Andersons pediatric cardiology 1492

staphylococcalIEforpenicillin MICtovancomycinis>1mg/L.
allergic(anaphylaxis)patients
andintreatmentofmethicillinresistantstaphylococciwhen
vancomycincannotbeused
Treatmentofenterococcal
Treatmentofenterococcalspp.:
spp.:
■UseofampicillinandceftriaxoneinthetherapyofE.
■Ampicillinplusceftriaxone
faecalisIE,whetherthereishigh-levelresistanceto
(foraminoglycoside-resistant
gentamicinornot,althoughthecombinationofampicillin
enterococcioraminoglycoside- andgentamicinisstilladvocated,withsomeexperts
intolerantpatient)givenas
sayingonly2weeksofgentamicinneedstobegiven;this
alternativetherapy.
couldbegivenasasingledailydose.
■Aminoglycosidegivefor
wholedurationoftherapy
Localpoliciesshouldbeadjustedforthespecifictestingmethodologiesusedintheirlab
(CLSIorEUCAST).
Highdosesofdaptomycinarerequired(10mg/kg)and,duetoincreaseclearanceof
thisdruginveryyoungchildrenandinfants,specialistdosingadviceneedstobe
sought.
AHA,AmericanHeartAssociation;ESC,EuropeanSocietyofCardiology;IE,infective
endocarditis;MIC,minimuminhibitoryconcentration;MRSA,methicillin-resistant
Staphylococcusaureus;MSSA,methicillin-sensitiveStaphylococcusaureus.
Table56.7
AntibioticTreatmentofInfectiveEndocarditisDuetoViridansOraland
GastrointestinalStreptococci
Antibiotic

Dose
Comments
HIGHLYSUSCEPTIBLESTRAINS(MIC≤0.1MG/L)STANDARD4-WEEK
REGIMEN
PenicillinG
200,000–300,000U/kg/day
Give6weeksifPVE
divided4hourlydoses
Amoxicillin
200–300mg/kg/dayin4–6
divideddoses
Ceftriaxone
100mg/kg/day1/day
β-LACTAMALLERGIC
Vancomycin
40–45mg/kg/dayin2–3divided Serumtroughlevelsshouldbe
doses
10–15mg/L
RELATIVELYRESISTANTSTRAINS(MIC0.2–2MG/L)
PenicillinG
200,000–300,000U/kg/day
Give6weeksifPVE
dividedin4hourlydoses
Serumtroughlevels<1
mg/Lpeak3–5mg/L
Amoxicillin
200–300mg/kg/dayin4–6
divideddoses
Ceftriaxone
100mg/kg/day1/day

plus
Gentamicin(forfirst2
3–5mg/kg/dayin3divideddoses
weeks)
β-LACTAMALLERGICORSTRAINSHIGHLYRESISTANTTOPENICILLINMIC


>2MG/L
Vancomycin
plus

40–45mg/kg/dayin2–3divided
doses

Give6weeksifPVE
Serumtroughlevelsshould
be10–15mg/L
Gentamicin(forfirst2
3–5mg/kg/day3divideddoses
Serumtroughlevels<1mg/L
weeks
peak3–5mg/L
ANTIBIOTICTREATMENTOFINFECTIVEENDOCARDITISDUETO
ENTEROCOCCUSSPP.
Amoxicillin-SensitiveStrains(MainlyE.Faecalis)
Amoxicillin
200–300mg/kg/dayin4–6
Give6weeksifPVE
plus
divideddoses

Serumtroughlevels<1
mg/Lpeak3–5mg/L
Gentamicin(forfull
3–5mg/kg/dayin3divideddoses
durationoftherapy)
Amoxicillin-ResistantStrains(MainlyE.Faecium)orβ-LactamAllergy
Vancomycin
40–45mg/kg/dayin2–3divided
Give6weeksifPVE
plus
doses
Serumtroughlevelsshould
be10–15mg/L
Gentamicin(forfull
3–5mg/kg/dayin3divideddoses Serumtroughlevels<1mg/L
durationoftherapy)
peak3–5mg/L
MIC,Minimuminhibitoryconcentration;PVE,prostheticvalveendocarditis.
Table56.8
AntibioticTreatmentofInfectiveEndocarditisDuetoStaphylococcalSpecies
Antibiotic
Dose
Comments
NATIVEVALVEMETHICILLIN-SUSCEPTIBLESTAPHYLOCOCCI
(Flu)cloxacillin
200–300mg/kg/day Benefitofinitialadditionofgentamicinmustbe
plus
in4–6divided
weighedagainstpotentialotologic/renaltoxicity
doses

Gentamicin(forinitial 3–6mg/kg/dayin3
3–5daysoftherapy)
divideddoses
NATIVEVALVEMETHICILLIN-RESISTANTSTAPHYLOCOCCIβ-LACTAM–
INTOLERANTPATIENTS
Vancomycin
40–45mg/kg/dayin
Give6weeksifPVE
plus
2–3divideddoses
Serumtroughlevelsshouldbe10–15mg/L
Gentamicin(forinitial 3–6mg/kg/dayin3 Serumtroughlevels<1mg/Lpeak3–5mg/L
3–5daysoftherapy)
divideddoses
PROSTHETICVALVEMETHICILLIN-SUSCEPTIBLESTAPHYLOCOCCI
(Flu)cloxacillin
200–300mg/kg/day Serumtroughlevels<2mg/Lpeak5–7mg/L
plus
in4–6divided
doses
Gentamicin(for
3–6mg/kg/dayin3
initial2weeksof divideddoses
therapy)
plus
Rifampicin
10mg/kgtwice
daily
PROSTHETICVALVEMETHICILLIN-RESISTANTSTAPHYLOCOCCI
Vancomycin

40–60mg/kg/dayin Serumtroughlevelsshouldbe10–15mg/L


plus
Gentamicin(for
initial2weeksof
therapy)
plus
Rifampicin

3–4divideddoses
3–6mg/kg/day3
divideddoses

Serumtroughlevels<1mg/Lpeak3–5mg/L

10mg/kgtwice
daily
ANYIFVANCOMYCINβ-LACTAMINTOLERANT
Daptomycin
6–10mg/kgonce
Higherdosesneededinyoungchildren
daily
Consultwithinfectiousdiseaseor
microbiologyexpert
Therapeuticdrugmonitoringrequired
PVE,Prostheticvalveendocarditis.

4.Thereshouldbeaclearlocalantibioticguidanceforbothearlyempiric
therapyandtargetedtreatmentbasedoncultureandsensitivities.

5.Althoughthecurrentinternationalguidanceshouldformthebasisfor
thesepolices,someadjustmentneedstobemadeforcasemixofpatients
andlikelyresistancemechanismsofbacteriatowhichchildrenare
exposed.Forexample,unitswithahighprevalenceofmethicillinresistantS.aureusinfectionsmaywishtouseacombinationofβlactamase–stableantibiotics,suchasflucloxacillin/oxacillinplus
vancomycin,inempirictherapyofS.aureusuntilfullsensitivitiesare
available,duetothebetteractivityoftheseagentstomethicillinsensitivestrains.

TreatmentandOutcomesFromEmpiric
TreatmentforBloodCulture–Negative
Endocarditis
Therehavebeendifferentrecommendedprotocolsintheempirictreatmentfor
BCNE.Theresultsofthesealsovarybetweenstudies.Inonelargesingle-center
studyfromFranceinadults,104overall1-yearmortalityonanestablished
empiricprotocolwas5.1%(whichwaslowcomparedwithotherstudies);final
microbialdiagnosiswasachievedinonly22%ofcases.
Thecurrentlyrecommendedprotocolforempirictreatmentofchildrenpriorto
receivingresultsfromtheBCissummarizedinTable56.9.
Table56.9
InitialEmpiricAntimicrobialTherapyforTreatmentofInfective