Endocarditis infecciosa Actualizado 2015

1. ENDOCARDITIS INFECCIOSA
Hospital Regional Valentín Gómez Farías
Luis Ulises Flores Martínez

2. Endocarditis infecciosa
Colonización e invasión de las válvulas
cardíacas o el endocardio mural por
microorganismos, que produce
formación de vegetaciones
voluminosas y friables, compuestas de
restos trombóticos y microorganismos,
asociadas con destrucción de los
tejidos cardíacos subyacentes.

3. o En la era actual la presentación
suele ser aguda.

4. Etiología
● S. aureus — 31 percent
● Viridans group streptococci — 17 percent
● Enterococci — 11 percent
● Coagulase-negative staphylococci — 11
percent
● Streptococcus bovis — 7 percent
● Other streptococci — 5 percent
● Non-HACEK gram-negative bacteria — 2
percent
● Fungi — 2 percent
● HACEK — 2 percent

5. Etiología
o La presencia de VIH no tiene impacto
general demostrado sobre los agentes que
la causan.
o En 5 % los cultivos son negativos. 33-55%
debido a exposición previa a antibióticos.

6. Patogenia
o Presencia de daño endocárdico
o Agregado fibrionoplaquetario
o Invasión del microorganismo al agregado
fibrinoplaquetario.

9. Manifestaciones clínicas
Manchas Janeway
Manchas Roth
Nódulos de Osler

10. Manifestaciones clínicas

11. o Las petequias son la manifestaciones
dérmicas más comunes; menos específicas
Petechiae in subacute bacterial endocarditis

12. Splinter hemorrhages in infective endocarditis

13. o Las lesiones de Janeway, nódulos de Osler
y manchas de Roth son más especídicas,
suelen presentarse más en los cuadros
crónicos, por lo que actualmente son raros.

14. Las lesiones de Janeway son
lesiones maculares, eritematosas,
no dolorosas en palmas y plantas

15. o Los nódulos de Osler son dolorosos,
violáceos, encontrados en purplejos en
manos y pies y se observan más en los
casos subagudos.

16. o Las manchas de Roth son lesiones
hemorrágicas exudativas edematosas de la
retina.

18. Diagnóstico
o Se basa en la sospecha clínica, la
realización de hemocultivos o pruebas
serológicas para gérmenes de cultivo
dificultoso y en el estudio ecocardiográfico.
o Transesofágica 90%
o Transtorácica 70% (endocarditis de
localización tricuspídea

19. Diagnóstico
o Para el diagnóstico de las endocarditis por
Coxiella burnetii, Chlamydophila psittaci y
Bartonella quintana es útil la serología; el
diagnóstico de endocarditis por Legionella
spp. requiere medios de cultivo muy
especiales.

20. Criterios de Duke
o La documentación de dos criterios
mayores, un criterio mayor y tres menores o
de cinco criterios menores ayuda a
establecer diagnóstico.

22. Cultivos
o Se deben de obtener al menos 3 series de
cultivos.
o Si se ha iniciado antibioticoterapia, pueden
requerirse más cultivos.
o En presenaciones subagudas o crónicas, si
el paciente no está en estado crítico, se
puede retrasar la antibioticoterapia hasta
obtener cultivos y otros estudios
diagnósticos
o En presentación aguda o paciente crítico
se deben obtener 3 series de cultivos en
menos de una hora e iniciar tratamiento
empírico.

23. Cultivos
In one series including 206 cases of
endocarditis, the initial blood culture in
patients with streptococcal endocarditis was
positive in 96 percent of cases, and one of the
first two blood cultures was positive in 98
percent. In patients with IE caused by
organisms other than streptococcus, the first
blood culture was positive in 82 percent of
cases and one of the first two cultures was
positive in 100 percent of cases.
Studies on the bacteremia of bacterial endocarditis.
Werner AS, Cobbs CG, Kaye D, Hook

24. Cultivos
Agentes con cultivos negativos
Coxiella burnetii
• Brucella mellitensis
• Grupo HACEK (gramnegativos)
• Legionella pneumophila
• Bartonella quintana y Bartonella henselae
• Tropheryma whipplei
• Chlamydophila psittaci
• Hongos {Candida y Aspergillus)
• Estreptococos nutricionalmente variantes
(AbiotrophiayGranulicatella)

25. Estudios de laboratorio
No específicos
o ↑ VSG, Prot. C reactiva
o Anemia normocítica normocrómica
o En presentaciones subagudas de endocarditis la
WBC puede ser normal o elevada; la mayoría de los
pacientes con endocarditis estafilocóccica tienen
leucocitosis y algunos trombocitopenia.
o ●Hiperglobulinemia, crioglobulinemia, complejos
inmunes circulantes, hipocomplementemia, títulos
elevados de FR y falsos positivos en serología para
sífilis pueden estar presentes.

26. Tratamiento
o Suggested regimens for therapy of native valve endocarditis due to
penicillin-susceptible viridans streptococci and Streptococcus bovis
(MIC ≤0.12 mcg/mL)
American Heart Association
British Society for
Antimicrobial
Chemotherapy
European Society of
Cardiology
Adult
(for patients with normal
renal function)
Pediatric
(not to exceed dose of
normal adult)
4-week regimens*: 4-week regimens: 4- to 6-week regimens: 4-week regimens¶:
Aqueous penicillin G 12 to
18 million units per 24 hours
IV either continuously or
in four or six equally divided
doses
or
Ceftriaxone 2 g per 24
hours IV or IM in one dose
or
VancomycinΔ 30 mg/kg per
24 hours IV in two equally
divided doses not to
exceed 2 g per 24 hours
unless concentrations in
serum are inappropriately
low
Aqueous penicillin G
200,000 units/kg per 24
hours IV in four or six equally
divided doses
or
Ceftriaxone 100 mg/kg per
24 hours IV or IM in one
dose
or
VancomycinΔ 40 mg/kg per
24 hours IV in two or three
equally divided doses
Benzylpenicillin¥ 1.2 g every
4 hours IV
or
Ceftriaxone 2 g per 24
hours IV/IM
Aqueous penicillin G* 12 to
18 million units per 24 hours
IV in six equally divided
doses
or
Amoxicillin 100 to 200
mg/kg per 24 hours IV
in four to six equally divided
doses
or
Ampicillin 12 g per 24 hours
(or 100 to 200 mg/kg per 24
hours) IV in six equally
divided doses
or
Ceftriaxone*‡ 2 g per 24
hours IV or IM in one dose
or
VancomycinΔ 30 mg/kg per
24 hours IV in two equally
divided doses

27. Tratamiento
o Suggested regimens for therapy of native valve endocarditis due to
strains of viridans streptococci and Streptococcus bovis relatively
resistant to penicillin G (MIC >0.12 mcg/mL and ≤0.5 mcg/mL)*
American Heart Association
British Society for
Antimicrobial Chemotherapy
European Society of
Cardiology¶
Adult
(for patients with normal renal
function)
Pediatric
(not to exceed dose of
normal adult)
Either aqueous penicillin G 24
million units per 24 hours IV
either continuously or in four
or six equally divided doses
for four weeks
or
Ceftriaxone 2 g per 24 hours
IV or IM in one dose for four
weeks
plus
GentamicinΔ 3 mg/kg per 24
hours IV or IM in one dose or
in two to three equally
divided doses for two weeks
or
Monotherapy with
Vancomycin◊ 30 mg/kg per
24 hours IV in two equally
divided doses for four weeks;
not to exceed 2 g per 24
hours unless concentrations in
serum are inappropriately low
Either aqueous penicillin G
300,000 units/kg per 24 hours
IV in four or six equally
divided doses for four weeks
or
Ceftriaxone 100 mg/kg per 24
hours IV or IM in one dose
for four weeks
plus
GentamicinΔ 3 mg/kg per 24
hours IV or IM in one dose or
in three equally divided doses
for two weeks
or
Monotherapy with
Vancomycin◊ 40 mg/kg per
24 hours IV in two or three
equally divided doses for four
weeks
Benzylpenicillin§ 2.4 g every 4
hours IV for four to six weeks
plus
Gentamicin 1 mg/kg every 12
hours IV for two weeks
Either aqueous penicillin G 24
million units per 24 hours IV
in six equally divided doses
for four weeks
or
Amoxicillin 200 mg/kg per 24
hours IV in four or six equally
divided doses for four weeks
or
Ampicillin 12 g per 24 hours
(200 mg/kg per 24 hours) in six
equally divided doses for four
weeks
or
Vancomycin◊ 30 mg/kg per
24 hours IV in two equally
divided doses for four weeks
plus
GentamicinΔ 3 mg/kg per 24
hours IV or IM in one dose for
first two weeks

28. Tratamiento
o Suggested regimens for therapy of native valve endocarditis due to
enterococcal strains susceptible to penicillin, gentamicin, and
vancomycinAmerican Heart Association
British Society for
Antimicrobial
Chemotherapy
European Society of
Cardiology*¶
Adult
(for patients with normal
renal function)
Pediatric
(not to exceed dose of
normal adult)
GentamicinΔ 3 mg/kg per
24 hours IV or IM in three
equally divided doses for
four to six weeks◊
Plus one of the following◊:
Aqueous penicillin G 18 to
30 million units per 24 hours
IV either continuously or in
six equally divided doses for
four to six weeks◊
or
Ampicillin 12 g per 24 hours
IV in six equally divided
doses for four to six weeks◊
or
Vancomycin§ 30 mg/kg per
24 hours IV in two equally
divided doses for six weeks;
not to exceed 2 g per 24
hours unless concentrations
in serum are inappropriately
low
GentamicinΔ 3 mg/kg per
24 hours IV or IM in three
equally divided doses for
four to six weeks◊
Plus one of the following:
Aqueous penicillin G
300,000 units/kg per 24
hours IV in four to six equally
divided doses for four to six
weeks◊
or
Ampicillin 300 mg/kg per 24
hours IV in four to six equally
divided doses for four to six
weeks◊
or
Vancomycin§ 40 mg/kg per
24 hours IV in two or three
equally divided doses for six
weeks
GentamicinΔ 1 mg/kg every
12 hours IV for four to six
weeks
Plus one of the following:
Amoxicillin 2 g every four
hours IV for four to six weeks
or
Penicillin 2.4 g every four
hours IV for four to six weeks
or
Vancomycin§ 1 g IV every
12 hours for four to six weeks
or
Teicoplanin¥ 10 mg/kg IV
once every 24 hours for four
to six weeks
GentamicinΔ 3 mg/kg per
24 hours IV or IM in two or
three equally divided doses
for four to six weeks◊
Plus one of the following:
Amoxicillin 200 mg/kg per
24 hours IV in four to six
equally divided doses for
four to six weeks◊
or
Ampicillin 12 g per 24 hours
(200 mg/kg per 24 hours) IV
in six equally divided doses
for four to six weeks◊
or
Vancomycin§ 30 mg/kg per
24 hours IV in two equally
divided doses for six weeks

29. Tratamiento
o Suggested regimens for therapy of native valve endocarditis due to
enterococcal strains resistant to penicillin and susceptible to
aminoglycoside and vancomycin
American Heart Association
British Society for Antimicrobial
Chemotherapy
European Society of Cardiology*Adult
(for patients with normal renal
function)
Pediatric
(not to exceed dose of normal adult)
Beta-lactamase producing:
One of the following:
Gentamicin• 3 mg/kg per 24 hours IV
or IM in three equally divided doses
for six weeks
plus either
Ampicillin-sulbactamΔ 12 g per 24
hours IV in four equally divided doses
for six weeks
or
Vancomycin◊ 30 mg/kg per 24 hours
IV in two equally divided doses for six
weeks; not to exceed 2 g per 24 hours
unless concentrations in serum are
inappropriately low
Beta-lactamase producing:
One of the following:
Gentamicin• 3 mg/kg per 24 hours IV
or IM in three equally divided doses
for six weeks
plus either
Ampicillin-sulbactamΔ 300 mg/kg per
24 hours IV in four divided doses for six
weeks
or
Vancomycin◊ 40 mg/kg per 24 hours
IV in two or three equally divided
doses for six weeks
One of the following:
Gentamicin¥ 1 mg/kg IV every 8 to 12
hours for ≥4 weeks
plus either
Vancomycin◊ 1 g IV every 12 hours for
≥4 weeks
or
Teicoplanin‡ 10 mg/kg IV once daily
for ≥4 weeks
Beta-lactamase producing:
One of the following:
Gentamicin• 3 mg/kg per 24 hours IV
or IM in two or three equally divided
doses for four to six weeks†
plus either
Ampicillin-sulbactamΔ 12 g per 24
hours (or 300 mg/kg per 24 hours) IV in
four equally divided doses for four to
six weeks†
or
Amoxicillin-clavulanateΔ 200 mg/kg
(amoxicillin component) per 24 hours
IV in six equally divided doses for four
to six weeks†
or
Vancomycin◊ 30 mg/kg per 24 hours
IV in two equally divided doses for six
weeks
Intrinsic penicillin resistance§:
Vancomycin◊ 30 mg/kg per 24 hours
IV in two divided doses for six weeks
plus
Gentamicin• 3 mg/kg per 24 hours IV
or IM in three equally divided doses
for six weeks
Intrinsic penicillin resistance§:
Vancomycin◊ 40 mg/kg per 24 hours
IV in two or three divided doses for six
weeks
plus
Gentamicin• 3 mg/kg per 24 hours IV
or IM in three equally divided doses
for six weeks
Intrinsic penicillin resistance§:
Vancomycin◊ 30 mg/kg per 24 hours
IV in two equally divided doses for six
weeks
plus
Gentamicin• 3 mg/kg per 24 hours IV
or IM in two or three equally divided
doses for six weeks

30. Tratamiento
o Suggested regimens for therapy of native or prosthetic valve endocarditis
due to enterococcal strains resistant to penicillin, aminoglycoside, and
vancomycin*

31. Tratamiento
American Heart Association
British Society for Antimicrobial
Chemotherapy
European Society of
CardiologyAdult (for patients with normal
renal function)
Pediatric (not to exceed dose
of normal adult)
E. faecium:
One of the following:
Linezolid• 1200 mg per 24 h IV
or PO in 2 equally divided
doses for ≥8 wks
or
Quinupristin-dalfopristinΔ 22.5
mg/kg per 24 h IV in 3 equally
divided doses for ≥8 wks
E. faecium:
One of the following:
Linezolid• 30 mg/kg per 24 h IV
or PO in 3 equally divided
doses for ≥8 wks
or
Quinupristin-dalfopristinΔ 22.5
mg/kg per 24 h IV in 3 equally
divided doses for ≥8 wks
One of the following:
Linezolid• 1200 mg per 24 h IV
or PO in 2 equally divided
doses for ≥6 wks
or
Quinupristin-dalfopristinΔ 22.5
mg/kg per 24 h IV in 3 equally
divided doses for ≥6 wks
or
Teicoplanin◊ 10 mg/kg IV once
daily for ≥6 wks
or
Combinations of antibiotics
according to in vitro
susceptibility
E. faecium¥:
Linezolid• 1200 mg per 24 h IV
or PO in 2 equally divided
doses for ≥ 8 wks
or
Quinupristin-dalfopristinΔ 22.5
mg/kg per 24 h IV in 3 equally
divided doses for ≥8 wks
or
Combinations of antibiotics
according to in vitro
susceptibility‡
E. faecalis§:
Imipenem-cilastatin 2 g per 24
h (or 60-100 mg/kg per 24 h) IV
in 4 equally divided doses for
≥8 wks
plus
Ampicillin 12 g per 24 h (or 300
mg/kg per 24 h) IV in 6 equally
divided doses for ≥8 wks
or
Ceftriaxone 2 g per 24 h (or 100
mg/kg per 24 h) IV or IM in 1
dose for ≥8 wks
plus
Ampicillin 12 g per 24 h (or 300
mg/kg per 24 h) IV in 6 equally
divided doses for ≥8 wks
or
Combinations of antibiotics
according to in vitro
susceptibility‡
E. faecalis§:
Imipenem-cilastatin 2 g per 24
h IV in 4 equally divided doses
for ≥8 wks
plus
Ampicillin 12 g per 24 h IV in 6
equally divided doses for ≥8
wks
or
Ceftriaxone 4 g per 24 h IV or
IM in 2 equally divided doses
for ≥8 wks†
plus
Ampicillin 12 g per 24 h IV in 6
equally divided doses for ≥8
wks
E. faecalis§:
Imipenem-cilastatin 60-100
mg/kg per 24 h IV in 4 equally
divided doses for ≥8 wks
plus
Ampicillin 300 mg/kg per 24 h
IV in 4 to 6 equally divided
doses for ≥8 wks
or
Ceftriaxone 100 mg/kg per 24
h IV or IM in 2 equally divided
doses for ≥8 wks
plus
Ampicillin 300 mg/kg per 24 h
IV in 4 to 6 equally divided
doses for ≥8 wks

32. Tratamiento
o Suggested regimens for therapy of native valve endocarditis due to
staphylococcus
American Heart Association
British Society for
Antimicrobial Chemotherapy
European Society of
Cardiology*
Adult
(for patients with normal
renal function)
Pediatric
(not to exceed dose of
normal adult)
Oxacillin-susceptible
strains•Δ Oxacillin-susceptible strains• Methicillin-sensitive Methicillin-susceptible strains
Nafcillin or oxacillin 12 g per
24 h IV in 4 or 6 equally
divided doses for 6 wks, plus
optional addition of
gentamicin◊ 3 mg/kg per 24
h IV or IM in 2 or 3 equally
divided doses for 3 to 5 days
or
Cefazolin§ 6 g per 24 h IV in 3
equally divided doses for 6
wks, plus optional addition of
gentamicin◊ 3 mg/kg per 24
h IV or IM in 2 or 3 equally
divided doses for 3 to 5 days
Nafcillin or oxacillin 200
mg/kg per 24 h IV in 4 or 6
equally divided doses for 6
wks plus optional addition of
gentamicin◊ 3 mg/kg per 24
h IV or IM in 3 equally
divided doses for 3 to 5 days
or
Cefazolin§ 100 mg/kg per 24
h IV in 3 equally divided
doses for 6 wks plus optional
addition of gentamicin◊ 3
mg/kg per 24 h IV or IM in 3
equally divided doses for 3
to 5 days
Flucloxacillin 2 g IV every 4 to
6 hours for 4 wks
Oxacillin or cloxacillin or
flucloxacillin 12 g per 24 h IV
in 4-6 equally divided doses
for 4 to 6 wks plus optional
addition of gentamicin◊ 3
mg/kg per 24 h IV or IM
divided in 2 or 3 doses for 3
to 5 days
or
Vancomycin¥ 30 mg/kg per
24 h IV in 2 equally divided
doses for 4 to 6 wks plus
optional addition of
gentamicin◊ 3 mg/kg per 24
h IV or IM in 2 or 3 equally
divided doses for 3 to 5 days
Oxacillin-resistant strains Oxacillin-resistant strains Methicillin resistant Methicillin resistant strains
Vancomycin¥ 30 mg/kg per
24 h IV in 2 equally divided
doses for 6 wks; not to
exceed 2 g per 24 h unless
concentrations in serum are
Vancomycin¥ 40 mg/kg per
24 h IV in 2 or 3 equally
divided doses for 6 wks
Vancomycin¥ 1 g IV every 12
h for 4 wks
plus
Rifampin 300 to 600 mg PO
Vancomycin¥ 30 mg/kg per
24 h IV in 2 doses for 4 to 6
wks plus optional addition of
gentamicin◊ 3 mg/kg per 24
h IV or IM in 2 or 3 equally

33. Tratamiento
o Suggested regimens for therapy of native valve endocarditis due to
HACEK* microorganism
American Heart Association
British Society for
Antimicrobial
Chemotherapy
European Society of
CardiologyAdult (for patients with
normal renal function)
Pediatric (not to exceed
dose of normal adult)
One of the following:
Ceftriaxone• 2 g per 24 h IV
or IM in 1 dose for 4 wks
or
Ampicillin-sulbactam 12 g
per 24 h IV in 4 equally
divided doses for 4 wks
or
Ciprofloxacin§ 1000 mg per
24 h PO or 800 mg per 24 h
IV in 2 equally divided
doses for 4 wks
One of the following:
Ceftriaxone• 100 mg/kg
per 24 h IV or IM in 1 dose
for 4 wks
or
Ampicillin-sulbactam 300
mg/kg per 24 h IV in 4
equally divided doses
doses for 4 wks
or
Ciprofloxacin§ 20-30 mg/kg
per 24 h IV or PO in 2
equally divided doses for 4
wks
Either
AmpicillinΔ 2 g IV every 4 to
6 h for 4 wks
or
Ceftriaxone• 2 to 4 g per 24
h IV or IM in 1 dose for 4 wks
plus
Gentamicin◊ 1 mg/kg IV
every 8 to 12 h for 2 wks
One of the following:
Ceftriaxone• 2 g per 24 h IV
or IM in 1 dose for 4 wks
or
Combination therapy with:
ampicillinΔ 12 g per 24 h IV
in 4 or 6 equally divided
doses plus gentamicin◊ 3
mg/kg per 24 h IV or IM in 2
or 3 equally divided doses
for 4 wks
or
Ciprofloxacin§ 1000 mg per
24 h PO or 800 mg per 24 h
IV in 2 equally divided
doses for 4 wks

34. Tratamiento
o Suggested regimens for therapy of culture-negative native valve
endocarditisAmerican Heart Association
British Cardiac Society
European Society of
Cardiology
Adult
(for patients with normal
renal function)
Pediatric
(not to exceed dose of
normal adult)
One of the following:
Ampicillin-sulbactam 12 g
per 24 h IV in 4 equally
divided doses for 4-6 wks
plus
Gentamicin sulfateΔ 3 mg/kg
per 24 h IV or IM in 3 equally
divided doses for 4-6 wks
OR
Vancomycin• 30 mg/kg per
24 h IV in 2 equally divided
doses for 4-6 wks; not to
exceed 2 g per 24 h unless
concentrations in serum are
inappropriately low
plus
GentamicinΔ 3 mg/kg per 24
h IV or IM in 3 equally
divided doses for 4-6 wks
plus
Ciprofloxacin 1000 mg per
24 h PO or 800 mg per 24 h
IV in 2 equally divided doses
for 4 to 6 wks
One of the following:
Ampicillin-sulbactam 300
mg/kg per 24 h IV in 4 or 6
equally divided doses for 4-6
wks
plus
GentamicinΔ 3 mg/kg per 24
h IV or IM in 3 equally
divided doses for 4-6 wks
OR
Vancomycin• 40 mg/kg per
24 h IV in 2 or 3 equally
divided doses for 4-6 wks
plus
GentamicinΔ 3 mg/kg per 24
h IV or IM in 3 equally
divided doses for 4-6 wks
plus
Ciprofloxacin◊ 20-30 mg/kg
per 24 h IV or PO in 2 equally
divided doses for 4 to 6 wks
Vancomycin• 15 mg/kg IV
every 12 h for 6 wks
plus
Gentamicin 3-5 mg/kg IV or
IM per 24 h in 2 or 3 equally
divided doses for 2 wks
Ampicillin-sulbactam or
amoxicillin-clavulanate 12 g
per 24 h IV in 4 equally
divided doses for 4-6 weeks
plus
GentamicinΔ 3 mg/kg per 24
h IV or IM in 2 or 3 equally
divided doses for 4-6 weeks
OR
Vancomycin• 30 mg/kg per
24 h IV in 2 equally divided
doses for 4-6 wks
plus
GentamicinΔ 3 mg/kg per 24
h IV or IM in 2 or 3 equally
divided doses for 4-6 wks
plus
Ciprofloxacinפ 1000 mg PO
or 800 mg IV in 2 equally
divided doses for 4-6 wks

35. Tratamiento
o Suggested regimens for therapy of prosthetic valve endocarditis due to
Staphylococcus

36. American Heart Association
European Society of CardiologyAdult
(for patients with normal renal function)
Pediatric
(not to exceed dose of normal adult)
Oxacillin-susceptible strains Oxacillin-susceptible strains Methicillin-susceptible strains
One of the following:
Nafcillin or oxacillin* 12 g per 24 hours IV
in six equally divided doses for ≥6 weeks
or
Cefazolin◊ 6 g per 24 hours IV in three
equally divided doses for ≥6 weeks
or
Vancomycin§¥ 30 mg/kg per 24 hours IV
in two equally divided doses for ≥6
weeks
plus
Rifampin 900 mg per 24 hours IV
or orally in three equally divided doses
for ≥6 weeks
plus
Gentamicin‡ 3 mg/kg per 24 hours IV or
IM in two or three equally divided doses
for 2 weeks
One of the following:
Nafcillin or oxacillin* 200 mg/kg per 24
hours IV in four or six equally divided
doses for ≥6 weeks
or
Cefazolin◊ 100 mg/kg per 24 hours IV
in three equally divided doses for ≥6
weeks
or
Vancomycin§¥ 40 mg/kg per 24 hours IV
in two or three equally divided doses for
≥6 weeks
plus
Rifampin 20 mg/kg per 24 hours IV
or orally in three equally divided doses
for ≥6 weeks
plus
Gentamicin‡ 3 mg/kg per 24 hours IV or
IM in three equally divided doses for 2
weeks
One of the following:
Oxacillin or cloxacillin or flucloxacillin 12
g per 24 hours IV in four to six equally
divided doses for ≥6 weeks
or
Vancomycin§ 30 mg/kg per 24 hours IV
in two equally divided doses for ≥6
weeks
plus
RifampinΔ 1200 mg per 24 hours IV
or orally in two equally divided doses for
≥6 weeks
plus
Gentamicin¶ 3 mg/kg per 24 hours IV or
IM in two or three equally divided doses
for the first 2 weeks
Oxacillin-resistant strains Oxacillin-resistant strains Methicillin resistant strains
Vancomycin¥ 30 mg/kg per 24 hours IV
in two equally divided doses for ≥6
weeks
plus
Rifampin 900 mg per 24 hours IV
or orally in three equally divided doses
for ≥6 weeks
plus
Gentamicin‡ 3 mg/kg per 24 hours IV or
IM in two or three equally divided doses
for 2 weeks
Vancomycin¥ 40 mg/kg per 24 hours IV
in two or three equally divided doses for
≥6 weeks
plus
Rifampin 20 mg/kg per 24 hours IV
or orally in three equally divided doses
for≥6 weeks
plus
Gentamicin‡ 3 mg/kg per 24 hours IV or
IM in three equally divided doses for 2
weeks
Vancomycin¥ 30 mg/kg per 24 hours IV
in two equally divided doses for ≥6
weeks
plus
RifampinΔ 1200 mg per 24 hours IV or
orally in divided doses for ≥6 weeks
plus
Gentamicin¶ 3 mg/kg per 24 hours IV or
IM in three equally divided doses for
first 2 weeks