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Suggested regimens for therapy of native or prosthetic valve endocarditis due to enterococcal strains resistant to penicillin, aminoglycosides, and vancomycin*

Suggested regimens for therapy of native or prosthetic valve endocarditis due to enterococcal strains resistant to penicillin, aminoglycosides, and vancomycin*
American Heart Association (AHA) European Society of Cardiology (ESC)
Adult dose Pediatric dose Adult dose
  • Linezolid 600 mg IV or orally every 12 hours for >6 weeks
  • OR
  • DaptomycinΔ 10 to 12 mg/kg IV every 24 hours for >6 weeks
  • OR
  • Alternative regimens (ie, daptomycin plus ampicillin, or ceftaroline) may be reasonable in patients with persistent bacteremia or strains with daptomycin MIC at high end of susceptible range
  • Consultation with a pediatric infectious disease specialist is recommended
  • Daptomycin 10 mg/kg per 24 hours IV once per day for ≥8 weeks
  • PLUS
  • Ampicillin 12 g per 24 hours (or 200 mg/kg per 24 hours) IV in six divided doses for ≥8 weeks
  • OR
  • Linezolid 1200 mg per 24 hours IV or orally in two divided doses for ≥8 weeks
  • OR
  • Quinupristin-dalfopristin◊ 22.5 mg/kg per 24 hours IV in three divided doses for ≥8 weeks
  • OR
  • Combinations of antibiotics according to in vitro susceptibility§ (eg, daptomycin plus ertapenem or ceftaroline)
The doses in this table 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 Lexicomp drug-specific monographs for renal dose adjustments.
IV: intravenously; MIC: minimum inhibitory concentration; HLAR: high-level aminoglycoside resistance.
* Patients with endocarditis caused by these strains, most commonly Enterococcus faecium, should be treated in consultation with an infectious disease specialist; cardiac valve replacement may be necessary for bacteriologic cure; cure with antimicrobial therapy alone may be <50%.
¶ Linezolid use may be associated with potentially severe bone marrow suppression, neuropathy, and drug interactions. Monitor hematologic toxicity.
Δ Daptomycin is usually used in combination with either ampicillin (12 g/day in four or six divided doses) or ceftaroline (600 mg IV every 8 or 12 hours).
◊ Only effective against Enterococcus faecium and can cause severe myalgias, which may require discontinuation of therapy.
§ An alternative regimen for isolates with high-level resistance to gentamicin (MIC >500 mcg/mL) that do not have HLAR to streptomycin consists of streptomycin (15 mg/kg per 24 hours IV in two divided doses) in combination with beta-lactam or vancomycin.
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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