Infective Endocarditis

Admit patients with suspected infective endocarditis (IE) when bacteremia, acute valvular dysfunction, embolic disease, sepsis, prosthetic material, or a cardiac implantable electronic device (CIED) raises concern for an endovascular focus. In-hospital mortality is reported at 15%-20%, and 1-year mortality approaches 40%; use early cardiology, infectious diseases, cardiac surgery, and device-extraction expertise rather than serial uncoordinated consultations. ScienceDirect+1ScienceDirectRole of multimodality imaging in infective endocarditis: Contemporary diagnostic and prognostic considerations - ScienceDirectPubMedAortic Valve Endocarditis Surgical Treatment - StatPearls - NCBI Bookshelf

Before antimicrobial therapy, obtain at least two separate blood-culture sets for secure microbiologic diagnosis; preferably obtain three sets from different venous sites. Pre-culture antibiotic exposure is the leading cause of culture-negative IE and converts a potentially organism-directed regimen into a prolonged diagnostic problem. AHA Journals+1AHA JournalsSurgery for Infective Endocarditis | CirculationPubMedEndocarditis Antibiotic Regimens - StatPearls - NCBI Bookshelf

Assess urgently for acute heart failure from valve destruction, uncontrolled infection, prosthetic-valve involvement, conduction disturbance suggesting periannular extension, and neurologic embolic complications. Congestive heart failure, prosthetic-valve endocarditis, and uncontrolled infection are established surgical indications; do not wait for completion of a full antibiotic course when an operative indication is present. AHA Journals+1AHA JournalsSurgery for Infective Endocarditis | CirculationAHA Journals2020 ACC/AHA Guideline for the Management of Patients ...

Apply the 2023 Duke-International Society of Cardiovascular Infectious Diseases (Duke-ISCVID) framework, which incorporates clinical, microbiologic, imaging, and surgical standards. A microbiologic major criterion includes an organism commonly causing IE from two or more separate blood-culture sets; organisms that only occasionally or rarely cause IE require isolation from three or more separate sets. jaccjaccRecent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4

For culture-negative presentations, distinguish antibiotic-suppressed bacterial IE from specific fastidious etiologies. Duke-ISCVID major laboratory evidence includes blood PCR or another nucleic acid-based assay for Coxiella burnetii, Bartonella species, or Tropheryma whipplei; C. burnetii phase I IgG greater than 1:800 is also major evidence. jaccjaccRecent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4

Interpret imaging in the clinical context. Echocardiography can identify vegetations and structural complications including pseudoaneurysm, intracardiac fistula, valve perforation, and valve aneurysm; these findings constitute major imaging evidence in contemporary criteria. AHA Journals+2AHA JournalsMultimodality Imaging in Infective EndocarditisAHA JournalsMultimodality Imaging in Infective Endocarditis | CirculationjaccRecent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4

Perform transthoracic echocardiography first in suspected IE, then use transesophageal echocardiography (TEE) for confirmation and complication assessment. In comparative summaries, reported sensitivity is approximately 75% for TTE and 90% for TEE, with specificity of approximately 90% for each; TEE performs better than CT for valvular IE-related lesions. ScienceDirect+2ScienceDirectDiagnostic performance of cardiac computed tomography versus transesophageal echocardiography in infective endocarditis: A contemporary comparative meta-analysis - ScienceDirectScienceDirectDiagnostic Performance of Transesophageal Echocardiography and Cardiac Computed Tomography in Infective Endocarditis - ScienceDirectScienceDirectRole of multimodality imaging in infective endocarditis: Contemporary diagnostic and prognostic considerations - ScienceDirect

Use cardiac CT when the key question is paravalvular extension or when echocardiography cannot define the anatomy. CT detects paravalvular lesions comparably to TEE in surgically confirmed left-sided IE, and one meta-analysis summary reported higher sensitivity for CT than TEE for paravalvular abscess detection (88% versus 74%). ScienceDirect+1ScienceDirectDiagnostic Performance of Transesophageal Echocardiography and Cardiac Computed Tomography in Infective Endocarditis - ScienceDirectPubMedInfective Endocarditis - StatPearls - NCBI Bookshelf

Reserve cardiac FDG-PET/CT principally for prosthetic-valve or device-associated infection and for identifying distant embolic infection. Its sensitivity for cardiac infection in native-valve IE is too low for routine use, although it may improve diagnostic classification in selected patients with possible native-valve IE. AHA Journals+2AHA JournalsMultimodality Imaging in Infective Endocarditis | CirculationScienceDirect[18F]FDG-PET CT for the evaluation of native valve endocarditis - ScienceDirectScienceDirectRole of multimodality imaging in infective endocarditis: Contemporary diagnostic and prognostic considerations - ScienceDirect

Start antimicrobial therapy after cultures are obtained unless unstable sepsis makes delay unsafe, then narrow promptly once the organism and susceptibility profile are known. Antibiotic therapy is most effective when the responsible organism and susceptibilities are identified; management should be pathogen-directed rather than driven by a fixed empiric regimen. AHA Journals+1AHA JournalsSurgery for Infective Endocarditis | CirculationPubMedEndocarditis Antibiotic Regimens - StatPearls - NCBI Bookshelf

For MRSA endocarditis, source summaries identify vancomycin 30 mg/kg or daptomycin 6-10 mg/kg as treatment options. Do not routinely combine vancomycin with an aminoglycoside: this increases nephrotoxicity and ototoxicity with minimal survival benefit, and the American Heart Association discourages the combination for MRSA. PubMedPubMedEndocarditis Antibiotic Regimens - StatPearls - NCBI Bookshelf

Monitor clinical response and obtain blood cultures every 24-48 hours until negative. Most patients become afebrile within 3-5 days of appropriate therapy, but defervescence does not replace microbiologic clearance or imaging reassessment when valve dysfunction, embolic disease, persistent bacteremia, or abscess is present. PubMed+1PubMedInfective Endocarditis - StatPearls - NCBI BookshelfPubMedEndocarditis Antibiotic Regimens - StatPearls - NCBI Bookshelf

Refer to an endocarditis team early when IE is complicated by congestive heart failure, prosthetic-valve endocarditis, or uncontrolled infection. Early surgery is defined as intervention during the initial hospitalization before completion of an appropriate antimicrobial course. AHA Journals+1AHA JournalsSurgery for Infective Endocarditis | CirculationAHA Journals2020 ACC/AHA Guideline for the Management of Patients ...

Use imaging to make the surgical question explicit: valvular destruction and vegetation are best characterized by TEE, whereas abscess, pseudoaneurysm, fistula, and other paravalvular extension may require cardiac CT for operative anatomy. AHA Journals+3AHA JournalsMultimodality Imaging in Infective EndocarditisAHA JournalsMultimodality Imaging in Infective Endocarditis | CirculationScienceDirectDiagnostic Performance of Transesophageal Echocardiography and Cardiac Computed Tomography in Infective Endocarditis - ScienceDirectScienceDirectRole of multimodality imaging in infective endocarditis: Contemporary diagnostic and prognostic considerations - ScienceDirect

Neurologic events require coordinated timing rather than reflex cancellation of surgery. In patients with a surgical indication and stroke but without intracranial hemorrhage or extensive neurologic damage, surgery without delay may be considered. The ESC discussion identifies severely decreased consciousness as Glasgow Coma Scale 4 or less or NIH Stroke Scale greater than 18; brain imaging should define hemorrhage and structural injury before proceeding. AHA Journals+1AHA Journals2020 ACC/AHA Guideline for the Management of Patients ...PubMed2023 European Society of Cardiology guidelines for the management of infective endocarditis

Classify risk before invasive exposures. High-risk groups include prior IE, prosthetic valves, ventricular assist devices, and congenital heart disease other than isolated congenital valve abnormalities; the intermediate-risk category includes rheumatic heart disease, nonrheumatic degenerative valve disease, bicuspid aortic valve disease, CIEDs, and hypertrophic cardiomyopathy. PubMedPubMed2023 European Society of Cardiology guidelines for the management of infective endocarditis

After treatment, arrange serial echocardiography when needed to assess valve function and treatment response, and reassess for heart failure, recurrent bacteremia, embolic complications, and device or prosthetic dysfunction. Persistent or recurrent concerns should prompt repeat cultures and TEE, with cardiac CT when paravalvular disease is suspected. AHA Journals+2AHA JournalsMultimodality Imaging in Infective EndocarditisAHA JournalsMultimodality Imaging in Infective Endocarditis | CirculationPubMedEndocarditis - StatPearls - NCBI Bookshelf

Address modifiable exposure risks. In patients with congenital heart disease, tattooing and piercing have been associated with IE, and ESC guidance recommends avoiding them; antibiotic prophylaxis for these exposures remains unclear. PubMedPubMedEndocarditis in Adult Congenital Heart Disease Patients: Prevention, Recognition, and Management