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Suggested regimens for therapy of prosthetic valve endocarditis due to penicillin-susceptible viridans streptococci and Streptococcus gallolyticus (bovis) (MIC ≤0.12 mcg/mL)*

Suggested regimens for therapy of prosthetic valve endocarditis due to penicillin-susceptible viridans streptococci and Streptococcus gallolyticus (bovis) (MIC ≤0.12 mcg/mL)*
American Heart Association (AHA) European Society of Cardiology (ESC)
Adult Pediatric (not to exceed dose of normal adult) Adult 

Either

Aqueous penicillin G 24 million units per 24 hours IV either continuously or in four or six divided doses for six weeks

or

Ampicillin 2 g IV every 4 hours for six weeks

or 

Ceftriaxone 2 g per 24 hours IV in one dose for six weeks

with or without

GentamicinΔ◊ 3 mg/kg per 24 hours IV or IM in one dose for first two weeks

Beta-lactam-intolerant patients:

Vancomycin§ 30 mg/kg per 24 hours IV in two divided doses for six weeks

Either 

Aqueous penicillin G 200,000 to 300,000 units/kg per 24 hours IV in six divided doses (maximum dose: 24 million units per 24 hours) for six weeks

or

Ampicillin 200 to 300 mg/kg per 24 hours IV divided in four or six divided doses (maximum dose: 12 g per 24 hours) for six weeks

or

Ceftriaxone 100 mg/kg per 24 hours IV​ in two divided doses or 80 mg/kg in one daily dose (maximum dose: 4 g per 24 hours; if dose is >2 g per 24 hours, use divided dosing every 12 hours) for six weeks

plus

GentamicinΔ◊ 3 to 6 mg/kg per 24 hours IV in three divided doses for first two weeks

Beta-lactam-intolerant patients:

Vancomycin§ 40 mg/kg per 24 hours IV in two or three divided doses (maximum dose: 2 g per 24 hours unless levels are inappropriately low) for six weeks plus gentamicin (dosing as above) for first two weeks

Either

Aqueous penicillin G 12 to 18 million units per 24 hours IV in four or six divided doses or continuously for six weeks

or

Amoxicillin 100 to 200 mg/kg per 24 hours IV in four or six divided doses for six weeks

or

Ampicillin 12 g per 24 hours (or 100 to 200 mg/kg per 24 hours) IV in four or six divided doses for six weeks

or

Ceftriaxone 2 g per 24 hours IV in one dose for six weeks

or

Vancomycin§ 30 mg/kg per 24 hours IV in two divided doses for six weeks
The doses above are intended for patients with normal renal function. The doses of many of these agents must be adjusted in the setting of renal insufficiency; refer to the individual Lexicomp drug monographs for renal dose adjustments.
Wherever intramuscular administration is provided as an alternative, intravenous route is preferred, particularly in infants and children.
MIC: minimum inhibitory concentration; IV: intravenously; IM: intramuscularly.
* AHA adult guidelines use MIC ≤0.12 mcg/mL; AHA pediatric guidelines use MIC ≤0.1 mcg/mL; ESC guidelines use MIC ≤0.125 mcg/mL.
¶ Alternative in patients with nonsevere penicillin allergy; preferred for outpatient therapy.
Δ Gentamicin should be omitted in patients with potential for nephrotoxicity, patients with creatinine clearance <30 mL/min, or patients with impaired VIII cranial nerve function or severe decreased vision. In adults, aminoglycosides are dosed based on ideal body weight.
◊ Renal function and gentamicin serum concentrations should be monitored at least once per week. Gentamicin dosage adjusted for peak serum concentration 3 to 4 mcg/mL, trough <1 mcg/mL when two to three divided doses used; when given in a single daily dose, pre-dose (trough) concentrations should be <1 mcg/mL. Per AHA guidelines, there is no role for measuring peak gentamicin concentration following single daily dosing.
§ Vancomycin therapy only recommended for patients allergic to penicillins or cephalosporins. Penicillin desensitization can be attempted in stable patients. In adults, vancomycin is dosed based on actual body weight. The dose should be adjusted for trough concentration of 10 to 15 mcg/mL.
Data from:
  1. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: Diagnosis, antimicrobial therapy, and management of complications: A scientific statement for healthcare professionals from the American Heart Association. Circulation 2015; 132:1435.
  2. Baltimore RS, Gewitz M, Baddour LM, et al. Infective Endocarditis in Childhood: 2015 Update: A Scientific Statement From the American Heart Association. Circulation 2015; 132:1487.
  3. Authors/Task Force Members, Habib G, Lancellotti P, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC) Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075.
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