From the Guidelines
The recommended treatment for enterococcal endocarditis is a combination of ampicillin 200 mg/kg/day IV in 4-6 doses plus gentamicin 3 mg/kg/day IV or IM in 1 dose for 4-6 weeks, as suggested by the 2015 ESC guidelines 1. This treatment approach is based on the synergistic bactericidal activity of a cell wall-active antibiotic (such as ampicillin) and an aminoglycoside (such as gentamicin).
- The dosage and duration of treatment may vary depending on the specific strain of Enterococcus and the patient's clinical condition.
- For penicillin-susceptible strains, ampicillin or penicillin G can be used, while for penicillin-resistant or aminoglycoside-resistant strains, vancomycin may be an alternative option 1.
- In cases of vancomycin-resistant enterococci (VRE), linezolid or daptomycin may be necessary, as suggested by the 2005 AHA statement 1.
- The American Heart Association also recommends that patients with enterococcal endocarditis caused by strains resistant to penicillin, aminoglycoside, and vancomycin should be treated in consultation with an infectious diseases specialist 1.
- The treatment duration is generally 4-6 weeks, with longer courses for prosthetic valve endocarditis, as recommended by the 2015 AHA statement 1.
- Blood cultures should be monitored to confirm clearance of bacteremia, and aminoglycoside levels should be checked regularly to prevent nephrotoxicity and ototoxicity 1.
From the Research
Treatment Overview
The recommended treatment for enterococcal endocarditis typically involves a combination of antibiotics.
- The combination of a penicillin and an aminoglycoside has become an accepted standard of treatment for this disease 2.
- Patients treated with aminoglycosides and penicillins or vancomycin had significantly better outcomes than those who did not receive aminoglycosides 2.
- Enterococcal endocarditis should be treated for four to six weeks with a combination of aqueous penicillin G together with either streptomycin or gentamicin 3.
Antibiotic Regimens
Different antibiotic regimens have been studied for the treatment of enterococcal endocarditis.
- Teicoplanin in combination with aminoglycosides may represent a rational alternative to standard penicillin/gentamicin therapy 4.
- The combination of a beta-lactam with an aminoglycoside shortens the treatment of endocarditis due to penicillin-sensitive streptococci 5.
- For strains highly resistant to both aminoglycosides, treatment with a cell wall-active agent alone is warranted 6.
Duration of Treatment
The duration of treatment for enterococcal endocarditis is typically four to six weeks.
- Excellent cure rates may be achieved after treatment for less than four weeks with an aminoglycoside in combination with penicillin or vancomycin 2.
- Patients at higher risk should be treated with penicillin for 4 weeks in combination with an aminoglycoside for 2 weeks 5.
Special Considerations
Certain considerations should be taken into account when treating enterococcal endocarditis.
- Enterococcal isolates should be screened for high-level resistance to streptomycin and gentamicin 5.
- Gentamicin is the preferred agent if susceptibility testing is not performed 5.
- For ampicillin- and vancomycin-susceptible strains, ampicillin would seem preferable because this drug typically demonstrates greater bactericidal activity in vitro as a single agent 6.