For children who are unable to tolerate -lactam antibiotic drugs, vancomycin is an effective substitute, and current practice includes the addition of genta- micin for a 4-week course (Table 7). Caution should be exer- cised by obtaining blood levels of vancomycin and gentamicin, as well as serum creatinine levels, weekly because of the pos- sibility of nephrotoxicity with this combination. S pneumoniae accounts for 3% to 5% of cases in children (Table 5). Because of the potential for multidrug resistance and the infrequency of the syndrome of pneumococcal IE, no optimal therapy has been established for this illness.116 118 A review of pneumococcal endocarditis published in 2004 reported on 11 cases of pneumococcal IE over a 10-year period at 8 children s hospitals, and 10 of the 11 survived to the time All isolates were susceptible to ceftriaxone, and 9 were susceptible to penicillin. One was resistant to pen- icillin, and 1 demonstrated an intermediate susceptibility to penicillin. Therapy consisted of cefotaxime or ceftriaxone for 5 patients, cefotaxime plus vancomycin for 2, penicillin for 2, and clindamycin for 1, and 1 patient received many different antibiotic drugs. One patient died during cardiac surgery and had received vancomycin and cefotaxime for a pneumococ- cal isolate intermediately susceptible to penicillin. Generally, for penicillin-susceptible strains, penicillin with or without an aminoglycoside has been used. It was the consensus of the writing group that consultation with an infectious disease spe- cialist should be considered for all children with IE but espe- cially for IE caused by S pneumoniae that is not susceptible to penicillin. Recommendations 1. 