additional points: TDM.

IV 3 mg/kg ideal body weight every 24 hours (once a day) initial dose - see gentamicin guidelines

• fe = 0.9, adjust dose if CrCl reduced.

Mild penicillin allergy

cefazolin HMLSchedNZFPMLnoids Cefazolin F: n/a Half life: 2 hours Elimination: renal fe: 0.9

IV 2 g every eight hours

• fe = 0.9. If CrCl < 30 mL/min, seek advice from infectious diseases/pharmacy.

AND

• fe = 0.9, adjust dose if CrCl reduced.

Severe penicillin allergy

vancomycin HMLSchedNZFPMLnoids Vancomycin F: n/a Half life: 6 hours Elimination: renal fe: 0.9 Additional points: TDM

See dosing guidelines (use high doses)

• fe = 0.9, adjust dose if CrCl reduced.
• Must be given diluted (1 g in at least 200 mL) and slowly (≤ 1000 mg/hour) to minimise infusion reactions.

AND

• fe = 0.9, adjust dose if CrCl reduced.

Prosthetic valves, implantable cardiac devices, or hospital-acquired endocarditis

• fe = 0.7. If CrCl < 30 mL/min, seek advice from infectious diseases/pharmacy.
• Risk of hepatotoxicity is increased in females, patients > 55 years old, high doses, and courses longer than 14 days duration.

AND

• fe = 0.9, adjust dose if CrCl reduced.
• Must be given diluted (1 g in at least 200 mL) and slowly (≤ 1000 mg/hour) to minimise infusion reactions.

AND

• fe = 0.9, adjust dose if CrCl reduced.

Penicillin allergy

Consult Infectious Diseases/Clinical Microbiology.

Pathogens Known

Consult Infectious Diseases/Clinical Microbiology.

Topic Code: 99217

must be prescribed or recommended by a consultant.