mg/kg IV q 12 h plus gentamicin 1 mg/kg q 8 h plus rifampin 300 po q 8 h. IV drug abusers receive nafcillin 2 g IV q 4 h.

In all regimens, penicillin-allergic patients require substitution of vancomycin 15 mg/kg IV q 12 h.

when the organism is S. aureus, a gram-negative bacillus, or a fungus), surgery may be required after only 24 to 72 h of antimicrobial therapy. In patients with prosthetic valves, surgery may be required when TEE shows

Table 2152. ANTIBIOTIC REGIMENS FOR ENDOCARDITIS

TYPE DRUG AND DOSAGE FOR ADULTS DRUG AND DOSAGE FOR ADULTS ALLERGIC TO PENICILLIN

PenicillinPenicillin G 1218 million units/day Ceftriaxone 2 g once/day IV for 4 wk susceptible strepto- IV continuously or 23 million or, if gentamicin 1 mg/kg* IV (up to cocci (penicillin G units q 4 h for 4 wk or, if gentami- 80 mg) q 8 h is given concurrently, for MIC 0.1 g/mL), cin 1 mg/kg* IV (up to 80 mg) q 2 wk through a central venous catheincluding most vir- 8 h is given concurrently, for 2 wk ter (can be given on outpatient basis) idans streptococci if there is no history of penicillin anaphylaxis or Vancomycin 15 mg/kg IV q 12 h for 4 wk Streptococci relaGentamicin 1 mg/kg* IV q 8 h plus Desensitization to penicillin tively resistant to penicillin G 1830 million units/ or penicillin (penicil- day IV or ampicillin 12 g/day IV Vancomycin 15 mg/kg IV (up to 1 g) lin G MIC > 0.1 g/ continuously or 2 g q 4 h for q 12 h plus gentamicin 1mg/kg* IV q mL), including en- 46 wk 8 h for 46 wk terococci, some other streptococcal strains, and Abiotrophia defectiva (previously S. defectivus) Pneumococci or Penicillin G 1218 million units/ Ceftriaxone 2 g once/day IV for 4 wk group A streptoday IV continuously for 4 wk if through a central venous catheter (can cocci susceptible to penicillin be given on outpatient basis) if there is or no history of penicillin anaphylaxis Vancomycin 15 mg/kg IV q 12 h or for 4 wk for pneumococci with Vancomycin 15 mg/kg IV q 12 h for penicillin G MIC 2 g/mL 4 wk
Table continues on the following page.

Table 2152. ANTIBIOTIC REGIMENS FOR ENDOCARDITIS (Continued )

TYPE DRUG AND DOSAGE FOR ADULTS DRUG AND DOSAGE FOR ADULTS ALLERGIC TO PENICILLIN

Penicillin-resistant Staphylococcus aureus strains

Oxacillin and nafcillin-resistant S. aureus strains HACEK microorganisms

Coliform bacilli

Pseudomonas aeruginosa

For patients with a left-sided native Cefazolin 2 g IV q 8 h for 46 wk valve: Oxacillin or nafcillin 2 g IV if staphylococci are susceptible to oxacillin or nafcillin and if there is q 4 h for 46 wk For patients with a right-sided na- no history of penicillin anaphylaxis or tive valve: Oxacillin or nafcillin 2 g IV q 4 h for 24 wk plus gen- Cefazolin 2 g IV q 8 h for 24 wk plus tamicin 1 mg/kg* IV q 8 h for 2 wk gentamicin 1 mg/kg* IV q 8 h for 2 wk or For patients with a prosthetic valve: Cefazolin 2 g IV q 8 h for 46 wk plus Oxacillin or nafcillin 2 g IV q 4 h for 68 wk plus gentamicin gentamicin 1 mg/kg* IV q 8 h for 2 wk plus rifampin 300 mg po q 8 h for 1 mg/kg* IV q 8 h for 2 wk plus 68 wk rifampin 300 mg po q 8 h for or 68 wk Vancomycin 15 mg/kg IV q 12 h alone if native valve, plus gentamicin 1 mg/ kg* IV q 8 h for 2 wk plus rifampin 300 mg po q 8 h for 46 wk if prosthetic valve Vancomycin 15 mg/kg IV q 12 h alone if native valve, plus gentamicin 1 mg/kg IV* q 8 h for 2 wk plus rifampin 300 mg po q 8 h for 68 wk if prosthetic valve Ceftriaxone 2 g once/day IV for Ceftriaxone 2 g once/day IV for 4 wk 4 wk or, if gentamicin 1 mg/kg* IV (up to or 80 mg) q 8 h is given concurrently, for Ampicillin 12 g/day IV continu2 wk if there is no history of penicillin ously or 2 g q 4 h plus gentamicin anaphylaxis 1 mg/kg* IV q 8 h for 4 wk Sensitivity-proven -lactam anti- microbial (eg, ceftriaxone 2 g IV q 1224 h or ceftazidime 2 g IV q 8 h) plus an aminoglycoside (eg, gentamicin 2 mg/kg* IV q 8 h) for 46 wk Ceftazidime 2 g IV q 8 h or cefepime Ceftazidime 2 g IV q 8 h or cefepime 2 g IV q 8 h or imipenem 500 mg 2 g IV q 8 h plus tobramycin 2.5 mg/ IV q 6 h plus tobramycin 2.5 mg/kg kg q 8 h for 68 wk; amikacin 5 mg/kg q 8 h for 68 wk; amikacin 5 mg/kg q 12 h substituted for tobramycin q 12 h substituted for tobramycin if if bacteria are susceptible only to bacteria are susceptible amikacin

*Based on ideal rather than actual weight in obese patients. With vancomycin, serum levels must be monitored if doses > 2 g/24 h are administered. If enterococcal endocarditis lasts > 3 mo and involves large vegetations or vegetations on prosthetic valves, treatment should last for 6 wk. Some clinicians add gentamicin 1 mg/kg IV q 8 h for 35 days if patients have a native valve. HACEK microorganisms: Haemophilus parainfluenzae, H. aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae.
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