CAR 2.2 Endocarditis - Streptococci and Abiotrophia/Granulicatella/Gemella spp.

Recommendations

≥ 18 years

Indications: Viridans group streptococci and S. gallolyticus, penicillin MIC ≤ 0.125 mg/L
	Dosage	Remarks
	benzylpenicillin iv 12 million IU/24 h 2 weeks + gentamicin iv 3 mg/kg once daily 2 weeks	Native valve, uncomplicated (NO cardiac abscess or extracardiac focus and NO contraindication to gentamicin)
	benzylpenicillin iv 12 million IU/24 h 4 weeks	Native valve, complicated (cardiac abscess, extracardiac focus and/or contraindication to gentamicin)
	benzylpenicillin iv 12 million IU/24 h 6 weeks	Prosthetic valve

≥ 18 years

Indications: Viridans streptococci and S. gallolyticus, penicillin MIC 0.250 - 2 mg/L
	Dosage	Remarks
	benzylpenicillin iv 18 million IU/24 h 4 weeks + gentamicin iv 3 mg/kg once daily 2 weeks	Native valve
	benzylpenicillin iv 18 million IU/24 h 6 weeks + gentamicin iv 3 mg/kg once daily 2 weeks	Prosthetic valve

≥ 18 years

Indications: S. pneumoniae, penicillin MIC ≤ 0.12 mg/L
	Dosage	Remarks
	benzylpenicillin iv 12 million IU/24 h for 4 weeks	Native valve
	benzylpenicillin iv 12 million IU/24 h for 6 weeks	Prosthetic valve

≥ 18 years

Indications: Beta-haemolytic streptococci groups A, B, C and G
	Dosage	Remarks
	benzylpenicillin iv 12 million IU/24 h for 4 weeks	Native valve (groups B, C and G possibly with addition of gentamicin iv 3 mg/kg once daily during the first 2 weeks)
	benzylpenicillin iv 12 million IU/24 h for 6 weeks	Prosthetic valve (groups B, C and G possibly with addition of gentamicin iv 3 mg/kg once daily during the first 2 weeks)

Management in case of allergy

Allergy: penicillins contraindicated

Allergy: cephalosporins contraindicated

Replace ceftriaxone with vancomycin iv (for vancomycin dosing see vancomycine). Do not add gentamicin.

General advice

After starting treatment, take two blood cultures every 48 hours until cultures are negative. For determining treatment duration, day 1 is the day on which the blood cultures are first negative.
The treatment duration after surgery is determined by the result of the valve culture. In the case of a positive culture a full course of treatment is given after the operation. If the culture is negative, the postoperative therapy duration is the prescribed treatment duration minus the duration of treatment prior to surgery.
If a patient with native valve endocarditis undergoes surgery with implantation of prosthetic material, and the valve cultures are negative, the postoperative regimen for native valve endocarditis is followed.
Gentamicin and vancomycin levels must be monitored.
Gentamicin should be stopped in case of toxicity.
Consult the infectious diseases specialist and the cardiologist for advice regarding additional investigations and for guidance of therapy.