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Endocarditis infecciosa

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Endocarditis infecciosa Actualizado 2015

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Endocarditis infecciosa

  1. 1. ENDOCARDITIS INFECCIOSA Hospital Regional Valentín Gómez Farías Luis Ulises Flores Martínez
  2. 2. Endocarditis infecciosa Colonización e invasión de las válvulas cardíacas o el endocardio mural por microorganismos, que produce formación de vegetaciones voluminosas y friables, compuestas de restos trombóticos y microorganismos, asociadas con destrucción de los tejidos cardíacos subyacentes.
  3. 3. o En la era actual la presentación suele ser aguda.
  4. 4. Etiología ● S. aureus — 31 percent ● Viridans group streptococci — 17 percent ● Enterococci — 11 percent ● Coagulase-negative staphylococci — 11 percent ● Streptococcus bovis — 7 percent ● Other streptococci — 5 percent ● Non-HACEK gram-negative bacteria — 2 percent ● Fungi — 2 percent ● HACEK — 2 percent
  5. 5. Etiología o La presencia de VIH no tiene impacto general demostrado sobre los agentes que la causan. o En 5 % los cultivos son negativos. 33-55% debido a exposición previa a antibióticos.
  6. 6. Patogenia o Presencia de daño endocárdico o Agregado fibrionoplaquetario o Invasión del microorganismo al agregado fibrinoplaquetario.
  7. 7. Manifestaciones clínicas Manchas Janeway Manchas Roth Nódulos de Osler
  8. 8. Manifestaciones clínicas
  9. 9. o Las petequias son la manifestaciones dérmicas más comunes; menos específicas Petechiae in subacute bacterial endocarditis
  10. 10. Splinter hemorrhages in infective endocarditis
  11. 11. o Las lesiones de Janeway, nódulos de Osler y manchas de Roth son más especídicas, suelen presentarse más en los cuadros crónicos, por lo que actualmente son raros.
  12. 12. Las lesiones de Janeway son lesiones maculares, eritematosas, no dolorosas en palmas y plantas
  13. 13. o Los nódulos de Osler son dolorosos, violáceos, encontrados en purplejos en manos y pies y se observan más en los casos subagudos.
  14. 14. o Las manchas de Roth son lesiones hemorrágicas exudativas edematosas de la retina.
  15. 15. Diagnóstico o Se basa en la sospecha clínica, la realización de hemocultivos o pruebas serológicas para gérmenes de cultivo dificultoso y en el estudio ecocardiográfico. o Transesofágica 90% o Transtorácica 70% (endocarditis de localización tricuspídea
  16. 16. Diagnóstico o Para el diagnóstico de las endocarditis por Coxiella burnetii, Chlamydophila psittaci y Bartonella quintana es útil la serología; el diagnóstico de endocarditis por Legionella spp. requiere medios de cultivo muy especiales.
  17. 17. Criterios de Duke o La documentación de dos criterios mayores, un criterio mayor y tres menores o de cinco criterios menores ayuda a establecer diagnóstico.
  18. 18. Cultivos o Se deben de obtener al menos 3 series de cultivos. o Si se ha iniciado antibioticoterapia, pueden requerirse más cultivos. o En presenaciones subagudas o crónicas, si el paciente no está en estado crítico, se puede retrasar la antibioticoterapia hasta obtener cultivos y otros estudios diagnósticos o En presentación aguda o paciente crítico se deben obtener 3 series de cultivos en menos de una hora e iniciar tratamiento empírico.
  19. 19. Cultivos In one series including 206 cases of endocarditis, the initial blood culture in patients with streptococcal endocarditis was positive in 96 percent of cases, and one of the first two blood cultures was positive in 98 percent. In patients with IE caused by organisms other than streptococcus, the first blood culture was positive in 82 percent of cases and one of the first two cultures was positive in 100 percent of cases. Studies on the bacteremia of bacterial endocarditis. Werner AS, Cobbs CG, Kaye D, Hook
  20. 20. Cultivos Agentes con cultivos negativos Coxiella burnetii • Brucella mellitensis • Grupo HACEK (gramnegativos) • Legionella pneumophila • Bartonella quintana y Bartonella henselae • Tropheryma whipplei • Chlamydophila psittaci • Hongos {Candida y Aspergillus) • Estreptococos nutricionalmente variantes (AbiotrophiayGranulicatella)
  21. 21. Estudios de laboratorio No específicos o ↑ VSG, Prot. C reactiva o Anemia normocítica normocrómica o En presentaciones subagudas de endocarditis la WBC puede ser normal o elevada; la mayoría de los pacientes con endocarditis estafilocóccica tienen leucocitosis y algunos trombocitopenia. o ●Hiperglobulinemia, crioglobulinemia, complejos inmunes circulantes, hipocomplementemia, títulos elevados de FR y falsos positivos en serología para sífilis pueden estar presentes.
  22. 22. Tratamiento o Suggested regimens for therapy of native valve endocarditis due to penicillin-susceptible viridans streptococci and Streptococcus bovis (MIC ≤0.12 mcg/mL) American Heart Association British Society for Antimicrobial Chemotherapy European Society of Cardiology Adult (for patients with normal renal function) Pediatric (not to exceed dose of normal adult) 4-week regimens*: 4-week regimens: 4- to 6-week regimens: 4-week regimens¶: Aqueous penicillin G 12 to 18 million units per 24 hours IV either continuously or in four or six equally divided doses or Ceftriaxone 2 g per 24 hours IV or IM in one dose or VancomycinΔ 30 mg/kg per 24 hours IV in two equally divided doses not to exceed 2 g per 24 hours unless concentrations in serum are inappropriately low Aqueous penicillin G 200,000 units/kg per 24 hours IV in four or six equally divided doses or Ceftriaxone 100 mg/kg per 24 hours IV or IM in one dose or VancomycinΔ 40 mg/kg per 24 hours IV in two or three equally divided doses Benzylpenicillin¥ 1.2 g every 4 hours IV or Ceftriaxone 2 g per 24 hours IV/IM Aqueous penicillin G* 12 to 18 million units per 24 hours IV in six equally divided doses or Amoxicillin 100 to 200 mg/kg per 24 hours IV in four to six equally divided doses or Ampicillin 12 g per 24 hours (or 100 to 200 mg/kg per 24 hours) IV in six equally divided doses or Ceftriaxone*‡ 2 g per 24 hours IV or IM in one dose or VancomycinΔ 30 mg/kg per 24 hours IV in two equally divided doses
  23. 23. Tratamiento o Suggested regimens for therapy of native valve endocarditis due to strains of viridans streptococci and Streptococcus bovis relatively resistant to penicillin G (MIC >0.12 mcg/mL and ≤0.5 mcg/mL)* American Heart Association British Society for Antimicrobial Chemotherapy European Society of Cardiology¶ Adult (for patients with normal renal function) Pediatric (not to exceed dose of normal adult) Either aqueous penicillin G 24 million units per 24 hours IV either continuously or in four or six equally divided doses for four weeks or Ceftriaxone 2 g per 24 hours IV or IM in one dose for four weeks plus GentamicinΔ 3 mg/kg per 24 hours IV or IM in one dose or in two to three equally divided doses for two weeks or Monotherapy with Vancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for four weeks; not to exceed 2 g per 24 hours unless concentrations in serum are inappropriately low Either aqueous penicillin G 300,000 units/kg per 24 hours IV in four or six equally divided doses for four weeks or Ceftriaxone 100 mg/kg per 24 hours IV or IM in one dose for four weeks plus GentamicinΔ 3 mg/kg per 24 hours IV or IM in one dose or in three equally divided doses for two weeks or Monotherapy with Vancomycin◊ 40 mg/kg per 24 hours IV in two or three equally divided doses for four weeks Benzylpenicillin§ 2.4 g every 4 hours IV for four to six weeks plus Gentamicin 1 mg/kg every 12 hours IV for two weeks Either aqueous penicillin G 24 million units per 24 hours IV in six equally divided doses for four weeks or Amoxicillin 200 mg/kg per 24 hours IV in four or six equally divided doses for four weeks or Ampicillin 12 g per 24 hours (200 mg/kg per 24 hours) in six equally divided doses for four weeks or Vancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for four weeks plus GentamicinΔ 3 mg/kg per 24 hours IV or IM in one dose for first two weeks
  24. 24. Tratamiento o Suggested regimens for therapy of native valve endocarditis due to enterococcal strains susceptible to penicillin, gentamicin, and vancomycinAmerican Heart Association British Society for Antimicrobial Chemotherapy European Society of Cardiology*¶ Adult (for patients with normal renal function) Pediatric (not to exceed dose of normal adult) GentamicinΔ 3 mg/kg per 24 hours IV or IM in three equally divided doses for four to six weeks◊ Plus one of the following◊: Aqueous penicillin G 18 to 30 million units per 24 hours IV either continuously or in six equally divided doses for four to six weeks◊ or Ampicillin 12 g per 24 hours IV in six equally divided doses for four to six weeks◊ or Vancomycin§ 30 mg/kg per 24 hours IV in two equally divided doses for six weeks; not to exceed 2 g per 24 hours unless concentrations in serum are inappropriately low GentamicinΔ 3 mg/kg per 24 hours IV or IM in three equally divided doses for four to six weeks◊ Plus one of the following: Aqueous penicillin G 300,000 units/kg per 24 hours IV in four to six equally divided doses for four to six weeks◊ or Ampicillin 300 mg/kg per 24 hours IV in four to six equally divided doses for four to six weeks◊ or Vancomycin§ 40 mg/kg per 24 hours IV in two or three equally divided doses for six weeks GentamicinΔ 1 mg/kg every 12 hours IV for four to six weeks Plus one of the following: Amoxicillin 2 g every four hours IV for four to six weeks or Penicillin 2.4 g every four hours IV for four to six weeks or Vancomycin§ 1 g IV every 12 hours for four to six weeks or Teicoplanin¥ 10 mg/kg IV once every 24 hours for four to six weeks GentamicinΔ 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for four to six weeks◊ Plus one of the following: Amoxicillin 200 mg/kg per 24 hours IV in four to six equally divided doses for four to six weeks◊ or Ampicillin 12 g per 24 hours (200 mg/kg per 24 hours) IV in six equally divided doses for four to six weeks◊ or Vancomycin§ 30 mg/kg per 24 hours IV in two equally divided doses for six weeks
  25. 25. Tratamiento o Suggested regimens for therapy of native valve endocarditis due to enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin American Heart Association British Society for Antimicrobial Chemotherapy European Society of Cardiology*Adult (for patients with normal renal function) Pediatric (not to exceed dose of normal adult) Beta-lactamase producing: One of the following: Gentamicin• 3 mg/kg per 24 hours IV or IM in three equally divided doses for six weeks plus either Ampicillin-sulbactamΔ 12 g per 24 hours IV in four equally divided doses for six weeks or Vancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for six weeks; not to exceed 2 g per 24 hours unless concentrations in serum are inappropriately low Beta-lactamase producing: One of the following: Gentamicin• 3 mg/kg per 24 hours IV or IM in three equally divided doses for six weeks plus either Ampicillin-sulbactamΔ 300 mg/kg per 24 hours IV in four divided doses for six weeks or Vancomycin◊ 40 mg/kg per 24 hours IV in two or three equally divided doses for six weeks One of the following: Gentamicin¥ 1 mg/kg IV every 8 to 12 hours for ≥4 weeks plus either Vancomycin◊ 1 g IV every 12 hours for ≥4 weeks or Teicoplanin‡ 10 mg/kg IV once daily for ≥4 weeks Beta-lactamase producing: One of the following: Gentamicin• 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for four to six weeks† plus either Ampicillin-sulbactamΔ 12 g per 24 hours (or 300 mg/kg per 24 hours) IV in four equally divided doses for four to six weeks† or Amoxicillin-clavulanateΔ 200 mg/kg (amoxicillin component) per 24 hours IV in six equally divided doses for four to six weeks† or Vancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for six weeks Intrinsic penicillin resistance§: Vancomycin◊ 30 mg/kg per 24 hours IV in two divided doses for six weeks plus Gentamicin• 3 mg/kg per 24 hours IV or IM in three equally divided doses for six weeks Intrinsic penicillin resistance§: Vancomycin◊ 40 mg/kg per 24 hours IV in two or three divided doses for six weeks plus Gentamicin• 3 mg/kg per 24 hours IV or IM in three equally divided doses for six weeks Intrinsic penicillin resistance§: Vancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for six weeks plus Gentamicin• 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for six weeks
  26. 26. Tratamiento o Suggested regimens for therapy of native or prosthetic valve endocarditis due to enterococcal strains resistant to penicillin, aminoglycoside, and vancomycin*
  27. 27. Tratamiento American Heart Association British Society for Antimicrobial Chemotherapy European Society of CardiologyAdult (for patients with normal renal function) Pediatric (not to exceed dose of normal adult) E. faecium: One of the following: Linezolid• 1200 mg per 24 h IV or PO in 2 equally divided doses for ≥8 wks or Quinupristin-dalfopristinΔ 22.5 mg/kg per 24 h IV in 3 equally divided doses for ≥8 wks E. faecium: One of the following: Linezolid• 30 mg/kg per 24 h IV or PO in 3 equally divided doses for ≥8 wks or Quinupristin-dalfopristinΔ 22.5 mg/kg per 24 h IV in 3 equally divided doses for ≥8 wks One of the following: Linezolid• 1200 mg per 24 h IV or PO in 2 equally divided doses for ≥6 wks or Quinupristin-dalfopristinΔ 22.5 mg/kg per 24 h IV in 3 equally divided doses for ≥6 wks or Teicoplanin◊ 10 mg/kg IV once daily for ≥6 wks or Combinations of antibiotics according to in vitro susceptibility E. faecium¥: Linezolid• 1200 mg per 24 h IV or PO in 2 equally divided doses for ≥ 8 wks or Quinupristin-dalfopristinΔ 22.5 mg/kg per 24 h IV in 3 equally divided doses for ≥8 wks or Combinations of antibiotics according to in vitro susceptibility‡ E. faecalis§: Imipenem-cilastatin 2 g per 24 h (or 60-100 mg/kg per 24 h) IV in 4 equally divided doses for ≥8 wks plus Ampicillin 12 g per 24 h (or 300 mg/kg per 24 h) IV in 6 equally divided doses for ≥8 wks or Ceftriaxone 2 g per 24 h (or 100 mg/kg per 24 h) IV or IM in 1 dose for ≥8 wks plus Ampicillin 12 g per 24 h (or 300 mg/kg per 24 h) IV in 6 equally divided doses for ≥8 wks or Combinations of antibiotics according to in vitro susceptibility‡ E. faecalis§: Imipenem-cilastatin 2 g per 24 h IV in 4 equally divided doses for ≥8 wks plus Ampicillin 12 g per 24 h IV in 6 equally divided doses for ≥8 wks or Ceftriaxone 4 g per 24 h IV or IM in 2 equally divided doses for ≥8 wks† plus Ampicillin 12 g per 24 h IV in 6 equally divided doses for ≥8 wks E. faecalis§: Imipenem-cilastatin 60-100 mg/kg per 24 h IV in 4 equally divided doses for ≥8 wks plus Ampicillin 300 mg/kg per 24 h IV in 4 to 6 equally divided doses for ≥8 wks or Ceftriaxone 100 mg/kg per 24 h IV or IM in 2 equally divided doses for ≥8 wks plus Ampicillin 300 mg/kg per 24 h IV in 4 to 6 equally divided doses for ≥8 wks
  28. 28. Tratamiento o Suggested regimens for therapy of native valve endocarditis due to staphylococcus American Heart Association British Society for Antimicrobial Chemotherapy European Society of Cardiology* Adult (for patients with normal renal function) Pediatric (not to exceed dose of normal adult) Oxacillin-susceptible strains•Δ Oxacillin-susceptible strains• Methicillin-sensitive Methicillin-susceptible strains Nafcillin or oxacillin 12 g per 24 h IV in 4 or 6 equally divided doses for 6 wks, plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 3 to 5 days or Cefazolin§ 6 g per 24 h IV in 3 equally divided doses for 6 wks, plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 3 to 5 days Nafcillin or oxacillin 200 mg/kg per 24 h IV in 4 or 6 equally divided doses for 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 3 to 5 days or Cefazolin§ 100 mg/kg per 24 h IV in 3 equally divided doses for 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 3 to 5 days Flucloxacillin 2 g IV every 4 to 6 hours for 4 wks Oxacillin or cloxacillin or flucloxacillin 12 g per 24 h IV in 4-6 equally divided doses for 4 to 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM divided in 2 or 3 doses for 3 to 5 days or Vancomycin¥ 30 mg/kg per 24 h IV in 2 equally divided doses for 4 to 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 3 to 5 days Oxacillin-resistant strains Oxacillin-resistant strains Methicillin resistant Methicillin resistant strains Vancomycin¥ 30 mg/kg per 24 h IV in 2 equally divided doses for 6 wks; not to exceed 2 g per 24 h unless concentrations in serum are Vancomycin¥ 40 mg/kg per 24 h IV in 2 or 3 equally divided doses for 6 wks Vancomycin¥ 1 g IV every 12 h for 4 wks plus Rifampin 300 to 600 mg PO Vancomycin¥ 30 mg/kg per 24 h IV in 2 doses for 4 to 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally
  29. 29. Tratamiento o Suggested regimens for therapy of native valve endocarditis due to HACEK* microorganism American Heart Association British Society for Antimicrobial Chemotherapy European Society of CardiologyAdult (for patients with normal renal function) Pediatric (not to exceed dose of normal adult) One of the following: Ceftriaxone• 2 g per 24 h IV or IM in 1 dose for 4 wks or Ampicillin-sulbactam 12 g per 24 h IV in 4 equally divided doses for 4 wks or Ciprofloxacin§ 1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses for 4 wks One of the following: Ceftriaxone• 100 mg/kg per 24 h IV or IM in 1 dose for 4 wks or Ampicillin-sulbactam 300 mg/kg per 24 h IV in 4 equally divided doses doses for 4 wks or Ciprofloxacin§ 20-30 mg/kg per 24 h IV or PO in 2 equally divided doses for 4 wks Either AmpicillinΔ 2 g IV every 4 to 6 h for 4 wks or Ceftriaxone• 2 to 4 g per 24 h IV or IM in 1 dose for 4 wks plus Gentamicin◊ 1 mg/kg IV every 8 to 12 h for 2 wks One of the following: Ceftriaxone• 2 g per 24 h IV or IM in 1 dose for 4 wks or Combination therapy with: ampicillinΔ 12 g per 24 h IV in 4 or 6 equally divided doses plus gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 4 wks or Ciprofloxacin§ 1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses for 4 wks
  30. 30. Tratamiento o Suggested regimens for therapy of culture-negative native valve endocarditisAmerican Heart Association British Cardiac Society European Society of Cardiology Adult (for patients with normal renal function) Pediatric (not to exceed dose of normal adult) One of the following: Ampicillin-sulbactam 12 g per 24 h IV in 4 equally divided doses for 4-6 wks plus Gentamicin sulfateΔ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 4-6 wks OR Vancomycin• 30 mg/kg per 24 h IV in 2 equally divided doses for 4-6 wks; not to exceed 2 g per 24 h unless concentrations in serum are inappropriately low plus GentamicinΔ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 4-6 wks plus Ciprofloxacin 1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses for 4 to 6 wks One of the following: Ampicillin-sulbactam 300 mg/kg per 24 h IV in 4 or 6 equally divided doses for 4-6 wks plus GentamicinΔ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 4-6 wks OR Vancomycin• 40 mg/kg per 24 h IV in 2 or 3 equally divided doses for 4-6 wks plus GentamicinΔ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 4-6 wks plus Ciprofloxacin◊ 20-30 mg/kg per 24 h IV or PO in 2 equally divided doses for 4 to 6 wks Vancomycin• 15 mg/kg IV every 12 h for 6 wks plus Gentamicin 3-5 mg/kg IV or IM per 24 h in 2 or 3 equally divided doses for 2 wks Ampicillin-sulbactam or amoxicillin-clavulanate 12 g per 24 h IV in 4 equally divided doses for 4-6 weeks plus GentamicinΔ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 4-6 weeks OR Vancomycin• 30 mg/kg per 24 h IV in 2 equally divided doses for 4-6 wks plus GentamicinΔ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 4-6 wks plus Ciprofloxacin◊§ 1000 mg PO or 800 mg IV in 2 equally divided doses for 4-6 wks
  31. 31. Tratamiento o Suggested regimens for therapy of prosthetic valve endocarditis due to Staphylococcus
  32. 32. American Heart Association European Society of CardiologyAdult (for patients with normal renal function) Pediatric (not to exceed dose of normal adult) Oxacillin-susceptible strains Oxacillin-susceptible strains Methicillin-susceptible strains One of the following: Nafcillin or oxacillin* 12 g per 24 hours IV in six equally divided doses for ≥6 weeks or Cefazolin◊ 6 g per 24 hours IV in three equally divided doses for ≥6 weeks or Vancomycin§¥ 30 mg/kg per 24 hours IV in two equally divided doses for ≥6 weeks plus Rifampin 900 mg per 24 hours IV or orally in three equally divided doses for ≥6 weeks plus Gentamicin‡ 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for 2 weeks One of the following: Nafcillin or oxacillin* 200 mg/kg per 24 hours IV in four or six equally divided doses for ≥6 weeks or Cefazolin◊ 100 mg/kg per 24 hours IV in three equally divided doses for ≥6 weeks or Vancomycin§¥ 40 mg/kg per 24 hours IV in two or three equally divided doses for ≥6 weeks plus Rifampin 20 mg/kg per 24 hours IV or orally in three equally divided doses for ≥6 weeks plus Gentamicin‡ 3 mg/kg per 24 hours IV or IM in three equally divided doses for 2 weeks One of the following: Oxacillin or cloxacillin or flucloxacillin 12 g per 24 hours IV in four to six equally divided doses for ≥6 weeks or Vancomycin§ 30 mg/kg per 24 hours IV in two equally divided doses for ≥6 weeks plus RifampinΔ 1200 mg per 24 hours IV or orally in two equally divided doses for ≥6 weeks plus Gentamicin¶ 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for the first 2 weeks Oxacillin-resistant strains Oxacillin-resistant strains Methicillin resistant strains Vancomycin¥ 30 mg/kg per 24 hours IV in two equally divided doses for ≥6 weeks plus Rifampin 900 mg per 24 hours IV or orally in three equally divided doses for ≥6 weeks plus Gentamicin‡ 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for 2 weeks Vancomycin¥ 40 mg/kg per 24 hours IV in two or three equally divided doses for ≥6 weeks plus Rifampin 20 mg/kg per 24 hours IV or orally in three equally divided doses for≥6 weeks plus Gentamicin‡ 3 mg/kg per 24 hours IV or IM in three equally divided doses for 2 weeks Vancomycin¥ 30 mg/kg per 24 hours IV in two equally divided doses for ≥6 weeks plus RifampinΔ 1200 mg per 24 hours IV or orally in divided doses for ≥6 weeks plus Gentamicin¶ 3 mg/kg per 24 hours IV or IM in three equally divided doses for first 2 weeks

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