Day 1 - Infective Endocarditis
Empiric Investigations for Endocarditis
Blood cultures x 3 - 3 locations, 15 minutes apart
If central line present, ensure culture drawn from port/line
ECG
Monitor for PR elongation - signs of developing heart block throughout hospitalization
Echocardiogram
Start with TTE, if negative, move on to TEE
Empiric Drug Dosing
Cefriaxone 2g IV q24h
Vancomycin 15-20mg/kg loading dose, then Vancomycin 1g IV BID
Vancomycin trough pre-4th dose
Consider renal dosing for patients with CKD or AKI
Targeted Drug Dosing
MSSA - Cefazoline 2g IV q8h or Cloxacillin 2g IV q4h
MRSA - Vancomycin 15-20mg/kg loading dose, then target to therapeutic vancomycin level
Streptococcus IE - Ceftriaxone 2g IV q24h
Enterococcus - Requires speciation to E.Faecium or E. Faecalis - Generally either Vancomycin or Ampicillin
Duration of Treatment
Generally at least 6 weeks for left sided endocarditis, but antibiotic therapy should be guided by organism, location and size of lesion
Patients will generally require PICC line once blood cultures negative for at least 48 hours
Frequently Asked Questions
Can I use oral antibiotics?
There is emerging evidence for oral antibiotics as defined by the POET trial. However, the POET trial required significant antibiotic susceptibility testing, follow-up of patients and excluded marginalized populations including intravenous drug users, making it difficult to apply to the Canadian healthcare system and parts of our population.
What if the patient has a prosthetic valve?
This should be guided by infectious disease specialists and cardiologists. Depending on the size and location as well as blood culture clearance, antibiotics may be trialled before the decision to surgically remove the valve.
The antibiotic regimen for patients with prosthetic valves may require the addition of an aminoglycloside and rifampin for better penetration.
