Version July 2025
| American Heart Association (AHA) | European Society of Cardiology (ESC) | |
| Adult | Pediatric (not to exceed dose of normal adult) | Adult |
| Either Aqueous penicillin G 24 million units per 24 hours IV either continuously or in 4 or 6 divided doses for 6 weeks or Ampicillin 2 g IV every 4 hours for 6 weeks or Ceftriaxone¶ 2 g per 24 hours IV in 1 dose for 6 weeks with or without GentamicinΔ◊ 3 mg/kg per 24 hours IV or IM in 1 dose for first 2 weeks | Either Aqueous penicillin G 200,000 to 300,000 units/kg per 24 hours IV in 6 divided doses (maximum dose: 24 million units per 24 hours) for 6 weeks or Ampicillin 200 to 300 mg/kg per 24 hours IV divided in 4 or 6 divided doses (maximum dose: 12 g per 24 hours) for 6 weeks or Ceftriaxone 100 mg/kg per 24 hours IV in 2 divided doses or 80 mg/kg in 1 daily dose (maximum dose: 4 g per 24 hours; if dose is >2 g per 24 hours, use divided dosing every 12 hours) for 6 weeks plus GentamicinΔ◊ 3 to 6 mg/kg per 24 hours IV in 3 divided doses for first 2 weeks | Either Aqueous penicillin G 12 to 18 million units per 24 hours IV in 4 or 6 divided doses or continuously for 6 weeks or Amoxicillin 100 to 200 mg/kg per 24 hours IV in 4 or 6 divided doses for 6 weeks or Ceftriaxone¶ 2 g per 24 hours IV in 1 dose for 6 weeks |
| Beta-lactam-intolerant patients: Vancomycin§ 30 mg/kg per 24 hours IV in 2 divided doses for 6 weeks | Beta-lactam-intolerant patients: Vancomycin§ 40 mg/kg per 24 hours IV in 2 or 3 divided doses (maximum dose: 2 g per 24 hours unless levels are inappropriately low) for 6 weeks | Beta-lactam-intolerant patients: Vancomycin§ 30 mg/kg per 24 hours IV in 2 divided doses for 6 weeks |
The doses above are intended for patients with normal kidney function. The doses of many of these agents must be adjusted in the setting of kidney function impairment; refer to the individual drug monographs included within UpToDate for renal dosing adjustments.
Wherever intramuscular administration is provided as an alternative, intravenous route is preferred, particularly in infants and children.IM: intramuscularly; IV: intravenously; MIC: minimum inhibitory concentration; PVE: prosthetic valve endocarditis.
* AHA adult guidelines use MIC ≤0.12 mcg/mL; AHA pediatric guidelines use MIC ≤0.1 mcg/mL; ESC guidelines use MIC ≤0.125 mcg/mL.
¶ Alternative in patients with nonsevere penicillin allergy; preferred for outpatient therapy.
Δ Gentamicin should be omitted in patients with potential for nephrotoxicity, patients with creatinine clearance <30 mL/min, or patients with impaired VIII cranial nerve function or severe decreased vision. In adults, aminoglycosides are dosed based on ideal body weight.
◊ Kidney function and gentamicin serum concentrations should be monitored at least once per week. Gentamicin dosage adjusted for peak serum concentration 3 to 4 mcg/mL, trough <1 mcg/mL when 2 to 3 divided doses used; when given in a single daily dose, pre-dose (trough) concentrations should be <1 mcg/mL. Per AHA guidelines, there is no role for measuring peak gentamicin concentration following single daily dosing.
§ Vancomycin therapy is only recommended for patients severely allergic to penicillins or cephalosporins. Penicillin desensitization can be attempted in stable patients. In adults, vancomycin is dosed based on actual body weight. The dose should be adjusted for trough concentration of 10 to 15 mcg/mL. Daptomycin is not a substitute for vancomycin for treatment of streptococcal PVE (refer to UpToDate topic on treatment of PVE for further discussion).