The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

Table 19.9 Therapy for native valve or prosthetic valve enterococcal endocarditis caused by strains susceptible to penicillin, gentamicin,
and vancomycin*

Regimen Dosage and route

Duration

(weeks)

Strength of

recommendation Comments

Ampicillin sodium

or

a queous crystalline
penicillin G sodium
plus
gentamicin sulfate†

12 g/24 h IV in 6 equally divided doses

18–30 million U/24 h IV either

continuously or in 6 equally divided doses

3 mg/kg per 24 h IV/IM in 3 equally

divided doses

Pediatric dose**: Ampicillin 300 mg/kg per

24 h IV in 4–6 equally divided doses;

penicillin 300,000 U/kg per 24 h IV in 4–6

equally divided doses; gentamicin 3 mg/kg

per 24 h IV/IM in 3 equally divided doses

4–6

4–6

4–6

IA

IA

Native valve: 4-wk therapy

recommended for patients with

symptoms of illness ≤3 mo; 6-

wk therapy recommended for

patients with symptoms >3 mo.

Prosthetic valve or other

prosthetic cardiac material: A

minimum of 6 wk of therapy

recommended.

Vancomycin
hydrochloride‡

plus
gentamicin sulfate†

30 mg/kg per 24 h IV in 2 equally divided

doses

3 mg/kg per 24 h IV/IM in 3 equally

divided doses

Pediatric dose: Vancomycin 40 mg/kg per

24 h IV in 2 or 3 equally divided doses;

gentamicin 3 mg/kg per 24 h IV/IM in 3

equally divided doses

6

6

IB Vancomycin therapy

recommended only for patients

unable to tolerate penicillin or

ampicillin.

6-wk of vancomycin therapy

recommended because of

decreased activity against

enterococci.

• Dosages recommended are for patients with normal renal function.
  ** Pediatric dose should not exceed that of a normal adult.
  † The dosage of gentamicin should be adjusted to achieve a peak serum concentration of 3–4 μg/mL and a trough concentration of < 1 μg/mL. See Table 19.4 for

appropriate dosage of gentamicin.
‡ See Table 19.4 for appropriate dosing of vancomycin.

IM indicates intramuscular.

antibiotic regimen for the individual patient with
culture-negative endocarditis.

Complications and their treatment
Surgical therapy
Patients with IE and CHF, irrespective of the mecha-
nism, should be immediately evaluated for possible
surgical therapy (Class I, Level of Evidence: B).
Despite a higher operative mortality rate in patients

with CHF than in those without CHF, patients with

IE who have CHF and undergo valve surgery have a

substantially reduced mortality rate compared with

those treated with medical therapy alone. The inci-

dence of reinfection of newly implanted valves in

patients with active IE is ≈2% to 3% and is far less

than the mortality rate for IE and CHF without sur-

gical therapy, which can be as high as 51%. Surgical

approaches to CHF caused by different mechanisms

are discussed in the section on CHF.