CAR 1 Endocarditis - unknown pathogen

Recommendations

≥ 18 years
	Dosage	Remarks
	amoxicillin iv 2g 6 times daily + ceftriaxone iv 2g 2 times daily	Native valve; subacute onset; empirical therapy
	flucloxacillin iv 12 g continuous per 24 hours or flucloxacillin iv 2000 mg 6 times daily	Native valve; acute onset; empirical therapy If continuous infusion: loading dose 2 g flucloxacillin as a bolus, then continuous infusion
	flucloxacillin iv 12 g continuous per 24 hours + vancomycin iv	Prosthetic valve or other prosthetic material in/around the heart**; empirical therapy Loading dose 2 g flucloxacillin as a bolus, then continuous infusion (If continuous infusion is not possible, then flucloxacillin 2 g 6 times daily) For vancomycin dosing see vancomycin \| Radboud UMC

≥ 18 years

Indications: penicillins contraindicated*
	Dosage	Remarks
	ceftriaxone iv 2g once daily + vancomycin iv	Native valve; subacute onset; empirical therapy. For vancomycin dosing see vancomycin \| Radboud UMC
	cefazolin iv 1 g 6 times daily or cefazolin iv 6 g continuous per 24 hours	Native valve; acute onset; empirical therapy
	cefazolin iv 1 g 6 times daily + vancomycin iv	Prosthetic valve or other prosthetic material in/around the heart**; empirical therapy. For vancomycin dosing see vancomycin \| Radboud UMC

≥ 18 years

Indications: cephalosporins contraindicated*
	Dosage	Remarks
	vancomycin iv	Native valve; acute onset; empirical therapy. For vancomycin dosing see vancomycin \| Radboud UMC

General comments

Adjust empirical therapy based on culture results. See SWAB guideline
After starting treatment, take 2 blood cultures every 48 hours until the cultures are negative. For determining the duration of treatment, day 1 is the day on which the blood cultures are negative for the first time.
The duration of treatment after surgery is determined by the culture result of the heart valve. In case of a positive culture a full course of treatment is given after the operation. If the culture is negative, the duration of therapy after the operation is the prescribed total duration minus the duration of therapy prior to the operation.
If a patient with native valve endocarditis undergoes surgery with placement of prosthetic material, and the valve cultures are negative, then the post-operative regimen for native valve endocarditis is continued.
If blood cultures remain positive after valve replacement surgery in a patient with native valve endocarditis, the regimen for prosthetic valve endocarditis is recommended.

**Recommendations for a CIED (Cardiac Implantable Electronic Device) endocarditis:

In case of a (suspected) infected device, treat according to the antibiotic regimen for prosthetic valve endocarditis.
After removal of the infected device, therapy can be de-escalated to treatment targeted at the cultured microorganism in consultation with an infectious disease physician/microbiologist.
The duration of therapy is 14 days in this situation: an infected device with only vegetation on the lead or no visible vegetation, where the device has been completely removed AND there are negative blood cultures after removal AND there are no affected heart valves/tissue or extracardiac foci.
The duration of therapy is at least 4–6 weeks intravenously after the first negative blood culture in these situations:
1. an infected device that has been completely removed with subsequent negative blood cultures, but WITH extracardiac foci (infected thrombus, osteomyelitis, etc.) AND/OR affected heart valves/tissue.
2. an infected device that has been completely removed AND positive blood cultures after removal of the device. Duration of therapy depends on the focus.