Antimicrobial therapy of native valve endocarditis
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Issues related to the antimicrobial therapy of native valve infective endocarditis (IE) will be reviewed here; the content reflects American, British, and European guidelines [1-3]. The pathogenesis of vegetation formation, complications of IE, and indications for surgery are discussed separately. (See "Pathogenesis of vegetation formation in infective endocarditis" and "Complications and outcome of infective endocarditis" and "Surgery for left-sided native valve infective endocarditis" and "Infective endocarditis in injection drug users", section on 'Surgery'.)
Issues related to management of prosthetic valve IE and infection associated with cardiac devices are discussed separately. (See "Antimicrobial therapy of prosthetic valve endocarditis" and "Surgery for prosthetic valve endocarditis" and "Infections involving cardiac implantable electronic devices".)
Bactericidal agents are necessary for effective treatment of endocarditis. Therefore, antimicrobial therapy should be dosed to optimize sustained bactericidal serum concentrations throughout as much of the dosing interval as possible. In vitro determination of the minimum inhibitory concentration should be performed routinely.
Empiric therapy — In general, therapy for infective endocarditis (IE) should be targeted to the organism isolated from blood cultures; cultures are positive in over 90 percent of patients with IE. For patients with suspected IE who present without acute symptoms, empiric therapy is not always necessary, and therapy can await blood culture results. Results of blood cultures are usually available within one to three days, and an accurate diagnosis is a critical first step in designing a management strategy. (See "Clinical manifestations and evaluation of adults with suspected native valve endocarditis".)
For acutely ill patients with signs and symptoms strongly suggestive of IE, empiric therapy may be necessary. Such empiric therapy should be administered ONLY after at least two (preferably three) sets of blood cultures have been obtained from separate venipunctures and ideally spaced over 30 to 60 minutes.
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- GENERAL CONSIDERATIONS
- Empiric therapy
- Clinical response to initial therapy
- Duration of therapy
- Completing therapy
- Follow up
- Methicillin susceptible
- - Penicillin allergy
- - Uncomplicated right-sided endocarditis
- Methicillin resistant
- Coagulase-negative staphylococci
- VIRIDANS STREPTOCOCCI AND STREPTOCOCCUS BOVIS
- OTHER STREPTOCOCCAL SPECIES
- Susceptible strains
- Gentamicin-resistant strains
- High-level penicillin resistance
- High-level aminoglycoside or vancomycin resistance
- HACEK ORGANISMS
- OTHER GRAM-NEGATIVE ORGANISMS
- CULTURE-NEGATIVE ENDOCARDITIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS