The 2015 ESC Guidelines for the Management of Infective Endocarditis
The European Society of Cardiology (ESC) 2015 guidelines provide the antibiotic protocol for treating endocarditis. 1 These guidelines were developed by the Task Force for the Management of Infective Endocarditis of the European Society of Cardiology and were endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Nuclear Medicine (EANM).
Key Features of the ESC Guidelines
The ESC guidelines provide comprehensive antibiotic protocols for treating infective endocarditis based on the causative organism:
For Streptococcal Endocarditis:
- Penicillin-susceptible oral streptococci and Streptococcus bovis group are treated with:
- Penicillin or ceftriaxone with gentamicin or netilmicin
- Short-term 2-week therapy can be used in uncomplicated cases
- Vancomycin is recommended for penicillin-allergic patients
For Staphylococcal Endocarditis:
Native valve infections:
- Methicillin-susceptible staphylococci: (Flu)cloxacillin or oxacillin 12 g/day IV in 4-6 doses for 4-6 weeks 1
- Methicillin-resistant staphylococci: Vancomycin 30-60 mg/kg/day IV in 2-3 doses for 4-6 weeks
- Alternative therapy: Daptomycin 10 mg/kg/day IV once daily
Prosthetic valve infections:
- Treatment duration ≥6 weeks
- Addition of rifampin and gentamicin to the regimen
For Enterococcal Endocarditis:
- Amoxicillin 200 mg/kg/day IV in 4-6 doses plus gentamicin 3 mg/kg/day IV or IM for 6 weeks (for PVE) or 4 weeks (for uncomplicated NVE) 1
- Alternative: Ampicillin plus ceftriaxone for 6 weeks (particularly for HLAR E. faecalis)
For HACEK and Non-HACEK Gram-negative Bacteria:
- HACEK: Ceftriaxone 2 g/day for 4 weeks in NVE and 6 weeks in PVE
- Non-HACEK: Early surgery plus long-term (≥6 weeks) therapy with bactericidal combinations
Important Monitoring Recommendations
- Serum trough vancomycin levels should be ≥20 mg/L
- Renal function and aminoglycoside levels should be monitored weekly (twice weekly in renal failure)
- CPK levels should be monitored weekly when using daptomycin
Special Considerations
- The guidelines emphasize the importance of resistance testing
- Recommendations are based on clinical trials and cohort studies in patients with endocarditis
- Pediatric dosing recommendations are provided separately
- Specific modifications for penicillin-allergic patients are outlined
The ESC guidelines provide detailed tables with antibiotic regimens, dosages, duration, and levels of evidence for each recommendation, making them a comprehensive resource for clinicians managing patients with infective endocarditis.