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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