THE CONTEXT
Management combines multidisciplinary care, removal of infection sources, and antimicrobial selection based on presentation, suspected organism, prosthetic valves and penicillin allergy.
Team care and source control
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A multidisciplinary approach involving a physician, surgeon and microbiologist increases the chance of a successful outcome.
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Remove any source of infection as soon as possible. Examples include extracting a tooth with an apical abscess and removing an infected in-dwelling catheter or implantable device.
Timing and empirical antimicrobial choices
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In subacute presentations, antibiotics should ideally be withheld until blood culture results are available.
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When empirical treatment is necessary, the listed choices include amoxicillin 2 g intravenously six times daily with ceftriaxone 4 g/day, or flucloxacillin 12 g/day with gentamicin 3 mg/kg/day.
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Cefazolin 6 g/day or vancomycin 30 mg/kg/day can be used in patients with penicillin allergy.
Early prosthetic valve infection
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Suspected early prosthetic valve endocarditis should receive vancomycin and gentamicin at the stated doses, plus oral rifampicin 900–1200 mg daily.
Directed therapy and duration
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After identifying the causal organism, its minimum inhibitory concentration helps guide antibiotic therapy.
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Two weeks of treatment may suffice for fully sensitive streptococci when the specified eligibility conditions are met.