From the Guidelines
The treatment for infective endocarditis involves aggressive antibiotic therapy and sometimes surgery, with initial empiric intravenous antibiotics typically being a combination of vancomycin and gentamicin, as recommended by the 2015 ESC guidelines 1. The choice of antibiotics depends on the suspected or confirmed causative organism, with vancomycin and gentamicin being the initial empiric treatment for native valve endocarditis, and vancomycin, gentamicin, and rifampin for prosthetic valve endocarditis 1. Some key points to consider in the treatment of infective endocarditis include:
- The use of vancomycin and gentamicin as initial empiric therapy for native valve endocarditis, with dosages of 30-60 mg/kg/day for vancomycin and 3 mg/kg/day for gentamicin 1
- The addition of rifampin for prosthetic valve endocarditis, with a dosage of 900-1200 mg/day 1
- The importance of monitoring renal function and serum antibiotic levels to minimize toxicity and ensure effective treatment 1
- The consideration of alternative therapies, such as daptomycin or linezolid, for patients with resistant or complicated infections 1
- The need for surgical intervention in cases with heart failure, uncontrolled infection, large vegetations, or embolic events 1
In terms of specific antibiotic regimens, the 2015 ESC guidelines recommend:
- For native valve endocarditis caused by methicillin-susceptible staphylococci, (flu)cloxacillin or oxacillin at a dosage of 12 g/day in 4-6 doses, with a duration of 4-6 weeks 1
- For native valve endocarditis caused by methicillin-resistant staphylococci, vancomycin at a dosage of 30-60 mg/kg/day in 2-3 doses, with a duration of 4-6 weeks 1
- For prosthetic valve endocarditis caused by methicillin-susceptible staphylococci, (flu)cloxacillin or oxacillin at a dosage of 12 g/day in 4-6 doses, plus rifampin at a dosage of 900-1200 mg/day, with a duration of at least 6 weeks 1
Overall, the treatment of infective endocarditis requires a comprehensive approach that takes into account the causative organism, valve involvement, and patient-specific factors, with a focus on minimizing morbidity, mortality, and improving quality of life.
From the FDA Drug Label
Daptomycin for injection is indicated for the treatment of adult patients with Staphylococcus aureus bloodstream infections (bacteremia), including adult patients with right-sided infective endocarditis, caused by methicillin-susceptible and methicillin-resistant isolates. Gentamicin injection has been found effective when used in conjunction with a penicillin-type drug for treatment of endocarditis caused by group D streptococci
The treatment for infective endocarditis may include daptomycin for right-sided infective endocarditis caused by Staphylococcus aureus, and gentamicin in combination with a penicillin-type drug for endocarditis caused by group D streptococci 2 3.
From the Research
Treatment Strategies for Infective Endocarditis
The treatment for infective endocarditis involves various antibiotic regimens, depending on the causative organism and the patient's condition.
- For staphylococcal endocarditis, anti-staphylococcal penicillins or vancomycin are recommended, with the addition of gentamicin and rifampin for prosthetic-valve endocarditis 4.
- For streptococcal endocarditis, penicillin G alone or in combination with streptomycin is effective 5.
- For enterococcal endocarditis, a combination of penicillin G and streptomycin or gentamicin is recommended 5.
Antibiotic Treatment Duration
The optimal duration of antibacterial treatment is:
Oral Switch Therapy
Oral switch therapy is a feasible option in clinically stable patients with infective endocarditis, with a reduction in the relapse rate 6.
- A study found that changing to oral antibiotic treatment was noninferior to continued intravenous antibiotic treatment in patients with endocarditis on the left side of the heart who were in stable condition 7.
- Oral switch therapy seems to perform significantly better than intravenous treatment in terms of relapse of infection 6.
Salvage Therapies
Daptomycin and linezolid are effective salvage therapies for right-sided infective endocarditis caused by methicillin-resistant Staphylococcus aureus and accompanied by pulmonary complications 8.