Table 3.10-2. Antibiotic treatment for infective endocarditis caused by microorganisms other than streptococci and staphylococci


 – Amoxicillin (or ampicillin) 200 mg/kg/d IV in 4-6 divided doses for 4-6 weeksa + gentamicinb 3 mg/kg/d IV or IM as single dose for 2-6 weeks; or

 – Ampicillin 200 mg/kg/d IV in 4-6 divided doses for 6 weeks + ceftriaxone 4 g/d IV or IM in 2 divided doses for 6 weeksc; or

 – Vancomycin 30 mg/kg/d in 2 divided doses for 6 weeks + gentamicinb 3 mg/kg/d IV as single dose for 6 weeks

Beta-lactam–resistant strains

 – Resistance due to beta-lactamase production: ampicillin/sulbactam or amoxicillin/clavulanic acid

 – Resistance caused by penicillin-binding proteins: regimen with vancomycin

Multidrug-resistant strains (resistance to aminoglycosides, beta-lactams, and vancomycin)d

 – Daptomycin 10 mg/kg/d + ampicillin 200 mg/kg/d IV in 4-6 doses for ≥8 weeks; or

 – Linezolid 600 mg IV or PO bid for ≥8 weeks; or

 – Quinupristin/dalfopristin 7.5 mg/kg tid for ≥8 weeks

HACEK group

Third-generation cephalosporin (eg, ceftriaxone 2 g/d for 4 weeks in NVE or 6 weeks in PVE); non–beta-lactamase-producing strains: ampicillin 12 g/d IV in 4 or 6 divided doses combined with gentamicin 3 mg/kg/d in 2 or 3 divided doses for 4-6 weeks

Brucella spp

Doxycycline 200 mg/d + trimethoprim/sulfamethoxazole 960 mg bid + rifampin 300-600 mg/d for ≥3-6 months PO; in the first few weeks you may add streptomycin 15 mg/kg/d in 2 divided doses

Coxiella burnetii

Doxycycline 200 mg/d + hydroxychloroquine 200-600 mg/d PO (regimen preferred over doxycycline alone) for >18 months

Bartonella spp

Doxycycline 100 mg PO bid for 4 weeks + gentamicin 3 mg/kg/d IV for 2 weeks

Legionella spp

Levofloxacin 500 mg IV or PO bid for ≥6 weeks or clarithromycin 500 mg bid IV for 2 weeks, then PO for 4 weeks + rifampin 300-1200 mg for 6 weeks

Mycoplasma spp

Levofloxacin 500 mg IV or PO bid for ≥6 months

Tropheryma whipplei

Doxycycline 200 mg/d + hydroxychloroquined 200-600 mg/d PO (regimen preferred over doxycycline alone) for ≥18 months

a Six-week treatment is recommended in patients with symptoms persisting for >3 months and in those with a prosthetic valve.

b Monitor renal function and serum levels of gentamicin closely. The trough level should be <1 mg/L and level 1 h after IV dose should be 10-12 mg/L.

c Regimen recommended in Enterococcus faecalis infection. It is the treatment of choice for aminoglycoside-resistant E faecalis species. Ineffective for Enterococcus faecium.

d Cooperation with an infectious disease specialist is essential.

Based on Eur Heart J. 2015;36(44):3075-3128.

bid, 2 times a day; HACEK, Haemophilus spp, Aggregatibacter spp, Cardiobacterium hominis, Eikenella corrodens, Kingella spp; IM, intramuscular; IV, intravenous; NVE, native valve endocarditis; PO, oral; PVE, prosthetic valve endocarditis; tid, 3 times a day.