From the Guidelines
The treatment for infective endocarditis typically involves prolonged antibiotic therapy and sometimes surgery, with initial empiric antibiotic therapy including vancomycin (30-60 mg/kg/day i.v. in 2-3 doses) plus gentamicin (3 mg/kg/day i.v. or i.m. in 1 dose) while awaiting blood culture results, as recommended by the 2015 ESC guidelines 1.
Key Considerations
- The choice of empirical treatment depends on several factors, including whether the patient has received previous antibiotic therapy, the type of valve affected (native or prosthetic), and the place of infection (community, nosocomial, or non-nosocomial healthcare-associated) 1.
- For native valves, methicillin-susceptible staphylococci can be treated with (flu)cloxacillin or oxacillin (12 g/day i.v. in 4-6 doses) for 4-6 weeks, while methicillin-resistant staphylococci require vancomycin (30-60 mg/kg/day i.v. in 2-3 doses) for 4-6 weeks 1.
- Prosthetic valve endocarditis requires a combination of antibiotics, including vancomycin, gentamicin, and rifampin, for at least 6 weeks 1.
Surgical Intervention
- Surgical intervention is indicated for heart failure due to valve dysfunction, uncontrolled infection despite antibiotics, prevention of embolic events with large vegetations, or device-related infections 1.
Monitoring and Treatment Duration
- Treatment requires hospitalization for initial management, with close monitoring of clinical response, potential complications, and antibiotic levels 1.
- The extended duration of therapy is necessary to completely eradicate bacteria embedded in vegetations, where blood flow and antibiotic penetration may be limited 1.
Blood Culture-Negative Endocarditis
- For blood culture-negative endocarditis, empirical therapy may include doxycycline, cotrimoxazole, and rifampin, with consultation with an infectious disease specialist recommended 1.
From the FDA Drug Label
Daptomycin for injection is indicated for the treatment of adult patients with Staphylococcus aureus bloodstream infections (bacteremia), including adult patients with right-sided infective endocarditis, caused by methicillin-susceptible and methicillin-resistant isolates. Daptomycin for injection is not indicated for the treatment of left-sided infective endocarditis due to S. aureus. Gentamicin injection has also been found effective when used in conjunction with a penicillin-type drug for treatment of endocarditis caused by group D streptococci
The treatment for infective endocarditis may include daptomycin for right-sided infective endocarditis caused by Staphylococcus aureus, but it is not recommended for left-sided infective endocarditis due to S. aureus. Gentamicin may be used in combination with a penicillin-type drug for the treatment of endocarditis caused by group D streptococci 2 2 3.
From the Research
Treatment Overview
The treatment for infective endocarditis typically involves antibacterial therapy, with the specific treatment approach depending on the causative organism and the patient's individual circumstances 4, 5, 6.
Antibacterial Therapy
- For staphylococcal endocarditis, anti-staphylococcal penicillins or vancomycin may be used, depending on the susceptibility of the isolate 4, 6.
- For streptococcal endocarditis, penicillin or ceftriaxone may be used 5, 6.
- For enterococcal endocarditis, a combination of penicillin and an aminoglycoside such as gentamicin may be used 4, 5, 6.
- The optimal duration of antibacterial treatment is typically 4-6 weeks, depending on the type of endocarditis and the patient's response to treatment 4, 5, 6.
Administration and Dosage
- Aminoglycosides, such as gentamicin, should be administered once daily and for no longer than 2 weeks 4.
- Oxacillin may be administered via continuous infusion or intermittent infusion, with continuous infusion potentially improving microbiological cure 7.
Special Considerations
- For patients with prosthetic valve endocarditis, treatment may need to be reinforced with the addition of gentamicin and rifampin 4.
- For patients with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin or daptomycin may be used 4, 6.
- The oral switch is safe in patients stabilized after the initial intravenous course 4.