Patient handout

Cardiogenic shock — bacterial myocarditis (Staph, Strep, diphtheria, TB, meningococcal)

PRODUCTION

1. Your condition

This handout is for cardiogenic shock — bacterial myocarditis (staph, strep, diphtheria, tb, meningococcal). Your care team identified this based on: cardiogenic shock + fever + signs of bacteremia → bacterial myocarditis suspicion (staph, strep, meningococcal).

Other reasons your team may use this plan: recent severe pharyngitis (gray membrane) in unvaccinated patient + new carditis → diphtheria toxin myocarditis (medical emergency, antitoxin from cdc); subacute carditis + constitutional symptoms + pericardial effusion in hiv-positive / immunocompromised → tb myocarditis evaluation; meningococcemia (purpura fulminans, sepsis) with carditis features → meningococcal myocarditis.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
vancomycin	25-30 mg/kg IV load then 15-20 mg/kg q8-12h titrate trough 15-20 µg/mL	IV	q8-12h	IDSA MRSA + AHA 2015 endocarditis (Baddour PMID 26373316) — first-line for MSSA/MRSA/Strep coverage in bacterial myocarditis with bacteremia; trough monitoring for nephrotoxicity
ceftriaxone	2 g IV q24h (q12h for meningitis)	IV	q24h	Empiric coverage for Strep, meningococcal, susceptible Staph; first-line for meningococcal myocarditis + meningitis (CDC 2024 guidance)
piperacillin-tazobactam	4.5 g IV q6-8h	IV	q6-8h	Broader-spectrum empiric if HCAP / nosocomial source / pseudomonas risk; alternative to ceftriaxone
oxacillin	2 g IV q4h	IV	q4h	AHA 2015 endocarditis — anti-staphylococcal penicillin preferred for MSSA over vancomycin (better outcomes); narrow spectrum after culture confirms MSSA
cefazolin	2 g IV q8h	IV	q8h	AHA 2015 endocarditis alternative to oxacillin for MSSA with mild PCN allergy; also for cardiac surgery prep if MCS
doxycycline	100 mg PO/IV BID	PO/IV	BID	Atypicals (Coxiella Q-fever, Rickettsia, Chlamydia, Lyme overlap); IDSA 2021 Lyme PMID 33417672
erythromycin	500 mg IV q6h × 14 days	IV	q6h	CDC diphtheria guidance — erythromycin or penicillin G for diphtheria; eradicate carriage; reduce toxin burden
penicillin g	2-4 million units IV q4h × 14 days	IV	q4h	CDC diphtheria + rheumatic carditis — penicillin G eradicates organism; for diphtheria, antitoxin is the primary therapy and antibiotics secondary
rifampin	600 mg PO daily	PO	daily	WHO TB 2023 RIPE protocol — rifampin core agent; 2 mo intensive then 4 mo continuation
isoniazid	300 mg PO daily + pyridoxine 25 mg	PO	daily	WHO TB 2023 RIPE protocol — INH core agent with pyridoxine for neuropathy prevention
pyrazinamide	15-30 mg/kg PO daily (max 2 g)	PO	daily	WHO TB 2023 RIPE intensive phase × 2 mo; hepatotoxicity surveillance required
ethambutol	15-25 mg/kg PO daily	PO	daily	WHO TB 2023 RIPE intensive phase × 2 mo; ophthalmology baseline for optic neuritis monitoring
norepinephrine	0.05–0.5 µg/kg/min titrate MAP ≥65	IV	continuous	SOAP-II PMID 20200382 — NE first-line in CS + septic shock; preferred over dopamine
dobutamine	2.5–10 µg/kg/min titrate	IV	continuous	CAUTIOUS in active myocarditis — arrhythmogenic; use only if persistent low CO after volume + NE optimization
dexamethasone	0.15 mg/kg IV q6h × 4 days (meningitis adjunct)	IV	q6h	IDSA meningitis — dexamethasone with first dose of antibiotics in pneumococcal/meningococcal meningitis; AVOID routine immunosuppression in bacterial myocarditis (worsens infection — distinct from autoimmune myocarditis)

Plan: Bacterial myocarditis CS — targeted antibiotics by organism + standard CS support; AVOID immunosuppression (distinct from autoimmune myocarditis)

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent shock or new arrhythmia → ED + CICU
TB drug resistance → MDR-TB regimen + ID
New bacteremia / fever → ID + endocarditis re-workup
Persistent EF<40 at 6 months → cardiology long-term + chronic HFrEF management
Cardiac MRI fibrosis progression → advanced HF evaluation

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Failure to start sepsis bundle (cultures + abx within 1 h) in bacterial myocarditis CS — every hour of antibiotic delay associated with ~7-8% mortality increase(life-threatening)
Bacterial myocarditis traced to vaccine-preventable etiology in unvaccinated / under-vaccinated patient — diphtheria, meningococcal, pneumococcal, Hib; family / contact tracing + emergent vaccination
Steroids / immunosuppression mistakenly initiated in bacterial myocarditis (mistaking for autoimmune / giant-cell myocarditis) — worsens infection, sepsis progression(life-threatening)
Multidrug-resistant organism (MRSA with reduced vancomycin susceptibility, MDR-TB, ESBL Strep) → treatment failure on initial empiric regimen
Diphtheria suspicion → CDC stockpile equine antitoxin contact emergent; antitoxin only effective before tissue binding; do NOT delay for confirmation(life-threatening)
Meningococcemia with bilateral adrenal hemorrhage (Waterhouse-Friderichsen) → adrenal crisis + DIC + purpura fulminans + bacterial myocarditis component(life-threatening)

5. Follow-up

Cardiology + ID follow-up at 1-3 mo; cardiac MRI at 3-6 mo for fibrosis assessment + recovery confirmation; vaccination updates (diphtheria booster q10y; pneumococcal; meningococcal if at-risk); the four foundational heart-failure medications continuation if persistent EF<40; cardiac rehab; contact tracing for diphtheria / meningococcal / TB

6. Sources

Guideline: ESC 2013 myocarditis position statement (Caforio PMID 23824828); AHA 2020 Scientific Statement on Acute Myocarditis (PMID 32200645); CDC Diphtheria Clinical Guidance + 2024 vaccination schedule; CDC Meningococcal Disease Guidance + 2024 vaccination schedule; IDSA Lyme 2021 (Lantos PMID 33417672); WHO TB 2023; SCAI 2022 CS staging (Naidu PMID 35718438); SSC 2026 sepsis bundle