Sandbox endocarditis2

## Contents

* 1 Medical Therapy
* 1.1 Pharmacotherapy
* 1.1.1 Community-Acquired Meningitis
* 1.1.2 Empiric Treatment
* 2 References

## Medical Therapy[edit | edit source]

### Pharmacotherapy[edit | edit source]

#### Community-Acquired Meningitis[edit | edit source]

| Relatively Penicillin-Resistant Streptococci, MIC 0.2–0.5 µg/ml

Preferred Regimen
▸ Adult:Aqueous crystalline penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks
▸ Pediatrics:Aqueous crystalline penicillin G sodium 300 000 U/24 h IV in 4–6 equally divided doses X 4 Wks

▸Adult:Ceftriaxone 2 g/24 h IV/IM in 1 dose
▸Pediatrics:Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose
AND
▸ Adult:Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks
▸ Pediatrics: Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose or 3 equally divided doses X 2 Wks
Relatively Penicillin-Resistant Streptococci, MIC > 0.5 µg/ml, consider Enterococcal regimen
Preferred Regimen
▸ Adult:Aqueous crystalline penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks
AND
▸ Adult:Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks
Unable to tolerate Aqueous crystalline penicillin G sodium or Ceftriaxone
Preferred Regimen
▸ Adult: Vancomycin 30 mg/kg per 24 h IV in 2 equally divided doses not to exceed 2 g/24 h, unless serum concentrations are inappropriately low
▸ Pediatrics: Vancomycin 40 mg/kg 24 h in 2 or 3 equally divided doses X 4 Wks

| Newborn, Age <1 Week

Preferred Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Cefotaxime 100—150 mg/kg/day IV q8—12h
Alternative Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Gentamicin 2.5 mg/kg IV q12h
Newborn, Age 1—4 Weeks
Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Cefotaxime 150—200 mg/kg/day IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Gentamicin 2.5 mg/kg IV q8h

▸Tobramycin 2.5 mg/kg IV q8h

▸ Amikacin 10 mg/kg IV q8h
Infant and Children†
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q6h
to achieve serum trough concentrations of 15–20 μg/mL
AND
▸ Cefotaxime 225—300 mg/kg/day IV q6–8h

▸Ceftriaxone 80—100 mg/kg/day IV q12–24h

| Adult, Age <50 Years†

Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h
to achieve serum trough concentrations of 15–20 μg/mL
AND
▸ Cefotaxime 8–12 g/day IV q4–6h

▸Ceftriaxone 2 g IV q12h
Adult, Age >50 Years
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h
AND
▸ Ampicillin 2 g IV q4h
AND
▸ Cefotaxime 8–12 g/day IV q4–6h

▸Ceftriaxone 2 g IV q12h
Immunocompromised
Preferred Regimen
▸ Vancomycin 30–60 mg/kg/day IV q8–12h
AND
▸ Ampicillin 2 g IV q4h
AND
▸ Cefepime 2 g IV q8h

▸ Meropenem2 g IV q8h
Recurrent
Preferred Regimen
▸ Vancomycin 30—60 mg/kg/day IV q8–12h
AND
▸ Cefotaxime 8–12 g/day IV q4–6h

▸Ceftriaxone 2 g IV q12h

†Add Ampicillin 2 g IV q4h (50 mg/kg IV q6h for children) if meningitis caused by Listeria monocytogenesis also suspected.

Adapted from Advances in treatment of bacterial meningitis. Lancet. 2012;380(9854):1693-702.[1]

#### Empiric Treatment[edit | edit source]

* Do not wait for the results of the CT scan and the lumbar puncture; empiric treatment should be started as soon as possible.
* Blood cultures should be drawn before starting the antibiotic therapy, and then the antibiotic treatment should be changed once the blood culture results are out.

* Empiric antibiotic treatment should be started within 30 minutes after the patient presentation.
* In case of high suspicion of pneumococcal meningitis in adult patients, 0.15 mg/kg IV Q6H dexomethasone should be administered for 2 to 4 days.
* The first dose of dexomethasone is given along with or 20 minutes prior to starting the antibiotics treatment.

| Age <1 Week

Preferred Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Cefotaxime 100—150 mg/kg/day IV q8—12h
Alternative Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Gentamicin 2.5 mg/kg IV q12h

Age <1 Week

Preferred Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Cefotaxime 100—150 mg/kg/day IV q8—12h
Alternative Regimen
▸ Ampicillin 50 mg/kg IV q8h
AND
▸ Gentamicin 2.5 mg/kg IV q12h
| Age 1—4 Weeks

Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Cefotaxime 150—200 mg/kg/day IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Gentamicin 2.5 mg/kg IV q8h

▸Tobramycin 2.5 mg/kg IV q8h

▸ Amikacin 10 mg/kg IV q8h
| Age 1—23 Months

Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Cefotaxime 150—200 mg/kg/day IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Gentamicin 2.5 mg/kg IV q8h

▸Tobramycin 2.5 mg/kg IV q8h

▸ Amikacin 10 mg/kg IV q8h
| Age 1—4 Weeks

Preferred Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Cefotaxime 150—200 mg/kg/day IV q6—8h
Alternative Regimen
▸ Ampicillin 200 mg/kg/day IV q6—8h
AND
▸ Gentamicin 2.5 mg/kg IV q8h

▸Tobramycin 2.5 mg/kg IV q8h

▸ Amikacin 10 mg/kg IV q8h

## References[edit | edit source]

1. ↑ van de Beek, D.; Brouwer, MC.; Thwaites, GE.; Tunkel, AR. (2012). "Advances in treatment of bacterial meningitis". Lancet. 380 (9854): 1693–702. doi:10.1016/S0140-6736(12)61186-6. PMID 23141618. Unknown parameter `|month=` ignored (help)