From the Guidelines
Rifampicin is given in bacterial endocarditis, particularly in prosthetic valve endocarditis, due to its ability to penetrate biofilms and eradicate bacteria attached to foreign material, as recommended by the 2015 ESC guidelines 1.
Key Points
- Rifampicin is used in combination with other antibiotics, such as vancomycin or beta-lactams, for 6 weeks or more, depending on the specific case and guidelines.
- The typical dose of rifampicin is 900-1200 mg/day, given orally or intravenously in 2-3 divided doses, as outlined in the 2015 ESC guidelines 1.
- Rifampicin's ability to penetrate biofilms and reach high concentrations in vegetations and cardiac tissues makes it a valuable addition to standard antibiotic regimens for bacterial endocarditis, especially in cases involving prosthetic valves or methicillin-resistant Staphylococcus aureus (MRSA) 1.
- It is crucial to use rifampicin in combination with other effective antibiotics to minimize the risk of resistant mutant selection, as its sole use is associated with a high frequency of microbial resistance 1.
- Patients receiving rifampicin should be monitored for hepatotoxicity and drug interactions, as rifampicin induces cytochrome P450 enzymes and can reduce the effectiveness of many medications, including warfarin, oral contraceptives, and some antiretrovirals 1.
Considerations
- The 2015 ESC guidelines recommend rifampicin as part of the treatment regimen for prosthetic valve endocarditis caused by methicillin-susceptible or methicillin-resistant staphylococci, in combination with other antibiotics such as vancomycin or beta-lactams 1.
- The guidelines also emphasize the importance of monitoring renal function and serum gentamicin concentrations when using gentamicin in combination with rifampicin and other antibiotics 1.
- The choice of antibiotic regimen and duration of treatment should be individualized based on the specific case, taking into account factors such as the causative organism, the presence of prosthetic material, and the patient's clinical response to treatment, as recommended by the 2015 ESC guidelines 1 and the 2015 American Heart Association scientific statement 1.
From the Research
Rationale for Rifampicin Use in Bacterial Endocarditis
- Rifampicin is used in combination with other antibiotics for the treatment of bacterial endocarditis, particularly for infections caused by Staphylococcus species 2, 3, 4, 5, 6.
- The addition of rifampin to standard therapy has been shown to increase serum bactericidal activity and improve cure rates in some cases, especially when combined with vancomycin 2.
- However, the use of rifampin is not without risks, and its addition to treatment regimens can lead to the development of rifampin-resistant strains of bacteria, as well as hepatotoxicity and significant drug-drug interactions 4.
Specific Indications for Rifampicin Use
- Rifampicin is recommended for the treatment of prosthetic valve endocarditis caused by Staphylococcus epidermidis, particularly when combined with vancomycin 2.
- The use of rifampin in native valve infective endocarditis caused by Staphylococcus aureus is more controversial, with some studies suggesting that it may not provide a significant benefit and may even be associated with increased risk of adverse effects 4, 5.
- In the case of surgically treated staphylococcal infective endocarditis, the use of rifampin as adjunctive therapy has not been shown to provide a significant benefit in terms of reducing the risk of death or reoperation for IE relapse 5.
Current Recommendations and Guidelines
- International guidelines recommend rifampin-based combinations for staphylococcal prosthetic valve endocarditis, but the evidence supporting this recommendation is not robust, and rifampin tolerability is a concern 6.
- A large multicenter retrospective study found that the use of rifampin was not associated with improved outcomes in terms of 1-year mortality or relapse rates in patients with staphylococcal prosthetic valve endocarditis 6.