Penicillin hypersensitivity regimens 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 who report penicillin hypersensitivity, verify their allergy. In some patients it may be appropriate to directly delabel their allergy by taking an extensive allergy history (see Clinical history for initial assessment of patients reporting penicillin hypersensitivity). In patients whose penicillin allergy has been delabeled, a penicillin-based regimen should be used.
Seek expert advice for patients with a verified allergy. For patients who have had a nonsevere (immediate or delayed) or a severe immediate1 hypersensitivity reaction to a penicillin, options that an infectious diseases physician or clinical microbiologist may use include:
- performing desensitisation
- using vancomycin plus gentamicin (see dosage below).
For adults and children with native or prosthetic valve enterococcal endocarditis susceptible to penicillin and gentamicin who have had a severe delayed2 hypersensitivity reaction to a penicillin, a suitable regimen is:
vancomycin intravenously for 6 weeks; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults or Intermittent vancomycin dosing for young infants and children vancomycin vancomycin vancomycin
PLUS
gentamicin (adult and child) 1 mg/kg intravenously, 8-hourly for 6 weeks (monitor plasma concentration; see Principles of aminoglycoside use)3. gentamicin gentamicin gentamicin
Vancomycin is intrinsically not as effective against enterococci as penicillin; therefore, treatment must be given for 6 weeks. For patients with hypersensitivity to penicillins, if either gentamicin or vancomycin is contraindicated, seek expert advice.