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Treatment of Infective Endocarditis
- Donald Kaye, MD
- Medical College of Pennsylvania and Hahnemann, University, Philadelphia, PA 19102-1192 Requests for Reprints: Donald Kaye, MD, Medical College of Pennsylvania and Hahnemann University, Broad and Vine Streets, Mail Stop 400, Philadelphia, PA 19102.
The American Heart Association's recently published recommendations for treating infective endocarditis [1] contain many substantial changes from the previous version [2].
The first major change is the addition of a regimen suitable for outpatient treatment of infective endocarditis in patients with strains of streptococci that are highly susceptible to penicillin. This regimen consists of ceftriaxone, 2 g administered intravenously or intramuscularly once daily for 4 weeks. In the past, outpatient treatment with oral agents was not advocated because of the possibility of variable absorption of agents and lack of patient compliance. Furthermore, the previously used parenteral regimens for home therapy required two or three daily injections. The long half-life of ceftriaxone, which permits once-daily injection, is a major advantage in terms of cost and convenience. The daily injection can be given by a visiting nurse or family member in the home or can be given at a physician's office or an emergency department. An intravenous central line catheter may be required. Home therapy should be reserved for hemodynamically stable patients who have no complications of endocarditis.
Two studies have been published on the treatment of streptococcal endocarditis with once-daily ceftriaxone [3, 4]. In these studies, one possible relapse occurred among 70 patients treated for 4 weeks, yielding a bacteriologic cure rate of more than 98%. These results are similar to those seen with all other previously recommended regimens. Preliminary results from studies currently in progress suggest that once-daily injection of ceftriaxone plus an aminoglycoside for 14 days may be equally effective.
A second major change in the American Heart Association's recommendations is the recognition that enterococci are becoming increasingly resistant not only to aminoglycosides but also to penicillin G and vancomycin. Traditionally, enterococci are moderately resistant to penicillin G or ampicillin; a median of 2 µg of penicillin …
