What is the treatment for endocarditis?

From the Guidelines

The treatment for endocarditis primarily involves prolonged antibiotic therapy, typically administered intravenously for 4-6 weeks, with the specific regimen depending on the causative organism and its susceptibility pattern, as recommended by the most recent guidelines from the European Society of Cardiology 1. The initial empiric therapy often includes a combination of antibiotics such as vancomycin (15-20 mg/kg IV every 12 hours) plus ceftriaxone (2g IV daily) to cover common pathogens like Staphylococcus, Streptococcus, and Enterococcus species.

• For methicillin-susceptible Staphylococcus aureus, the recommended treatment is a semisynthetic, β-lactamase–resistant penicillin (nafcillin or oxacillin) given intravenously for a minimum of 4 to 6 weeks, with or without gentamicin for the first 3 to 5 days 1.
• For methicillin-resistant Staphylococcus aureus, the recommended treatment is vancomycin for a minimum of 6 weeks, with or without gentamicin for the first 3 to 5 days 1.
• For enterococcal endocarditis, the treatment regimen should be a combination therapy of penicillin G or ampicillin together with gentamicin for 4 to 6 weeks, with a longer duration of therapy in cases involving prosthetic material 1. Once the causative organism is identified through blood cultures, therapy is narrowed to target the specific pathogen.
• Surgical intervention is necessary in about 50% of cases, particularly for complications such as heart failure due to valve dysfunction, uncontrolled infection despite antibiotics, or prevention of embolic events from large vegetations. During treatment, patients require close monitoring with serial blood cultures, echocardiography, and assessment for complications like embolic events or heart failure. Endocarditis treatment is intensive because the infection involves cardiac valves where blood flow patterns make it difficult for antibiotics to penetrate bacterial colonies, and the biofilm formation by bacteria further protects them from immune responses and antimicrobials. The management of patients with endocarditis should always involve infectious disease consultation as the standard of care, especially for complex cases or those with resistant organisms 1.

From the FDA Drug Label

Vancomycin Hydrochloride for Injection, USP is effective in the treatment of staphylococcal endocarditis Vancomycin Hydrochloride for Injection, USP has been reported to be effective alone or in combination with an aminoglycoside for endocarditis caused by S. viridans or S. bovis. For endocarditis caused by enterococci (e.g., E. faecalis), vancomycin has been reported to be effective only in combination with an aminoglycoside. The treatment of endocarditis and osteomyelitis may require a longer duration of therapy.

The treatment for endocarditis includes:

• Vancomycin alone or in combination with an aminoglycoside for endocarditis caused by S. viridans or S. bovis 2
• Vancomycin in combination with an aminoglycoside for endocarditis caused by enterococci (e.g., E. faecalis) 2
• Nafcillin for at least 14 days for severe staphylococcal infections, and a longer duration of therapy may be required for endocarditis 3

From the Research

Treatment for Endocarditis

The treatment for endocarditis typically involves antibiotic therapy, with the specific regimen depending on the causative organism and other factors.

• The use of aminoglycosides for the treatment of endocarditis has been dramatically reduced over the last 20 years, and should be administered once daily, and no longer than 2 weeks 4.
• For staphylococcal endocarditis, anti-staphylococcal penicillins, such as cefazolin, or vancomycin are recommended 4, 5.
• For enterococcal endocarditis, a combination of aqueous penicillin G and an aminoglycoside, such as gentamicin or streptomycin, is recommended 5, 6.
• The optimal duration of antibacterial treatment is 4 weeks for most native valve endocarditis, and 6 weeks for prosthetic-valve endocarditis 4.
• The oral switch is safe in patients stabilized after the initial intravenous course 4.

Antibiotic Regimens

Different antibiotic regimens have been compared in clinical trials, but the evidence is limited and of low to very low quality.

• A comparison of different antibiotic regimens found no conclusive differences in terms of cure rates or other relevant clinical outcomes 7, 8.
• Some studies have suggested that combination antibiotic therapy, such as the use of aminoglycosides and cell wall-active agents, may be effective for certain types of endocarditis 6.
• However, the current evidence does not support or reject any specific regimen of antibiotic therapy for the treatment of infective endocarditis 7, 8.

Treatment Duration and Switch to Oral Therapy

The duration of treatment and the switch to oral therapy are important considerations in the management of endocarditis.

• The optimal duration of treatment is typically 4-6 weeks, depending on the type of endocarditis and the response to therapy 4, 5.
• The switch to oral therapy can be considered in patients who are clinically stable and have shown a good response to initial intravenous therapy 4.