What is the recommended treatment for enterococcus endocarditis?

From the Guidelines

The recommended treatment for enterococcus endocarditis is a combination of ampicillin and gentamicin for 4-6 weeks, with ampicillin dosed at 200 mg/kg/day IV in 4-6 doses and gentamicin dosed at 3 mg/kg/day IV or IM in 1 dose, as per the 2015 ESC guidelines 1. This treatment approach is based on the most recent and highest quality evidence available, which prioritizes the use of ampicillin and gentamicin for the treatment of enterococcus endocarditis.

• The standard regimen consists of ampicillin plus gentamicin, with a recommended duration of 6 weeks for patients with symptoms or prosthetic valve endocarditis.
• For penicillin-allergic patients, vancomycin can replace ampicillin, with a recommended dose of 30 mg/kg/day IV in 2 doses.
• In cases of high-level aminoglycoside resistance, ampicillin plus ceftriaxone is recommended, with ceftriaxone dosed at 4 g/day IV or IM in 2 doses.
• For vancomycin-resistant enterococci, linezolid or daptomycin may be used, with linezolid dosed at 1200 mg/24 h IV/PO in 2 equally divided doses and daptomycin dosed at 10 mg/kg/day IV. The American Heart Association also recommends a similar treatment approach, with ceftriaxone-ampicillin combination therapy being reasonable for IE caused by aminoglycoside-resistant enterococcal strains 1. Regular monitoring of renal function and drug levels is essential to prevent toxicity, especially with aminoglycosides, and surgical intervention should be considered for complications like heart failure, persistent infection despite antibiotics, large vegetations, or abscess formation.
• Blood cultures should be monitored to confirm clearance of bacteremia, and treatment duration may extend to 6 weeks for prosthetic valve endocarditis. The dual antibiotic approach is necessary because enterococci are relatively resistant to cell wall-active agents alone, and the synergistic effect of aminoglycosides enhances bacterial killing, as supported by the 2015 ESC guidelines 1 and the American Heart Association recommendations 1.

From the FDA Drug Label

For endocarditis caused by enterococci (e.g., E. faecalis), vancomycin has been reported to be effective only in combination with an aminoglycoside. Enterococcal endocarditis: Streptomycin in doses of 1 g b.i.d. for 2 weeks and 500 mg b.i. d. for an additional 4 weeks is given in combination with penicillin.

The recommended treatment for enterococcus endocarditis is a combination of an aminoglycoside, such as streptomycin, and penicillin. The dosage of streptomycin is 1 g twice daily for 2 weeks, followed by 500 mg twice daily for an additional 4 weeks. Alternatively, vancomycin can be used in combination with an aminoglycoside, although the specific dosage is not specified in the provided drug label 2 3.

• Key points:
  • Combination therapy with an aminoglycoside and penicillin or vancomycin is recommended.
  • Streptomycin dosage: 1 g b.i.d. for 2 weeks, then 500 mg b.i.d. for 4 weeks.
  • Vancomycin can be used as an alternative to penicillin, but dosage is not specified.

From the Research

Treatment for Enterococcus Endocarditis

The recommended treatment for enterococcus endocarditis typically involves a combination of antibiotics. Key points to consider include:

• The combination of a penicillin and an aminoglycoside has become an accepted standard of treatment for this disease 4.
• Patients treated with aminoglycosides and penicillins or vancomycin had significantly better outcomes than those who did not receive aminoglycosides 4.
• Excellent cure rates may be achieved after treatment for less than four weeks with an aminoglycoside in combination with penicillin or vancomycin 4.
• Enterococcal endocarditis requires combined treatment for 4 to 6 weeks 5, 6, 7.
• Gentamicin is the preferred agent if susceptibility testing is not performed 5.
• The minimal duration of therapy is 4 weeks 6.
• Curative treatments recommended for streptococcal or enterococcal endocarditis, including penicillin, amoxicillin or vancomycin in association with gentamicin, were found to be appropriate for 98.5 per cent of cases 8.

Antibiotic Regimens

Some specific antibiotic regimens that have been recommended for enterococcus endocarditis include:

• A combination of aqueous penicillin G together with either streptomycin or gentamicin for 4 to 6 weeks 7.
• Penicillin or amoxicillin in association with gentamicin 8.
• Vancomycin in combination with an aminoglycoside 4, 8.

Duration of Therapy

The duration of therapy for enterococcus endocarditis is typically:

• 4 to 6 weeks 5, 6, 7.
• Less than four weeks with an aminoglycoside in combination with penicillin or vancomycin may be sufficient in some cases 4.