Treatment of Ie

TREATMENT
Antimicrobial therapy
Surgery
ANTIMICROBIAL THERAPY
 To cure IE, all bacteria in the vegetation must be killed.
 Therapy must be bactericidal and prolonged.
 Antibiotics are generally given parenterally to achieve serum
concentrations that, through passive diffusion, result in effective
concentrations in the depths of the vegetation.
 Blood cultures should be repeated until sterile.
 Results should be rechecked if there is recrudescent fever and at 4–6

weeks after therapy to document cure.
 If patients are febrile for 7 days despite antibiotic therapy, an evaluation for
para-valvular or extracardiac abscesses should be performed.
 Patients with acute endocarditis require antibiotic treatment as soon as three sets of
blood culture samples are obtained, but patients with subacute disease who are
clinically stable should have antibiotics withheld until a diagnosis is made.
 Patients treated with vancomycin or an aminoglycoside should have serum drug levels
monitored.
 Tests to detect renal, hepatic, and/or hematologic toxicity should be performed

periodically.
ORGANISM SPECIFIC
THERAPIES
STREPTOCOCCI
 The recommended therapies for streptococcal IE are based on the minimal inhibitory
concentration (MIC) of penicillin for the causative isolate.
 The 2-week penicillin/gentamicin and ceftriaxone/gentamicin regimens should not

be used to treat NVE complicated by cardiac or extracardiac abscess or PVE.
 Caution should be exercised in considering aminoglycoside-containing regimens in

patients at increased risk for aminoglycoside toxicity (renal or eighth cranial nerve).
ENTEROCOCCI
 Enterococci are resistant to oxacillin, nafcillin and cephalosporins and
are only inhibited—not killed—by the cell wall–active agents penicillin,
ampicillin, teicoplanin and vancomycin.
 To reduce potential nephrotoxicity: penicillin or ampicillin is the

preferred cell wall–active agent for use in combination with gentamicin.
ENTEROCOCCI
E. faecalis
 High concentrations of ampicillin plus ceftriaxone or cefotaxime, by expanded
binding of penicillin-binding proteins.
 High-dose regimens using ampicillin-ceftriaxone appear comparable and less
nephrotoxic than penicillin or ampicillin plus gentamicin for treatment of E.
faecalis.
 The combinations of vancomycin (or teicoplanin) or gentamicin with ceftriaxone
are not bactericidal for E. faecalis and are not recommended for treatment of
enterococcal IE.
ENTEROCOCCI
E. faecalis
 Treatment of IE caused by E. faecium, which is generally more antibiotic resistant than
E. faecalis or may be vancomycin resistant, is not well established.
 Successful treatment of IE caused by vancomycin-resistant enterococci with high-dose
daptomycin (10–12 mg/kg IV once daily), occasionally in combination with
ampicillin, has been reported.
 If the isolate susceptibility allows treatment with penicillin/ampicillin plus

gentamicin, this is preferred.
STAPHYLOCOCCI
 Treatment of staphylococcal IE is based on the presence of a prosthetic valve or
foreign device, the native valve(s) involved (right vs left side) and the antibiotic
susceptibility of the isolate.
 Penicillin resistance and methicillin resistance is widespread among staphylococci.

 Thus, empirical therapy for possible staphylococcal IE should use a regimen
effective against methicillin-resistant organisms.
 Therapy should be revised to a β-lactam agent (preferably an antistaphylococcal
penicillin) if the isolate is susceptible to methicillin
STAPHYLOCOCCI
 For treatment of NVE due to methicillin-resistant S. aureus (MRSA):
 Vancomycin, dosed to achieve trough concentrations of at least 15 μg/mL, is
recommended.
 MSSA IE that is uncomplicated and limited to the tricuspid or pulmonic valve:

 2 weeks of Oxacillin or Nafcillin
 Prolonged fever (≥5 days) during therapy or multiple septic pulmonary emboli
mandates standard- duration therapy.
STAPHYLOCOCCI
 Right-sided MRSA IE:
 Treated for at least 4 weeks with vancomycin or daptomycin (6 mg/kg daily)
 Staphylococcal PVE:
 Treated for 6–8 weeks with a multidrug regimen
 To achieve long-term bacterial eradication, rifampin, which kills staphylococci
embedded in biofilm adherent to foreign material, is an essential component of this
regimen.
EMPIRIC THERAPY AND TREATMENT FOR
CULTURE NEGATIVE IE
 Empirical therapy (either before culture results are known or when cultures are negative)
depends on epidemiologic clues to etiology (e.g., endocarditis in an IV drug user, health
care–associated endocarditis).
 In the setting of no prior antibiotic therapy and negative blood cultures, S. aureus, CoNS, and
enterococcal infection are unlikely; empirical therapy in this situation should target nutritionally
variant organisms, the HACEK group, and Bartonella.
 If negative cultures are confounded by prior antibiotic therapy, broader empirical therapy
is indicated and should cover pathogens inhibited by the prior therapy.
EMPIRIC THERAPY AND TREATMENT FOR CULTURE NEGATIVE
IE
 Empirical therapy for acute IE should cover MRSA or for health care–associated NVE potentially
antibiotic-resistant gram-negative bacilli.
 Treatment with vancomycin plus gentamicin or cefepime, initiated immediately after blood cultures are obtained,
covers these organisms
 For empirical treatment of NVE with a subacute presentation, vancomycin plus ceftriaxone is
reasonable.
 For blood culture–pending PVE, vancomycin, gentamicin, and cefepime should be used if the
prosthetic valve has been in place for ≤1 year.
EMPIRIC THERAPY AND TREATMENT FOR CULTURE NEGATIVE
IE
 Blood culture–negative subacute NVE

 Treated with vancomycin plus ampicillin-sulbactam (12 g every 24 h) or
ceftriaxone
 Doxycycline (100 mg twice daily) is added for enhanced Bartonella coverage.
SURGICAL TREATMENT
INDICATIONS
CONGESTIVE HEART FAILURE
Moderate to severe refractory CHF caused by new or worsening valve
dysfunction or intracardiac fistulae is the major indication for cardiac
surgery.
The survival benefit with surgery is inversely related to the severity

of preoperative CHF; thus surgery should not be delayed in the face of
deteriorating hemodynamics.
PARAVALVULAR INFECTION
 This complication, which is most common with aortic valve infection, occurs in 10–
15% of patients with NVE and in 45–60% of those with PVE.
 Clinically presents with persistent unexplained fever during appropriate therapy,

new electrocardiographic conduction disturbances, or pericarditis.
 Requires surgery, especially when fever persists, fistulae develop, prostheses are
dehisced and unstable, or infection relapses after appropriate relapses.
UNCONTROLLED INFECTION
Continued positive blood cultures or otherwise unexplained
persistent fevers despite optimal antibiotic therapy.
S. AUREUS IE
 The mortality rate for S. aureus PVE exceeds 50% with medical treatment and
may be reduced with surgical treatment.
 Nevertheless, surgery is not routinely advised for uncomplicated S. aureus PVE.

 Rather, survival benefits are most likely in those with paravalvular infection,
dysfunctional valves and CHF.
TIMING OF CARDIAC SURGERY
 Non- urgent cardiac surgery should be delayed for 2–3 weeks after a large
non-hemorrhagic embolic infarction and for 4 weeks after a significant
cerebral hemorrhage.
 A ruptured mycotic aneurysm should be treated before cardiac surgery.
 In a non-obtunded patient with an ischemic stroke and hemorrhage excluded

by imaging, cardiac surgery, if urgent, should be performed early.
INDICATIONS
INDICATIONS
INDICATIONS
ANTIBIOTIC AFTER CARIAC SURGERY
 In uncomplicated NVE caused by susceptible organisms, the duration of
preoperative plus postoperative treatment should equal the total duration of
recommended therapy.
 For IE complicated by perivalvular abscess, partially treated PVE, or valves

culture-positive for the original organism, a full course of therapy should be given
postoperatively.
EXTRA CARDIAC COMPLICATIONS
Splenic abscess develops in 3–5% of patients with IE.
Mycotic aneurysms occur in 2–15% of IE patients, one-half of these cases

involve the cerebral arteries and present as headaches, focal neurologic
symptoms, or hemorrhage.
Cerebral aneurysms should be monitored by angiography. Some will

resolve with effective antimicrobial therapy, but those that have leaked or
persist or enlarge should be treated surgically, if possible.
PREVENTION
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TREATMENT

 Results should be rechecked if there is recrudescent fever and at 4–6

 Tests to detect renal, hepatic, and/or hematologic toxicity should be performed

 The 2-week penicillin/gentamicin and ceftriaxone/gentamicin regimens should not

 Caution should be exercised in considering aminoglycoside-containing regimens in

 To reduce potential nephrotoxicity: penicillin or ampicillin is the

 If the isolate susceptibility allows treatment with penicillin/ampicillin plus

 Penicillin resistance and methicillin resistance is widespread among staphylococci.

 MSSA IE that is uncomplicated and limited to the tricuspid or pulmonic valve:

 Blood culture–negative subacute NVE

The survival benefit with surgery is inversely related to the severity

 Clinically presents with persistent unexplained fever during appropriate therapy,

 Nevertheless, surgery is not routinely advised for uncomplicated S. aureus PVE.

 A ruptured mycotic aneurysm should be treated before cardiac surgery.

 In a non-obtunded patient with an ischemic stroke and hemorrhage excluded

 For IE complicated by perivalvular abscess, partially treated PVE, or valves

Mycotic aneurysms occur in 2–15% of IE patients, one-half of these cases

Cerebral aneurysms should be monitored by angiography. Some will

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