Getting to the heart of the matter—are two agents really better than one for the treatment of staphylococcal infective endocarditis?

The recently published European Society of Cardiology guidelines for infective endocarditis management recommends daptomycin combination therapy for the treatment of staphylococcal endocarditis in severe penicillin allergy, rather than daptomycin monotherapy. We discuss the evidence-base behind this recommendation, highlighting concerns regarding lack of robust clinical studies, increased cost and logistical considerations, and adverse effects of combination therapy. Although further studies are required to elucidate the role of combination versus monotherapy in these patients, we propose a pragmatic management approach to reduce the risk of adverse antimicrobial side-effects and limit costs, while aiming to maintain treatment efficacy.