What is the management of infective endocarditis?

From the Guidelines

Endocarditis management requires prompt antibiotic therapy and potential surgical intervention, with initial treatment involving empiric intravenous antibiotics with vancomycin (15-20 mg/kg IV every 12 hours) plus ceftriaxone (2g IV daily) while awaiting blood culture results, as recommended by the American Heart Association 1.

Key Considerations

• The choice of antibiotic therapy should be tailored to the specific causative organism once identified, with considerations for methicillin-sensitive and resistant strains, as well as other potential pathogens such as Streptococci and Enterococci 1.
• Surgical intervention is indicated for heart failure, uncontrolled infection, prevention of embolic events, or large vegetations (>10mm), with recent data suggesting that early surgery may be beneficial even in patients with preexisting neurological complications 1.
• Patients require close monitoring for complications including heart failure, embolic events, and adverse drug reactions, with antibiotic prophylaxis before dental procedures recommended for high-risk patients with prosthetic valves, previous endocarditis, certain congenital heart diseases, or cardiac transplant recipients with valvulopathy 1.

Antibiotic Therapy

• For Streptococcal endocarditis, penicillin G (12-18 million units IV daily divided every 4 hours) or ceftriaxone (2g IV daily) for 4-6 weeks is recommended 1.
• Staphylococcal endocarditis often requires nafcillin or oxacillin (2g IV every 4 hours) for methicillin-sensitive strains or vancomycin for resistant strains, typically for 6 weeks 1.
• Enterococcal infections may need combination therapy with ampicillin plus gentamicin, with the specific regimen tailored to the individual patient's needs and the results of susceptibility testing 1.

Surgical Intervention

• Surgical intervention should be considered early in the course of treatment, particularly in patients with heart failure, uncontrolled infection, or large vegetations (>10mm) 1.
• The decision to proceed with surgery should be made in consultation with a multidisciplinary team, including cardiac surgeons, cardiologists, infectious diseases specialists, and other relevant experts 1.

Monitoring and Prophylaxis

• Patients with endocarditis require close monitoring for complications, including heart failure, embolic events, and adverse drug reactions 1.
• Antibiotic prophylaxis before dental procedures is recommended for high-risk patients, including those with prosthetic valves, previous endocarditis, certain congenital heart diseases, or cardiac transplant recipients with valvulopathy 1.

From the Research

Endocarditis Management Overview

• Endocarditis is a serious infection of the heart that requires prompt and effective treatment 2, 3, 4.
• The choice of antibiotic regimen depends on the causative organism, with different regimens recommended for streptococcal, staphylococcal, and enterococcal endocarditis 2, 4, 5.

Antibiotic Regimens

• For streptococcal endocarditis, penicillin G or ceftriaxone are commonly used, with or without gentamicin 3, 4, 5.
• For staphylococcal endocarditis, anti-staphylococcal penicillins or vancomycin are recommended, with the addition of gentamicin and rifampin for prosthetic valve endocarditis 2.
• For enterococcal endocarditis, a combination of penicillin G and an aminoglycoside is often used, with therapeutic drug monitoring recommended to optimize penicillin G dosing and exposure 5.

Treatment Duration and Oral Switch

• The optimal duration of antibacterial treatment is 4 weeks for most native valve endocarditis and 6 weeks for prosthetic valve endocarditis 2.
• The oral switch is safe in patients stabilized after the initial intravenous course, but the choice of oral antibiotic and duration of treatment should be individualized based on the causative organism and patient factors 2, 6.

Comparative Effects of Antibiotic Regimens

• Limited and low to very low-quality evidence suggests that the comparative effects of different antibiotic regimens in terms of cure rates or other relevant clinical outcomes are uncertain 6.
• Further research is needed to determine the most effective antibiotic regimens for the treatment of infective endocarditis, with a focus on reducing the risk of bias and improving the quality of evidence 6.