From the Guidelines
Rifampin should be added to standard antibiotic therapy for infective endocarditis when treating Staphylococcus aureus prosthetic valve endocarditis or when dealing with other device-related infections, as recommended by the 2015 ESC guidelines 1. The typical dosing is rifampin 900-1200 mg i.v. or orally in 2 or 3 divided doses, usually combined with a beta-lactam antibiotic (such as nafcillin or oxacillin) and gentamicin. For methicillin-resistant S. aureus (MRSA), rifampin is paired with vancomycin. Treatment duration is typically 6 weeks for prosthetic valve endocarditis, as stated in the guidelines 1. Rifampin is particularly valuable because it penetrates biofilms that form on prosthetic materials and can reach bacteria in vegetations that other antibiotics might miss, as noted in the 2009 ESC guidelines 1. It also has good intracellular activity against staphylococci that may be sequestered within host cells. However, rifampin should never be used as monotherapy due to the rapid development of resistance, as warned in the guidelines 1. Patients should be monitored for rifampin's side effects including hepatotoxicity, drug interactions (as it induces cytochrome P450 enzymes), and body fluid discoloration (orange-red urine, tears, and sweat), as advised in the guidelines 1. Some key points to consider when using rifampin include:
- Rifampin increases the hepatic metabolism of warfarin and other drugs, as noted in the 2009 ESC guidelines 1.
- Rifampin should be started 3-5 days later than vancomycin and gentamicin, as suggested by some experts in the 2015 ESC guidelines 1.
- The use of rifampin is only recommended for prosthetic valve endocarditis (PVE), as stated in the guidelines 1. It is essential to follow the guidelines and consult with an infectious disease specialist to ensure the best possible outcome for patients with infective endocarditis, as recommended in the guidelines 1.
From the Research
Indication to Add Rifampin in Treating Infective Endocarditis
The use of rifampin in treating infective endocarditis is a topic of interest, with various studies examining its efficacy and safety.
- The addition of rifampin to standard therapy for native valve infective endocarditis caused by Staphylococcus aureus has been studied, with results suggesting that the potential for hepatotoxicity, drug-drug interactions, and the emergence of resistant S. aureus isolates warrants a careful risk-benefit assessment 2.
- For staphylococcal prosthetic-valve endocarditis, rifampin is often recommended as part of the treatment regimen, with a duration of 6 weeks or more 3, 4.
- However, a study examining the use of rifampin in surgically treated staphylococcal infective endocarditis found that there was insufficient evidence to claim a reoperation-free survival benefit from treatment with rifampin 5.
- Another study found that the use of rifampin in staphylococcal prosthetic valve endocarditis was not associated with better outcomes, with similar 1-year mortality and relapse rates in patients treated with or without rifampin 6.
Key Findings
- Rifampin is recommended for staphylococcal prosthetic-valve endocarditis, but its use in native valve endocarditis is more controversial 3, 4.
- The addition of rifampin to standard therapy for native valve infective endocarditis caused by Staphylococcus aureus may be associated with increased risk of hepatotoxicity and drug-drug interactions 2.
- The use of rifampin in surgically treated staphylococcal infective endocarditis may not provide a significant benefit in terms of reoperation-free survival 5.
- The efficacy and safety of rifampin in staphylococcal prosthetic valve endocarditis require further study, with some studies suggesting that its use may not be associated with better outcomes 6.