Standard regimen for endocarditis caused by enterococci susceptible to penicillin and gentamicin
For adults and children with native or prosthetic valve enterococcal endocarditis susceptible to penicillin and gentamicin, as a 2-drug regimen, use:
1benzylpenicillin 2.4 g (child: 60 mg/kg up to 2.4 g) intravenously, 4-hourly for 4 to 6 weeks. For dosage adjustment in adults with kidney impairment, see benzylpenicillin dosage adjustment benzylpenicillin benzylpenicillin benzylpenicillin
OR
2amoxicillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 4-hourly for 4 to 6 weeks. For dosage adjustment in adults with kidney impairment, see amoxicillin dosage adjustment amoxicillin amoxicillin amoxicillin
OR
2ampicillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 4-hourly for 4 to 6 weeks. For dosage adjustment in adults with kidney impairment, see ampicillin dosage adjustment ampicillin ampicillin ampicillin
PLUS with one of the above drugs
gentamicin (adult and child) 1 mg/kg intravenously, 8-hourly for 4 to 6 weeks (monitor plasma concentration; see Principles of aminoglycoside use)1. gentamicin gentamicin gentamicin
For most patients, the duration of therapy is 6 weeks, and cardiac surgery may be required. Patients with uncomplicated native valve enterococcal endocarditis who respond well to treatment may be treated for 4 weeks. Treat patients who have prosthetic valve enterococcal endocarditis with 6 weeks of antibiotic therapy.
Prolonged gentamicin therapy can be a challenge in some patients due to toxicities (see Approach to managing enterococcal endocarditis for further information). However, some studies suggest that at least 2 weeks gentamicin therapy may have similar outcomes to longer durations, if a longer duration is not possible – seek expert adviceBeganovic, 2018Dahl, 2013.
For patients with Enterococcus faecalis endocarditis and relevant contraindications or precautions that preclude the use of gentamicin, use the regimen in Endocarditis caused by enterococci susceptible to penicillin but with high-level resistance to gentamicinBaddour, 2015. For patients with other types of enterococcal endocarditis, seek expert advice.