Key Points

1. Empiric therapy for the management of endocarditis in injection drug users (IVDUs) must target S. aureus particularly MRSA and should therefore contain an agent such as vancomycin which is effective against MRSA.

2. In addition to S. aureus and MRSA, Gram negative bacilli such as P. aeruginosa and fungi, such as Candida spp must be considered when initiating treatment of endocarditis in an IVDU.

3. For IVDUs with right sided endocarditis caused by methicillin susceptible S. aureus, a 2 week course of cloxacillin and gentamicin may be sufficient. However, the standard regimen must be used in the following circumstances:

• Delayed clinical or microbiologic response (> 96 hours)

• Right sided endocarditis complicated by the presence of right sided heart failure, large vegetation (>2 cm in diameter), respiratory failure, empyema, the presence of extrapulmonary metastatic foci such as osteomyelitis.

• Severe immunosuppression (<200 CD for cells/uL)

• Polymicrobial endocarditis or endocarditis caused by MRSA

• Therapy with agents other than cloxacillin

4. Surgery must not be delayed until blood cultures become negative, if the patient's condition warrants immediate intervention because of severe valvular destruction.

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