Treatment-bacterial endocarditis

Empiric

NVE or PVE >12 mos post-op: vanc + CTX PVE <12 mos post op: vanc + CTX ± gentamicin (if OK renal fxn)

Strep

Penicillin, ampicillin, cftx; if PVE consider gentamicin in discussion w/ ID

Staph (S. aureus and lugdunensis)

MRSA: vanc or dapto MSSA: nafcillin, oxacillin, or cefazolin (avoid if CNS involvement due to poor penetration); vanc inferior to β-lactam for MSSA For PCN allergy w/ MSSA consider desensitization Consider rifampin / gentamicin in PVE in discussion w/ ID

Enterococci

Ampicillin + [CTX or gent]; if VRE: linezolid, dapto, ampicillin if sensitive

Gram negatives

HACEK: CTX, ampicillin or FQ. Pseudomonas: 2 anti-Pseudomonal agents [eg, β-lactam + (aminoglycoside or FQ)]

Fungi (candida, aspergillus)

Candida: amphotericin B ± flucytosine or micafungin Aspergillus: amphotericin B or voriconazole Ophtho consult for fungemia to rule out endophthalmitis

• De-escalate abx to organism-directed therapy based on speciation and sensitivities

• If on anticoagulation or antiplatelet, typically can continue unless concern for stroke, intracranial hemorrhage, or need for emergent surgery

• Monitor for complications of endocarditis

• Duration is usually 4–6 wks After ≥10d IV abx can consider ∆’ing to PO if clinically appropriate and available PO abx in consultation with ID (NEJM 2019;380:415) Uncomplicated right-sided NVE or PCN-S Strep spp → 2 wks may be adequate

• IVDU-associated best managed by multidisciplinary teams including Addiction Medicine