From the Guidelines
The treatment for infective endocarditis involves prolonged antibiotic therapy, typically administered intravenously for 4-6 weeks, with initial empiric therapy often including a combination of antibiotics such as vancomycin and gentamicin, as recommended by the 2015 ESC guidelines 1.
Key Considerations
- The choice of antibiotics depends on the suspected or confirmed causative organism, with vancomycin and gentamicin being commonly used for initial empiric therapy.
- For Staphylococcus aureus, nafcillin or oxacillin is preferred for methicillin-sensitive strains, while vancomycin is used for methicillin-resistant strains.
- For viridans group streptococci, penicillin G plus gentamicin is often effective.
- Surgical intervention is necessary in approximately 50% of cases, particularly for patients with heart failure due to valve dysfunction, uncontrolled infection despite antibiotics, or prevention of embolic events with large vegetations.
Treatment Duration
- The duration of treatment varies depending on the causative organism and the presence of complications, with typical treatment durations ranging from 4-6 weeks, as outlined in the 2015 AHA statement 1 and the 2015 update on infective endocarditis in childhood 1.
Monitoring and Complications
- Patients require close monitoring for complications including heart failure, embolic events, and adverse effects of antibiotics.
- The aggressive treatment approach is necessary because infective endocarditis carries significant mortality risk (15-30%) and can cause permanent cardiac damage if not adequately treated, as highlighted in the 2005 AHA statement 1.
Empiric Therapy
- Initial empiric therapy often includes a combination of antibiotics such as vancomycin (30-60 mg/kg/day IV in 2-3 doses) and gentamicin (3 mg/kg/day IV or IM in 1 dose), as recommended by the 2015 ESC guidelines 1.
- The choice of empiric therapy depends on the suspected or confirmed causative organism, as well as the patient's clinical presentation and medical history.
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. Vancomycin Hydrochloride for Injection, USP has been reported to be effective for the treatment of diphtheroid endocarditis Vancomycin Hydrochloride for Injection, USP has been used successfully in combination with either rifampin, an aminoglycoside, or both in early-onset prosthetic valve endocarditis caused by S. epidermidis or diphtheroids.
The treatment for infective endocarditis may include vancomycin alone or in combination with other antibiotics, such as aminoglycosides or rifampin, depending on the causative organism.
- Staphylococcal endocarditis: vancomycin is effective
- Endocarditis caused by S. viridans or S. bovis: vancomycin alone or in combination with an aminoglycoside is effective
- Endocarditis caused by enterococci: vancomycin in combination with an aminoglycoside is effective
- Diphtheroid endocarditis: vancomycin is effective
- Early-onset prosthetic valve endocarditis: vancomycin in combination with rifampin, an aminoglycoside, or both is effective 2
From the Research
Treatment Overview
The treatment for infective endocarditis typically involves antibiotics, with the specific regimen depending on the causative microorganism 3, 4, 5. The goal of treatment is to sterilize the vegetative lesions characteristic of the disease 5.
Antibiotic Regimens
- For uncomplicated cases of endocarditis due to penicillin-susceptible viridans streptococci or Streptococcus bovis, 4 weeks of benzylpenicillin (or ceftriaxone) is the preferred regimen 3.
- For cases caused by strains of viridans streptococci or S. bovis relatively resistant to penicillin, or by enterococci, both benzylpenicillin and gentamicin are recommended 3.
- For staphylococcal endocarditis on native heart valves, nafcillin or oxacillin with or without gentamicin is the preferred regimen 3.
- Vancomycin is recommended for patients allergic to penicillin (or methicillin) 3, 6.
Duration and Administration of Therapy
- Treatment must be instituted parenterally to ensure complete bioavailability and good penetration into the vegetations 5.
- The duration of therapy is typically 4-6 weeks to prevent failure or relapse 3, 4, 5.
- Short-term therapy (2 weeks) with combined intramuscular administration of penicillin and streptomycin has been shown to be effective for streptococcal infective endocarditis 7.