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## Endocarditis, treatment   Return to Top 
- Infective endocarditis
- Culture-negative endocarditis
- Culture-negative, native valve endocarditis
- Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h 46 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 46 weeks
- Alternative regimen: Vancomycin 30 mg/kg/24h IV q12h for 46 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 46 weeks AND Ciprofloxacin 1000 mg/24h PO or 800 mg/24h IV q12h for 46 weeks
- Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q46h; Gentamicin 3 mg/kg/24h IV/IM q8h; Vancomycin 40 mg/kg/24h q812h; Ciprofloxacin 2030 mg/kg/24h IV/PO q12h
- Culture-negative, prosthetic valve endocarditis (early,  1 year)
- Preferred regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 2 weeks AND Cefepime 6 g/24h IV q8h for 6 weeks AND Rifampin 900 mg/24h PO/IV q8h for 6 weeks
- Pediatric dose: Vancomycin 40 mg/kg/24h IV q812h; Gentamicin 3 mg/kg/24h IV/IM q8h; Cefepime 150 mg/kg/24h IV q8h; Rifampin 20 mg/kg/24h PO/IV q8h
- Culture-negative, prosthetic valve endocarditis (late, > 1 year)
- Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
- Alternative regimen: Vancomycin 30 mg/kg/24h IV q12h for 46 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks AND Ciprofloxacin 1000 mg/24h PO or 800 mg/24h IV q12h for 6 weeks
- Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q4h; Gentamicin 3 mg/kg/24h IV/IM q8h; Vancomycin 40 mg/kg/24h q812h; Ciprofloxacin 2030 mg/kg/24h IV/PO q12h
- Culture-negative, prosthetic valve endocarditis (early,  1 year)
- Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h 46 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 46 weeks AND Rifampin 900 mg/24h PO/IV q8h for 6 weeks
- Alternative regimen: Vancomycin 30 mg/kg/24h IV q12h for 46 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 46 weeks AND Ciprofloxacin 1000 mg/24h PO or 800 mg/24h IV q12h for 46 weeks AND Rifampin 900 mg/24h PO/IV q8h for 6 weeks
- Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q46h; Gentamicin 3 mg/kg/24h IV/IM q8h; Vancomycin 40 mg/kg/24h IV q812h; Cefepime 150 mg/kg/24h IV q8h; Rifampin 20 mg/kg/24h PO/IV q8h
- Pathogen-directed antimicrobial therapy
- Bartonella
- Suspected Bartonella endocarditis
- Preferred regimen : Ceftriaxone sodium 2 g/24h IV/IM in 1 dose for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 2 weeks  Doxycycline 200 mg/kg/24h IV/PO q12h for 6 weeks
- Pediatric dose: Ceftriaxone 100 mg/kg/24h IV/IM once daily; Gentamicin 3 mg/kg/24h IV/IM q8h; Doxycycline 24 mg/kg/24h IV/PO q12h; Rifampin 20 mg/kg/24h PO/IV q12h
- Documented Bartonella endocarditis
- Preferred regimen: Doxycycline 200 mg/24h IV or PO q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 2 weeks
- Pediatric dose: Ceftriaxone 100 mg/kg/24h IV/IM once daily; Gentamicin 3 mg/kg/24h IV/IM q8h; Doxycycline 24 mg/kg/24h IV/PO q12h; Rifampin 20 mg/kg/24h PO/IV q12h
- Enterococcus
- Endocarditis caused by enterococcal strains susceptible to penicillin, gentamicin, and vancomycin
- Preferred regimen : Ampicillin 12 g/24h IV q4h for 46 weeks OR Penicillin G 1830 million U/24h IV either continuously or q4h for 46 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 46weeks
- Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
- Pediatric dose: Vancomycin 40 mg/kg/24h IV q812h; Gentamicin 3 mg/kg/24h IV/IM q8h
- Endocarditis caused by enterococcal strains susceptible to penicillin, streptomycin, and vancomycin and resistant to gentamicin
- Preferred regimen : Ampicillin 12 g/24h IV q4h for 46 weeks OR Penicillin G 24 million U/24h IV continuously or q4h for 46 weeks AND Streptomycin 15 mg/kg/24h IV/IM q12h for 46 weeks
- Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Streptomycin 15 mg/kg/24h IV/IM q12h for 6 weeks
- Pediatric dose: Ampicillin 300 mg/kg/24h IV q46h; Penicillin 300 000 U/kg/24h IV q46h; Streptomycin 2030 mg/kg/24h IV/IM q12h; Vancomycin 40 mg/kg/24h IV q812h; Streptomycin 2030 mg/kg/24h IV/IM q12h
- Endocarditis caused by enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin
- -Lactamaseproducing strain
- Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
- Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks
- Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q6h; Gentamicin 3 mg/kg/24h IV/IM q8h
- Intrinsic penicillin resistance
- Preferred regimen: Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
- Pediatric dose: Vancomycin 40 mg/kg/24h IV q812h; Gentamicin 3 mg/kg/24h IV/IM q8h
- Endocarditis caused by enterococcal strains resistant to penicillin, gentamicin, and vancomycin
- Enterococcus faecium
- Preferred regimen : Linezolid 1200 mg/24h IV/PO q12h for  8 weeks OR Quinupristin-Dalfopristin 22.5 mg/kg/24h IV q8h for 8 weeks
- Enterococcus faecalis
- Preferred regimen : Imipenem/cilastatin 2 g/24h IV q6h for  8 weeks AND Ampicillin 12 g/24h IV q4h for  8 weeks  OR Ceftriaxone sodium 4 g/24h IV/IM q12h for  8 weeks AND Ampicillin 12 g/24h IV q4h for  8 weeks
- Pediatric dose: Linezolid 30 mg/kg/24h IV/PO q8h; Quinupristin-Dalfopristin 22.5 mg/kg/24h IV q8h; Imipenem/cilastatin 60100 mg/kg/24h IV q6h; Ampicillin 300 mg/kg/24h IV q46h; Ceftriaxone 100 mg/kg/24h IV/IM q12h
- HACEK organisms
- Endocarditis caused by Haemophilus, Aggregatibacter (Actinobacillus), Cardiobacterium, Eikenella corrodens, or Kingella
- Preferred regimen : Ceftriaxone sodium 2 g/24h IV/IM in 1 dose for 4 weeks OR Ampicillin 12 g/24h IV q6h for 4 weeks OR Ciprofloxacin 1000 mg/24h PO or 800 mg/24h IV q12h for 4 weeks
- Pediatric dose: Ceftriaxone 100 mg/kg/24h IV/IM once daily; Ampicillin-sulbactam 300 mg/kg/24h IV divided into 4 or 6 equally divided doses; Ciprofloxacin 2030 mg/kg/24h IV/PO q12h
- Staphylococcus
- Native valve endocarditis caused by oxacillin-susceptible staphylococci
- Preferred regimen (1): Nafcillin or Oxacillin 12 g/24h IV q46h for 6 weeks  Gentamicin 3 mg/kg/24h IV/IM q812h for 35 days
- Preferred regimen (2): Cefazolin 6 g/24h IV q8h for 6 weeks  Gentamicin 3 mg/kg/24h IV/IM q812h for 35 days
- Pediatric dose: Nafcillin or Oxacillin 200 mg/kg/24h IV q46h; Gentamicin 3 mg/kg/24h IV/IM q8h; Cefazolin 100 mg/kg/24h IV q8h; Gentamicin 3 mg/kg/24h IV/IM q8h
- Native valve endocarditis caused by oxacillin-resistant staphylococci
- Preferred regimen: Vancomycin 30 mg/kg/24h IV q12h for 6 weeks
- Pediatric dose: Vancomycin 40 mg/kg/24h IV q812h
- Prosthetic valve endocarditis caused by oxacillin-susceptible staphylococci
- Preferred regimen: Nafcillin or Oxacillin 12 g/24h IV q4h for  6 weeks AND Rifampin 900 mg/24h IV/PO q8h for  6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q812h for 2 weeks
- Pediatric dose: Nafcillin or Oxacillin 200 mg/kg/24h IV q46h; Rifampin 20 mg/kg/24h IV/PO q8h; Gentamicin 3 mg/kg/24h IV/IM q8h
- Prosthetic valve endocarditis caused by oxacillin-resistant staphylococci
- Preferred regimen: Vancomycin 30 mg/kg 24 h q12h for  6 weeks AND Rifampin 900 mg/24h IV/PO q8h for  6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q812h for 2 weeks
- Pediatric dose: Vancomycin 40 mg/kg/24h IV q812h; Rifampin 20 mg/kg/24h IV/PO q8h (up to adult dose); Gentamicin 3 mg/kg/24h IV or IM q8h
- Viridans group streptococci and Streptococcus bovis
- Native valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC  0.12 g/mL)
- Preferred regimen: Penicillin G 1218 million U/24h IV either continuously or q46h for 4 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 4 weeks
- Alternative regimen (1): (Penicillin G 1218 million U/24h IV either continuously or q4h for 2 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 2 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
- Alternative regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
- Pediatric dose: Penicillin G 200,000 U/kg/24h IV q46h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q812h
- Native valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 to  0.5 g/mL)
- Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q46h for 4 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 4 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
- Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
- Pediatric dose: Penicillin G 200,000 U/kg/24h IV q46h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q812h
- Prosthetic valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC  0.12 g/mL)
- Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q46h for 6 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 6 weeks)  Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
- Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
- Pediatric dose: Penicillin G 200,000 U/kg/24h IV q46h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q812h
- Prosthetic valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 g/mL)
- Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q46h for 6 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 6 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
- Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
- Pediatric dose: Penicillin G 200,000 U/kg/24h IV q46h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q812h

# Endocarditis, prophylaxis
- Antibiotic Prophylactic Regimens for Dental Procedures
- Oral regimen
- Preferred regimen: Amoxicillin 2 g single dose 30-60 minutes before procedure.
- Pediatric dose: Amoxicillin 50 mg/kg single dose 30-60 minutes before procedure.
- Unable to take oral medication
- Preferred regimen: Ampicillin 2 g IM or IV single dose 30-60 minutes before procedure OR Cefazolin 1 g IM or IV single dose 30-60 minutes before procedure OR Ceftriaxone 1 g IM or IV single dose 30-60 minutes before procedure.
- Pediatric dose: Ampicillin 50 mg/kg; Cefazolin 50 mg/kg; Ceftriaxone 50 mg/kg
- Allergic to penicillins or ampicillin Oral regimen
- Preferred regimen: Cephalexin 2 g single dose 30-60 minutes before procedure OR Clindamycin 600 mg single dose 30-60 minutes before procedure OR Azithromycin 500 mg single dose 30-60 minutes before procedure OR Clarithromycin 500 mg  single dose 30-60 minutes before procedure.
- Pediatric dose:  Cephalexin 50 mg/kg single; Clindamycin 20 mg/kg; Azithromycin 15 mg/kg OR Clarithromycin 15 mg/kg.
- Allergic to penicillins or ampicillin and unable to take oral medication
- Preferred regimen: Cefazolin 1 g IM or IV single dose 30-60 minutes before procedure OR Ceftriaxone 1 g IM or IV single dose 30-60 minutes before procedure OR Clindamycin 600 mg IM or IV.
- Pediatric dose: Cefazolin 50 mg/kg IM or IV OR Ceftriaxone 20 mg/kg IM or IV.
- Gastrointestinal/Genitourinary Procedures
- Antibiotic prophylaxis solely to prevent IE is no longer recommended for patients who undergo a GI or GU tract procedure.
- Regimens for Respiratory Tract Procedures
- Oral regimen
- Preferred regimen: Amoxicillin 2 g single dose 30-60 minutes before procedure.
- Pediatric dose: Amoxicillin 50 mg/kg single dose 30-60 minutes before procedure.
- Unable to take oral medication
- Preferred regimen: Ampicillin 2 g IM or IV OR Cefazolin 1 g IM or IV OR Ceftriaxone 1 g IM or IV.
- Pediatric dose: Ampicillin 50 mg/kg; Cefazolin 50 mg/kg; Ceftriaxone 50 mg/kg.
- Allergic to penicillins or ampicillin Oral regimen
- Preferred regimen: Cephalexin 2 g single dose 30-60 minutes before procedure OR Clindamycin 600 mg single dose 30-60 minutes before procedure OR Azithromycin 500 mg single dose 30-60 minutes before procedure OR Clarithromycin 500 mg  single dose 30-60 minutes before procedure.
- Pediatric dose:  Cephalexin 50 mg/kg single; Clindamycin 20 mg/kg; Azithromycin or Clarithromycin 15 mg/kg.
- Allergic to penicillins or ampicillin and unable to take oral medication
- Preferred regimen: Cefazolin 1 g OR ceftriaxone 1 g IM or IV single dose 30-60 minutes before procedure OR Clindamycin 600 mg IM or IV.
- Pediatric dose: Cefazolin 50 mg/kg IM or IV OR Ceftriaxone 20 mg/kg IM or IV.
- Regimens for Procedures on Infected Skin, Skin Structure, or Musculoskeletal Tissue
- Patients who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against staphylococci and -hemolytic streptococci, such as an antistaphylococcal penicillin or a cephalosporin.
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