Pericarditis Organism-Specific Therapy 

Pericarditis Organism-Specific Therapy 

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Organism-specific therapeutic regimens for infectious pericarditis are provided below, including those for bacterial infections, viral infections, fungal infections, and mycobacterial infections. [1, 2]

Most cases of bacterial pericarditis require percutaneous or surgical pericardial drainage for cure. Early cardiology and cardiothoracic surgery consultation is strongly recommended.

Streptococcus pneumoniae

Penicillin-sensitive

First-line treatment: Penicillin G 4 million units IV q4h (penicillin MIC ≤2 µg/mL)

Second-line treatment: Ceftriaxone 2 g IV q24h (penicillin MIC >2 µg/mL and susceptible to ceftriaxone)

Duration of therapy: 2-6 weeks

Penicillin-resistant or patient with penicillin allergy

First-line treatment: Vancomycin 15 mg/kg IV q12h

Second-line treatment: Levofloxacin 750 mg IV/PO daily or moxifloxacin 400 mg IV/PO daily

Duration of therapy: 2-6 weeks

Staphylococcus aureus

Methicillin-sensitive (MSSA)

First-line treatment: Nafcillinor oxacillin 2 g IV q4h or  cefazolin 2 g IV q8h or ceftriaxone 2 g IV q24h

Second-line treatment: see agents listed for MRSA below

Duration of therapy: 2-6 weeks

Methicillin-resistant (MRSA)

First-line treatment: Vancomycin 15 mg/kg IV q12h

Second-line treatment: Linezolid 600 mg IV/PO q24h

Duration of therapy: 2-6 weeks

Neisseria meningitidis

First-line treatment: Ceftriaxone 2 g IV/IM q12h (may reduce to 2 g IV q24h only if concomitant meningitis is ruled out)

Second-line treatment: Ampicillin 2 g IV q4h

Third-line treatment: Penicillin G 4 million units IV q4h

Duration of therapy: 2-6 weeks

Pseudomonas aeruginosa

First-line treatments: Cefepime 2 g IV q8h or  piperacillin-tazobactam 4.5 g IV q6h or meropenem 2 g IV q8h

Second-line treatments: ciprofloxacin 400 mg IV q8h or  ciprofloxacin 750 mg PO bid or levofloxacin 750 mg IV/PO q24h

Duration of therapy: 2-6 weeks

Enteric gram-negative bacilli (community-acquired)

First-line treatment: Ceftriaxone 2 g IV q24h

Duration of first-line therapy: 2-6 weeks

Second-line treatment: Ciprofloxacin 400 mg IV q12 or ciprofloxacin 500 mg PO q12h or levofloxacin 500 mg IV/PO q24h

Duration of second-line therapy: 2-6 weeks

Legionella pneumophila

First-line treatment: Azithromycin 500 mg IV/PO q24h

Second-line treatment: Levofloxacin 500 mg IV/PO q24h

Duration of therapy: 2-6 weeks

Anaerobes (Prevotella, Peptostreptococcus, Bacteroides)

First-line treatment: Clindamycin 600 mg IV/PO q6h

Second-line treatment: Metronidazole 500 mg IV/PO q12h

Duration of therapy: 2-6 weeks

See Pericarditis Empiric Therapy

If associated with human immunodeficiency virus (HIV) infection, treat with antiretroviral therapy, monitor for immune reconstitution inflammatory syndrome, and screen for opportunistic infections according to CD4 count

If associated with hepatitis B or C, treat with antiviral therapy as dictated by specific virus and genotype.

If associated with influenza A or B, treat with oseltamivir 75 mg PO BID × 10 doses

Most cases of fungal pericarditis require percutaneous or surgical pericardial drainage for cure. Early cardiology and cardiothoracic surgery consultation is strongly recommended.

Candida albicans

Echinocandin therapy (micafungin, anidulafungin, caspofungin) as per Pericarditis Empiric Therapy

Fluconazole 6-12 mg/kg IV/PO q24h once susceptibility results available

Duration of therapy: 2-6 weeks

Non -albicans Candida species

Echinocandin therapy (micafungin, anidulafungin, caspofungin) as per Pericarditis Empiric Therapy

Once stabilized, switch to voriconazole 400 mg PO q12h × 2 doses, then 200 mg PO q12h

Duration of therapy: 2-6 weeks

Aspergillus

First-line treatment

Voriconazole 6 mg/kg IV q12h × 1d, then 4 mg/kg IV q12h (oral dosage is 200 mg q12h); or posaconazole 200 mg q6h initially, then 400 mg PO q12h once clinically stable

Duration of therapy: 2-6 weeks

Second-line treatment

Caspofungin 70-mg loading dose, then 50 mg IV q24h; or micafungin 100-150 mg IV daily

Duration of therapy: 2-6 weeks

Third-line treatment

Liposomal amphotericin B 3-5 mg/kg IV daily

Duration of therapy: 2-6 weeks

Histoplasmosis

Immunocompetent with mild illness: NSAIDs as per Pericarditis Empiric Therapy, Viral

Immunocompromised illness not responsive to NSAIDs, or hemodynamically unstable

Itraconazole 200 mg q8h × 3d, then q12h × 6-12wk

Prednisone 0.5-1.0 mg/kg IV daily (maximum, 80 mg daily), taper dose over 1-2wk

See Pericarditis Empiric Therapy, Mycobacterial.

Mycoplasma pneumoniae

First-line treatment

Doxycycline 100 mg IV/PO q12h

Duration of therapy: 2-6 weeks

Second-line treatment

Azithromycin 500 mg IV/PO q24h

Duration of therapy: 2-6 weeks

Third-line treatment

Erythromycin 500 mg IV/PO q6h

Duration of therapy: 2-6 weeks

Medscape Reference. WebMD. Available at http://www.medscape.com.

Alabed S, Cabello JB, Irving GJ, Qintar M, Burls A. Colchicine for pericarditis. Cochrane Database Syst Rev. 2014 Aug 28. 8:CD010652. [Medline].

Ryan C Maves, MD, FACP, FCCP, FIDSA Program Director, Infectious Diseases Fellowship, Naval Medical Center San Diego; Associate Professor of Medicine, Uniformed Services University of the Health Sciences

Ryan C Maves, MD, FACP, FCCP, FIDSA is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Armed Forces Infectious Diseases Society, HIV Medicine Association, Infectious Diseases Society of America, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Kelley Struble, DO Fellow, Department of Infectious Diseases, University of Oklahoma College of Medicine

Kelley Struble, DO is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Pericarditis Organism-Specific Therapy 

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