Clinical definition:
Infection of the endothelial surface of the heart. Symptoms may be variable and non-specific. Ideally, the diagnosis should be confirmed and an organism identified on blood culture before commencing treatment. However, if the patient presents with severe disease, empiric treatment should be started and directed at staphylococci and streptococci.
Neonate, Infant, Child & Adolescent | |||
| Preferred antibiotic choice | |||
| Drug | Formulation | Dosage | Duration |
| Combination therapy with: Benzylpenicillin (IV) PLUS Cloxacillin (IV) PLUS Gentamicin (IV) | Benzylpenicillin- Powder for injection: 600 mg (= 1 million IU); 3 g (= 5 million IU) (sodium or potassium salt) in vial | o First week of life (7 days or less): 100 000 IU/kg/dose 8 hourly o 8 days of age & older: 125 000 IU/kg/dose 6 hourly, maximum dose 5 million IU 6 hourly | 4 – 6 weeks
|
| Cloxacillin- Powder for injection: 500 mg (as sodium salt) in vial | o First week of life (7 days or less): 50 mg/kg/dose 12 hourly o 8 – 28 days: 50 mg/kg/dose 8 hourly o 28 days & older: 50 mg/kg/dose 6 hourly, maximum dose 3 g 6 hourly | ||
| Gentamicin- Injection: 10 mg, 40 mg (as sulfate) / mL in 2 mL vial | 3 mg/kg/dose once daily, maximum dose 360 mg | First 2 weeks of therapy | |
| Alternative antibiotic choice(s) | |||
| If Benzylpenicillin is not available, substitute with: Ampicillin (IV) Treat in combination with Cloxacillin (IV) PLUS Gentamicin (IV), as above. | Ampicillin- Powder for injection: 500 mg, 1 g (as sodium salt) in vial | o First week of life (7 days or less): 50 mg/kg/dose 8 hourly o 8 days of age & older: 50 mg/kg/dose 6 hourly, maximum dose 2 g 6 hourly | 4 – 6 weeks |
| If Cloxacillin is not available, substitute with: Cefazolin (IV) Treat in combination with Benzylpenicillin (IV) (Or Ampicillin (IV) PLUS Gentamicin (IV), as above. | Cefazolin- Powder for injection: 1 g (as sodium salt) in vial | o First week of life (7 days or less): 50 mg/kg/dose 12 hourly o 8 days of age & older: 50 mg/kg/dose 8 hourly, maximum dose 4 g 8 hourly
| 4 – 6 weeks |
| In case of confirmed drug allergy or medical contraindication | |||
| Drug | Formulation | Dosage | Duration |
| Vancomycin (IV) PLUS Gentamicin (IV)
| Vancomycin- Injection: 500 mg, 1 g vial (as hydrochloride) | 15 mg/kg/dose 6 hourly | 4 – 6 weeks |
| Gentamicin- Injection: 10 mg, 40 mg (as sulfate) / mL in 2 mL vial | 1.5 mg/kg/dose 12 hourly | First 2 weeks of therapy | |
Principles of Stewardship:
- For suspected infective endocarditis cases, 3 blood cultures should be obtained in rapid succession from 3 anatomic sites within 6 hours before initiation of antibiotic therapy.
- If a pathogen is identified in blood culture, antibiotic treatment should be tailored to that pathogen, in line with appropriate guidelines. The pathogen and anatomical site may affect the duration of therapy.
- Therapeutic drug monitoring and renal function monitoring on patients treated with vancomycin and/or gentamicin.
Notes:
- Obtain expert advice from a cardiologist and/or infectious diseases specialist (if available) in all cases of endocarditis (native valve or prosthetic valve endocarditis)