Is vancomycin (Vanco) and gentamicin appropriate for the treatment of infective endocarditis?

From the Guidelines

Vancomycin and gentamicin should not be used together for the treatment of infective endocarditis, except in specific cases such as enterococcal endocarditis, due to the lack of clinical benefit and increased risk of nephrotoxicity and ototoxicity associated with gentamicin use. The treatment of infective endocarditis depends on the suspected pathogen and patient factors. For native valve endocarditis, the recommended treatment is vancomycin (30-60 mg/kg/day IV in 2-3 doses) for 4-6 weeks, as stated in the guidelines by the European Society of Cardiology 1. Gentamicin is not recommended for routine use in native valve endocarditis due to the lack of clinical benefit and increased risk of toxicity, as noted in the guidelines 1. However, gentamicin may be considered for specific cases, such as enterococcal endocarditis, where it can be used in combination with vancomycin or other antibiotics, as recommended in the guidelines 1. For prosthetic valve endocarditis, a more aggressive approach may include vancomycin, rifampin, and gentamicin, but the use of gentamicin should be limited to 2 weeks due to the risk of toxicity, as stated in the guidelines 1.

Some key points to consider when treating infective endocarditis include:

• The importance of tailoring the treatment regimen based on culture results and susceptibility testing
• The need for renal function monitoring when using vancomycin and gentamicin
• The potential for gentamicin to enhance bactericidal activity against certain streptococci, but also the risk of nephrotoxicity and ototoxicity associated with its use
• The recommendation for early consultation with infectious disease specialists to optimize therapy, as stated in the guidelines 1

It is essential to note that the treatment of infective endocarditis should be individualized based on the specific patient and pathogen characteristics, and that the guidelines provided by the European Society of Cardiology and other reputable organizations should be consulted for the most up-to-date recommendations 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.

Vancomycin and gentamicin may be appropriate for the treatment of infective endocarditis, specifically for cases caused by S. viridans, S. bovis, or enterococci. The combination of vancomycin and an aminoglycoside, such as gentamicin, is recommended for certain types of endocarditis, including those caused by enterococci 2. However, the effectiveness of this combination may depend on the specific causative organism and its susceptibility to vancomycin and gentamicin.

• Key points:
  • Vancomycin is effective for staphylococcal endocarditis
  • Vancomycin and gentamicin may be used for endocarditis caused by S. viridans or S. bovis
  • Vancomycin and gentamicin are recommended for endocarditis caused by enterococci

From the Research

Treatment of Infective Endocarditis

The use of vancomycin and gentamicin for the treatment of infective endocarditis is supported by several studies 3, 4, 5.

• Vancomycin is bactericidal for Gram-positive cocci, except enterococci, and is often used in combination with gentamicin for optimal action 4.
• The combination of vancomycin and gentamicin is suitable for patients allergic to penicillin and is recommended for the treatment of infective endocarditis caused by staphylococci and streptococci 3, 5.
• A study published in 1981 reported a cure rate of 87% in 55 patients with infective endocarditis treated with vancomycin alone or in combination with other antibiotics 5.
• Another study published in 2001 recommended the use of vancomycin and gentamicin for the treatment of infective endocarditis in patients with high-risk cardiac conditions 3.

Comparison of Antibiotic Regimens

Several studies have compared different antibiotic regimens for the treatment of infective endocarditis, including vancomycin and gentamicin 6, 7.

• A 2016 Cochrane review found that the evidence for the use of different antibiotic regimens, including vancomycin and gentamicin, was limited and of very low quality 6.
• An updated Cochrane review published in 2020 found that the comparative effects of different antibiotic regimens, including vancomycin and gentamicin, were uncertain due to the limited and low-quality evidence 7.
• A study published in 1984 suggested that the combination of vancomycin and gentamicin was effective for the treatment of staphylococcal endocarditis, but emphasized the need for early surgery in some cases 4.

Clinical Outcomes

The clinical outcomes of patients with infective endocarditis treated with vancomycin and gentamicin have been reported in several studies 3, 6, 7, 5.

• A study published in 2001 reported that the combination of vancomycin and gentamicin was effective for the treatment of infective endocarditis, with a cure rate of 100% in patients with high-risk cardiac conditions 3.
• A 2016 Cochrane review found that the evidence for the clinical outcomes of patients with infective endocarditis treated with vancomycin and gentamicin was limited and of very low quality 6.
• An updated Cochrane review published in 2020 found that the comparative effects of different antibiotic regimens, including vancomycin and gentamicin, on clinical outcomes such as all-cause mortality, cure rates, and adverse events were uncertain due to the limited and low-quality evidence 7.