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ARTICLE

Guideline Updates for Infective Endocarditis, HAP, and VAP

JAN 01, 2017 | POLLY JEN, PHARMD, BCPS-AQ ID, AAHIVP, AND ELIZABETH LEUNG, PHARMD, BCPS-AQ ID
Antibiotic treatment of IE is determined by multiple factors, including the causative pathogen, susceptibility profile, involvement of native or prosthetic valve, and patient allergy history. Based on results from recent clinical studies, significant changes in the recommended antibiotic therapies for IE caused by S. aureus and penicillin-susceptible Enterococcus species were made. Gentamicin is no longer recommended as part of the treatment regimen for native valve staphylococcal IE. Monotherapy with either an anti-staphylococcal ß-lactam (for methicillin-susceptible S. aureus) or vancomycin (for methicillin-resistant S. aureus) is considered first-line treatment.1 The removal of gentamicin for native valve staphylococcal IE follows evidence demonstrating little to no clinical benefit and increased risk of nephrotoxicity compared to treatment with a single, effective, first-line antibiotic.1,6

For native or prosthetic valve IE caused by penicillin-susceptible Enterococcus, the combination regimen of ampicillin plus ceftriaxone has been added as a preferred treatment option. This double ß-lactam regimen is particularly useful in cases where aminoglycoside-related nephrotoxicity is a concern or if the Enterococcus species isolated is resistant to aminoglycosides (a growing observation in clinical practice). An international, multicenter study comparing ampicillin plus ceftriaxone with the previous standard of care, ampicillin plus gentamicin, demonstrated that dual ß-lactam therapy was associated with clinical and microbiological cure rates similar to those in the comparator group, with a significantly lower incidence of nephrotoxicity.1,7 Specific antibiotic recommendations by IE category can be found in the recently published guidelines.1

As recommended in both the 2005 and 2015 guidelines of the American Heart Association, surgical management should be considered in conjunction with medical therapy for patients with severe and complicated cases of IE. While the decision for surgical intervention is case-specific, early surgery (prior to completion of antibiotic therapy) is recommended for infections caused by fungi or multidrug-resistant bacteria, not responsive to appropriate antibiotic therapy, associated with severe valve dysfunction or myocardial involvement, and/ or involving recurrent emboli. Anticoagulation is not recommended as part of the treatment plan for native valve IE. For patients with mechanical prosthetic valve IE who develop a central nervous system embolic event, all anticoagulation agents should be discontinued for at least two weeks after the embolic event to minimize the risk of acute hemorrhagic transformation of embolic lesions.1,2



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