Empiric, acute endocarditis: [nafcillin or oxacillin 2g IV q4h
+ gentamicin or tobramycin1mg/kg IV q8h] OR [vancomycin 15mg/kg IV q12h
+ gentamicin 1mg/kg IV q8h].
Empiric, subacute endocarditis: [ampicillin/sulbactam 3g IV q 6h
+ gentamicin or tobramycin1mg/kg IV q8h] OR [vancomycin 15mg/kg q12h +
[ceftriaxone 2g IV q12hORgentamicin/tobramycin 1 mg/kg IV q8h].
Culture and sensitivity results when available will define treatment.
See "Pathogen Specific therapy" below for specifics.
Cefotaxime Good activity against penicillin-sensitive Staph and Strep, synergistic
with aminoglycosides, extensive and favorable experience with
Ceftazidime Anti-Pseudomonal. Combine with Tobramycin or Gentamicin for
treatment of endocarditis.
Nafcillin Common empirical choice for Staph (MSSA) and Strep coverage while
awaiting culture results.
Oxacillin Common empirical choice for Staph (MSSA) and Strep coverage while
awaiting culture results.
Tobramycin Recommended as synergistic treatment with beta-lactams as anti-
Vancomycin Increasing empirically chosen in populations at higher risk for MRSA,
e.g., IDU populations, nosocomially-related endocarditis. Should be
dosed 15mg/kg q 12h with trough goal of 15-20mcg/ml.
Linezolid Disadvantages are the relative lack of experience and bacteriostatic
rather than bacteriocidal activity.
Daptomycin Can be used for vancomycin-resistant enterococci (VRE), although
development of resistance while on therapy has been described.
Pathogen Specific Therapy
Pathogen 1st Line Agent 2nd Line Agent
Culture Negative Ampicillin/sulbactam 3gm IV q 6h + Vancomycin 15mg/kg IV q12h x 4-6 wks (if unable to
Endocarditis aminoglycoside (gentamicin 1 mg/kg IV tolerate PCN)+ gentamicin 1mg/kg IV q8h x 4-6wks
q8h) x 4-6 wks + ciprofloxacin 500mg + ciprofloxacin 500mg PO twice daily or 400mg IV q12h
PO twice daily or 400mg IV q12h
Brucellaspecies Doxycycline 100 mg IV/PO q12h Doxycycline + gentamicin or streptomycin
+rifampin 300 mg PO q12h x 6 wks
Staphylococcus Oxacillin/nafcillin 2 g IV q4h x 4 wks +/- Beta-lactam allergic: cefazolin 2 g IV q8h x 4-6 wks +/-
aureus (MSSA) gentamicin 1 mg/kg IV or IM q8h x 3-5 gentamicin 1 mg/kg IV q8h x 3-5 d
d OR vancomycin 15mg/kg IV q12h x 4-6 wks
Staphylococcus Vancomycin 15mg/kg IV q12h x 4-6 wks. Daptomycin 6 mg/kg/d x 4-6 wks
Staphylococcus Nafcillin/oxacillin 2g IV Vancomycin 15mg/kg IV q12h x 4-6 wks
aureus (IDU, q4h+ gentamicin 1mg/kg IV q8h x 2
tricuspid valve) wks.
Viridans MIC <0.1 mcg/ml: MIC >0.1 and <0.5:
Streptococci Penicillin G 12-18 mU IV/24h Penicillin G 18 mU/24h (continuously or divided q4h) x 4
(continuously or divided q4h) x 4 wks wks with gentamicin 1 mg/kg IV/IM q8h x 2 wks.
Ceftriaxone 2 g IV/IM q24h x 4 wks (Ceftriaxone 2gm/d IV/IM single dose.
Penicillin G 12-18 mU/24h (continuously Vancomycin 15mg/kg IV q12h x 4 wks.
or divided q4h) x 2 wks MIC >0.5: Follow standard treatment regimen for
with gentamicin 1 mg/kg IV/IM q8h enterococcal endocarditis
Penicillin allergy: vancomycin 1 g IV
q12h x 4 wks.
Streptococcus MIC <0.1 MIC >0.1 and <0.5:
bovis Follow treatment regimen for viridans Follow treatment regimen for viridans streptococci
streptococci MIC >0.5:
Follow treatment regimen for enterococcal endocarditis.
Enterococci and Penicillin G 18-30 mU/24h (continuously Vancomycin 15mg/kg IV q12h + gentamicin1 mg/kg
streptococci with or divided q4h) + gentamicin 1 mg/kg IV/IM q8h x 4-6 wks.
pen MIC > IV/IM q8h x 4-6 wks (4 wks if sx (Vancomycin if allergic to penicillin. Use doses for
0.5mcg/ml duration< 3 months). resistant Enterococci. Check for high level
Ampicillin 12 g/24h continuously or aminoglycoside resistance. Cephalosporins cannot be
divided q4h + gentamicin 1 mg/kg IV/IM used.)
q8h x 4-6 weeks. Vancomycin resistant
enterococci: considerdaptomycin (6mg/kg/IV/d dosing).
HACEK Organisms Ampicillin-sulbactam 3gm IV q 6h x 4 Ceftriaxone or other third generation cephalosporins.
wks or ceftriaxone 2 g IV/IM q24h x 4
Enteric gram Cephalosporin (2nd or 3rd generation) Betalactam-betalactamase inhibitors
Negative Bacilli +/- aminoglycoside x 4 wks. Fluoroquinolones
Carbapenem (imipenem, meropenem)
Candidaspecies Amphotericin B 0.8-1.0 mg/kg/24h IV Fluconazole 400 mg IV q24h x 4-6 wks (if organism
+Flucytosine 100-150 mg/kg/24h for susceptible)
total dose of Amphotericin B 30-40
mg/kg plus valve removal
Coagulase Follow treatment regimen for S. aureus.
Coxiella Doxycycline 100 mg IV/PO q12h
burnetii (Q Fever) and
ciprofloxacin (200 mg IV q12h or 500 mg
x 3-4 Years
Pathogen Specific Therapy
Pathogen 1st Line Agent 2nd Line Agent
PCN Penicillin G 18-24 mU IV/24h (continuously or Ceftriaxone 2g IV/IM qd x 6 wks + gentamicin 1 mg/kg IV or IM q8h x 2 wks
susceptibleStrep(MIC<=0.1ug/ml) divided q4h) x 6 wks + Gentamicin 1 mg/kg IV or Penicillin allergy: vancomycin 15mg/kg IV q12h x 6 wks
IM q8h x 2 wks
PCN resistantStrep(MIC>0.1ug/ml) Penicillin G 24-30 mU IV/24h (continuously or Ceftriaxone 2g IV/IM qd x 6 wks + Gentamicin 1 mg/kg IV or IM q8h x 4 wks
divided q4h) x 6 wks + Gentamicin 1 mg/kg IV or Penicillin allergy: Vancomycin 15mg/kg IV q12h x 6 wks
IM q8h x 4 wks
Staphylococci(Methicillin-susceptible) Oxacillin/Nafcillin 2g IV q4h x 6-8 wks Beta lactam Allergic: Cefazolin 2 g IV q8h x 6-8 wks + Gentamicin 1 mg/kg IV or IM
+ Gentamicin 1 mg/kg IV or IM q8h x 2 wks q8h x 2 wks +Rifampin 300mg po q8h x 6-8 wks
+ Rifampin 300mg po q8h x 6-8 wks If allergy is IgE mediated anaphylaxis, then desensitize or Vancomycin 15mg/kg IV q12h
x 6-8 wks + Gentamicin 1 mg/kg IV or IM q8h x 2 wks +Rifampin 300mg po q8h x 6-8
Staphylococci(Methicillin-resistant) Vancomycin 15mg/kg IV q12h x 6-8 wks Linezolid 600mg IV or PO bid x 6-8 wks (no/little experience)
+ Gentamicin 1 mg/kg IV/IM q8h x 2 wks Synercid (no/little experience)
+ Rifampin300mg po q8h x 6-8 wks Daptomycin (no/little experience)
Enterococci Penicillin G 24-30 mU IV/24h (continuously or Vancomycin 15mg/kg IV q12h + Gentamicin 1 mg/kg IV or IM q8h x 6 wks
divided q4h) +Gentamicin 1 mg/kg IV or IM q8h x 6 Vancomycin if allergic to PCN. Cephalosporins cannot be used.
wks Check for high level aminoglycoside resistance. If resistant to Gentamicin,
Ampicillin 12g IV/24h (continuously or divided q4h) test Streptomycin
+Gentamicin 1 mg/kg IV or IM q8h x 6 wks Vancomycin resistant enterococci: considerlinezolid or quinupristin/dalfopristin
Diphtheroids (nondiphtheria Penicillin G 18-24 mU IV/24h (continuously or Penicillin allergy or Gentamicin resistance:Vancomycin 15mg/kg IV q12h x 6 wks
corynebacteria) divided q4h) x 6 wks + Gentamicin 1 mg/kg IV or
IM q8h x 6 wks
HACEK organisms Ceftriaxone 2g IV/IM q24h x 6wks Ampicillin-sulbactam 12g IV/24h (continuously or divided q4h) x 6 wks
+ Gentamicin 1 mg/kg IV or IM q8h x 4 wks
Candida Amphotericin B 0.8-1.0 mg/kg/24h IV Fluconazole 400mg IV q24h x 4-6 wks (if organism susceptible)
+ Flucytosine 100-150 mg/kg/24h for a total dose Caspofungin (no/little experience)
ofAmphotericin B 30-40 mg/kg Voriconazole (no/little experience)
Culture-negative Vancomycin 15mg/kg IV q12h
+Gentamicin 1mg/kg IV or IM q8h x 6wks +/-
Cefepime 2 g IV q8h x 6 wks
Basis for Recommendations
Baddour LM, Wilson WR, Bayer AS, et al.; Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare
professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology,
Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America.; Circulation; 2005; Vol. 111; pp. e394-434;
Rating: Basis for recommendation
Comments:AHA recommendations used for this module.
Infectious Endocarditis Prophylaxis (2007 Revised AHA guidelines)
2007 AHA Guidelines dramatically reduce situations under which Infectious
Endocarditis (IE) prophylaxis is indicated.
IE is more likely to result from random bacteremias due to daily activities (e.g.
chewing, tooth brushing) than medical procedures. This exposure ratio may
exceed 5 million to one.
No level A (AHA classification system) evidence exists that prophylaxis is
beneficial, even in the highest risk patients.
Maintenance of optimal oral health is recommended, may reduce risk of IE, and is
more important than antibiotic prophylaxis to prevent IE resultant from dental
Patients in the highest risk category for IE (any of the following):
Prosthetic cardiac valve (or other prosthetic material used in valve repair: e.g.
prosthetic ring to which porcine valve is attached).
Cardiac transplant recipients with cardiac valvulopathy
Patients with Congenital Heart Disease, if the following specific situations apply:
o Un-repaired CHD, including palliative shunts/conduits
o Completely repaired congenital heart defects, but only during the six
months after the procedure (during which endothelialization occurs)
o Repaired CHD, with lack of endothelialization, such as when residual
defects exist that prevent endothelialization.
Who needs prophylaxis?
Prophylaxis is indicated in patients with the highest risk of IE undergoing the following
procedures (see also special circumstances* below):
Dental Procedures (Class IIa, evidence grade B): Any dental procedure that may
result in manipulation of gingival tissue or the periapical region of teeth, or
perforation of the oral mucosa. Specifically excludes injections through non-
infected tissue, adjustment / placement of orthodontic appliances.
Respiratory Procedures (Class IIa, evidence grade C): Bronchoscopy with incision
or biopsy, tonsillectomy, adenoidectomy. Specifically excludes routine
Surgical procedures involving infected skin/soft tissue, including musculoskeletal
tissue (Class IIb, evidence grade C)
o Antibiotic treatment of infected skin/soft tissue, when indicated, routine
covers staphylococci and streptococci, which are also the organism of
concern in IE. Therefore, treatment of the infection will also result in
prophylaxis against IE. Consider possibility of MRSA.
Special Circumstances and Considerations:
The above recommendations do NOT supercede general peri-operative antibiotic
recommendations, such as the need for antibiotics peri-operatively for cardiac
Highest risk patients undergoing GI/GU system procedures do NOT require
prophylaxis (Class III, evidence grade B).
o Exception 1: the antibiotic treatment of GI/GU infections may not
routinely include coverage of enteroccoci; thus, broadening coverage to
include prophylaxis against enteroccoci is reasonable in a patient with a
pre-existing infection of the GI/GU system undergoing a GI/GU
procedure, if the patient is also in the highest risk category for IE (Class
IIb, evidence level B).
o Exception 2: consider anti-enteroccoci therapy in patients colonized with
enteroccoci who are undergoing elective cystoscopy or urinary tract
manipulation, or in those undergoing emergent urinary tract procedures
(Class IIb, evidence level B).
Prophylactic Regimens (Dental and Respiratory Procedures):
Designed to cover strep veridans, the oral flora most likely to cause IE
Administer 30-60 minutes before procedure
Standard PO therapy: amoxicillin 2 g PO OR cephalexin 2 g PO. For penicillic
allergic patients: clindamycin 600 mg PO OR azithromycin/clarithromycin 500 mg
Non-oral therapy: ampicillin 2 g IM/IV OR ceftriaxone 1 g IM/IV OR cefazolin 1 g
IM/IV. For penicillic allergic patients: clindamycin 600 mg IM/IV