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{{Endocarditis}}
{{Endocarditis}}


{{CMG}}; '''Associate Editor-in-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor-in-Chief:''' {{Maliha}} {{CZ}} [[Kosar Doraghi, M.D.]][mailto:k.doraghi@yahoo.com]


==Overview==
==Overview==
Endocarditis is an [[inflammation]] of the [[heart valve]]s.
Endocarditis is an [[inflammation]] of the inner layer of the [[heart]], the [[endocardium]]. It usually involves the [[heart valve]]s. While [[acute bacterial endocarditis]] is caused by an [[infection]] with a [[virulent]] [[organism]] such as [[Staphylococcus aureus]], group A or other [[beta-hemolytic streptococci]], [[subacute bacterial endocarditis]] is an indolent infection with less virulent organisms such as [[streptococcus viridans]].  Patients with unexplained [[fever]] for more than 48 hours and who are at high risk for [[infective endocarditis]] and patients among whom [[valvular disease|valve regurgitation]] is newly diagnosed should undergo a diagnostic workup to rule out [[endocarditis]].  The diagnosis of [[endocarditis]] depends on a thorough history and physical exam as well as on the results of the blood cultures and the findings on [[TTE|transthoracic echocardiogram]] or [[TEE|transesophageal echocardiogram]].  The [[modified Duke criteria]] is used to establish the diagnosis of [[endocarditis]]. [[Endocarditis]] is initially treated with [[Empiric therapy|empiric]] antibiotic therapy until the causative agent is identified.
 
==Historical Perspective==
[[Endocarditis]] was first described in 1554. The [[Inflammation|inflammatory]] process associated with [[endocarditis]] was discovered in 1799. [[Vegetation (pathology)|Vegetations]] were first discovered to be associated with [[endocarditis]] in 1806.


==Classification==
==Classification==
Endocarditis is classified based upon the underlying pathophysiology of the process (infective versus non-infective), the acuity of the process (acute versus subacute or short incubation versus long incubation), the fastidiousness of the infectious agent (i.e. how hard it is to culture and isolate as culture positive versus culture negative), the type of valve involved (native versus prosthetic) and the valve infected (aortic, mitral, or tricuspid valve).
[[Endocarditis]] may be classified based on the underlying [[pathophysiology]] of the process ([[Infective endocarditis|infective]] vs. [[Non-infective endocarditis|non-infective]]), the onset of the disease (acute vs. subacute or short incubation vs. long incubation), results of the cultures (culture-positive vs. [[Culture-negative endocarditis|culture]]-negative), the nature of the valve (native vs. [[prosthetic]]) and the valve affected ([[aortic]], [[mitral]], or [[tricuspid valve]]).


==Pathophysiology==
==Pathophysiology==
The turbulent blood flow around the heart valves is a risk factor for the development of endocarditis.  The valves may be damaged congenitally, from [[surgery]], by [[auto-immune]] mechanisms, or simply as a consequence of old age. The damaged endothelium of these areas becomes a site for attachment of infectious agents in infectious endocarditis.  Dental procedures, [[colorectal cancer]], [[urinary tract infections]] and [[intravenous drug use]] are the most common routes of introducing the infectious agent into the bloodstream.  In non-bacterial thrombotic endocarditis (NBTE), the damaged part of a heart valve becomes covered with a blood clot which organizes.
The [[pathogenesis]] of [[infective endocarditis]] includes valvular damage, altered and turbulent flow, [[bacteremia]], and lack of blood supply to the [[valve]]s. Damaged [[endothelium]] becomes a site for attachment of infectious agents in infectious [[endocarditis]].  [[Nonbacterial thrombotic endocarditis]] is related to [[Hypercoagulable state|hypercoagulable]] states such as [[pregnancy]] or systemic [[bacterial]] [[infection]]. The characteristic lesion of [[endocarditis]] is [[Vegetation (pathology)|vegetation]]. Vegetations are composed of [[fibrin]], [[inflammatory]] cells, [[platelets]], and [[microorganisms]].
Many types of organism can cause infective endocarditis. These are generally isolated by [[blood culture]], where the patient's blood is sampled under sterile conditions, and any growth is noted and identified. It is therefore important to draw blood cultures before initiating antibiotic therapy. 70% of cases of endocarditis are due to the following three pathogens:


#Alpha-haemolytic [[Streptococcus|streptococci]], that are present in the mouth will often be the organism isolated if a dental procedure caused the bacteraemia.
==Causes==
#If the bacteraemia was introduced through the skin, such as contamination in surgery, during catheterization, or in an IV drug user, ''[[Staphylococcus aureus]]'' is common.
The majority of cases of [[infective endocarditis]] are due to [[bacteria]]. Common causes of [[infective endocarditis]] include ''[[Streptococcus viridans]]'', ''[[Staphylococcus aureus|Staphylococci]]'', and ''[[Enterococcus]]''.
#A third important cause of endocarditis is ''[[Enterococcus|Enterococci]]''. These bacteria enter the bloodstream as a consequence of abnormalities in the gastrointestinal or urinary tracts. ''[[Enterococcus|Enterococci]]'' are increasingly recognized as causes of nosocomial or hospital-acquired endocarditis. This contrasts with alpha-haemolytic [[streptococci]] and ''[[Staphylococcus aureus]]'' which are causes of community-acquired endocarditis.


==Differentiating Endocarditis From Other Diseases==
==Differentiating Endocarditis From Other Diseases==
Endocarditis often presents as an unexplained fever and must be distinguished from other causes of a [[fever of unknown origin]] ([[FUO]]).  Causes of a fever of unknown origin which endocarditis must be differentiated from include a [[drug fever]], [[lymphoma]], [[pulmonary embolism]], and [[deep vein thrombosis]].  Disseminated granulomatoses such as [[Tuberculosis]], [[Histoplasmosis]], [[Coccidioidomycosis]], [[Blastomycosis]] and [[Sarcoidosis]] can also cause a FUO.  [[Blood cultures]] prior to the administration of antibiotics and echocardiography are critical in differentiating endocarditis from these other syndromes.
[[Endocarditis]] must be differentiated from other causes of a [[fever of unknown origin]] ([[FUO]]) such as [[pulmonary embolism]], [[deep vein thrombosis]], [[lymphoma]], [[drug fever]], [[cotton fever]], and [[Disseminated disease|disseminated]] [[granulomatosis]].


==Risk Factors==
==Risk Factors==
The following are risk factors for the development of endocarditis:
Common risk factors for [[endocarditis]] include [[prosthetic heart valves]], [[valvular heart disease]], [[congenital heart disease]], [[intravenous]] drug use, age-related [[Degenerative disease|degenerative]] [[valvular]] lesions, [[immunosuppression]], and [[colon cancer]].
*Prosthetic (artificial) heart valves
*[[Congenital heart disease]] ([[atrial septal defect]], [[patent ductus arteriosus]], and others)
*Heart valve problems (such as [[mitral insufficiency]])
*History of [[rheumatic heart disease]]
*[[Intravenous drug users]] are also at risk for this condition, because unsterile needles can cause bacteria to enter the bloodstream.


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Incidence===
The [[incidence]] of native valve infective [[endocarditis]] is approximately 1.7-6.2 cases per 100,000 individuals per year in the United States and Europe. The [[prevalence]] of [[infective endocarditis]] among [[Intravenous drug use|IV drug]] users ranges from 10 to 15%. The [[incidence]] of [[endocarditis]] increases with age; the median age of patients is 47 to 69 years. There is an increased [[incidence]] of infective [[endocarditis]] in persons 65 years of age and older. Males are more commonly affected with [[endocarditis]] than females. The male to female ratio is approximately 1.7:1.
The incidence of infective endocarditis is approximately 2-4 cases per 100,000 persons per year worldwide. This rate has not changed in the past 5-6 decades.
 
===Age===
Infective endocarditis may occur in a person of any age. The frequency is increasing in elderly individuals, with 25-50% of cases occurring in those older than 60 years of age.
 
===Gender===
Infective endocarditis is 3 times more common in males than in females.


===Changes in Bacterial Species Causing Endocarditis===
==Natural History, Complications, and Prognosis==
There has been a decline in [[streptococcus viridans]] endocarditis and an increase in staphylococcal endocarditis.
If left untreated, patients with [[endocarditis]] may progress to develop [[congestive heart failure]]. [[Endocarditis complications|Complications of endocarditis]] can occur as a result of the locally destructive effects of the infection. These [[complications]] include [[perforation]] of valve leaflets causing [[congestive heart failure]], [[abscesses]], and disruption of the heart's [[Conduction System|conduction]] system.  [[Endocarditis]] may also cause [[embolization]] to the brain (causing a [[stroke]]), to the [[coronary artery]] (causing a [[heart attack]]), to the [[lung]] (causing [[pulmonary embolism]]), to the [[spleen]] (causing a splenic infarct), and to the [[kidney]] (causing a [[renal infarct]]). [[Prognosis]] of [[endocarditis]] is generally poor and the overall mortality rate for both native and [[prosthetic valve]] [[endocarditis]] ranges from 20-25%. The mortality rate for right-sided [[endocarditis]] in injection drug users is approximately 10%. The 5 year survival rate for [[endocarditis|native valve endocarditis]] is 70-80% and 50-80%  for [[endocarditis|prosthetic valve endocarditis]].
 
==Complications==
[[Endocarditis complications|Complications of endocarditis]] can occur as a result of the locally destructive effects of the infection. These complications include perforation of valve leaflets causing [[congestive heart failure]], [[abscesses]], disruption of the heart's conduction system, and embolization to the brain (causing a [[stroke]]), to the coronary artery (causing a [[heart attack]]), to the lung (causing [[pulmonary embolism]]), to the spleen (causing a [[splenic infarct]]) and to the kidney (causing a [[renal infarct]]).
 
==Prognosis==
[[Infective endocarditis]] is associated with a high (10% to 25%) mortality.  Operative mortality is 15 - 20%. The development of an infection of a prosthetic valve during operation for [[endocarditis|native valve endocarditis]] is 4%, it is higher (12 - 16%) if active [[endocarditis]] is present at the time of the surgery. Late survival at 5 years for [[endocarditis|native valve endocarditis]] is 70 - 80% and for [[endocarditis|prosthetic valve endocarditis]] is 50 - 80%.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>


==Diagnosis==
==Diagnosis==
===The Duke Criteria===
===Diagnostic Criteria===
The [http://www.medcalc.com/endocarditis.html Duke Criteria]<ref name=Durack>{{cite journal | author = Durack D, Lukes A, Bright D | title = New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. | journal = Am J Med | volume = 96 | issue = 3 | pages = 200-9 | year = 1994 | id = PMID 8154507}}</ref> can be used to establish the diagnosis of [[endocarditis]]. The Duke Clinical Criteria for Infective Endocarditis requires either:
The [[Duke criteria]] can be used to establish the diagnosis of [[endocarditis]]. The Duke clinical criteria for [[infective endocarditis]] require either: Two major criteria, or one major and three minor criteria, or five minor criteria.
 
* Two major criteria, or
 
* One major and three minor criteria, or
 
* Five minor criteria
 
===Major Criteria===
 
====1. Positive Blood Culture for Infective Endocarditis====
Typical microorganism consistent with infective endocarditis from 2 separate blood cultures, as noted below:
 
::{{unicode|☑}} [[Viridans streptococci]], [[Streptococcus bovis]], or
 
::{{unicode|☑}} [[HACEK]] group, or
 
::{{unicode|☑}} Community-acquired [[Staphylococcus aureus]] or [[enterococci]], in the absence of a primary focus
 
<center>'''''or'''''</center>
 
Microorganisms consistent with infective endocarditis from persistently positive blood cultures defined as:
::{{unicode|☑}} 2 positive cultures of blood samples drawn >12 hours apart, or
 
::{{unicode|☑}} All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
 
====2. Evidence of endocardial involvement====
Positive echocardiogram for infective endocarditis defined as:
 
::{{unicode|☑}} Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or
 
::{{unicode|☑}} On implanted material in the absence of an alternative anatomic explanation, or
 
::{{unicode|☑}} Abscess, or
 
::{{unicode|☑}} New partial dehiscence of prosthetic valve
 
<center>'''''or'''''</center>
 
::{{unicode|☑}} New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)
 
===Minor criteria:===
 
::{{unicode|☑}} Predisposition: predisposing heart condition or [[intravenous drug use]]
 
::{{unicode|☑}} [[Fever]]: temperature > 38.0° C (100.4° F)
 
::{{unicode|☑}} Vascular phenomena: major [[arterial emboli]], [[septic pulmonary infarct]]s, [[mycotic aneurysm]], [[intracranial hemorrhage]], [[conjunctival hemorrhage]]s, and [[Janeway lesions]]
 
::{{unicode|☑}} Immunologic phenomena: [[glomerulonephritis]], [[Osler's nodes]], [[Roth spot]]s, and [[rheumatoid factor]]
 
::{{unicode|☑}} Microbiological evidence: positive [[blood culture]] but does not meet a major criterion as noted above (see footnote) or serological evidence of active infection with organism consistent with infectious endocarditis


::{{unicode|☑}} Echocardiographic findings: consistent with infectious endocarditis but do not meet a major criterion as noted above
===History and Symptoms===
Common symptoms of [[endocarditis]] include [[fever]], [[chills]], new onset of [[murmur]], [[anorexia]], [[malaise]], [[weight loss]], and [[back pain]].


Footnote: It should be noted that the criteria exclude single positive cultures for [[coagulase-negative staphylococci]], [[diphtheroids]], and organisms that do not commonly cause endocarditis.
===Symptoms===
Common symptoms of endocarditis include [[fever]], [[chills]], [[anorexia]], [[malaise]],[[weight loss]], and [[back pain]].
===Physical Examination===
===Physical Examination===
Common signs on physical examination of endocarditis include [[fever]], [[rigors]], [[Osler's nodes]], [[Janeway lesions]] and evidence of embolization. [[Aortic insufficiency]] with a [[wide pulse pressure]], [[mitral regurgitation]] or [[tricuspid regurgitation]] may be present depending upon the valve that is infected.
Common signs on physical examination of [[endocarditis]] include [[fever]], [[rigors]], [[osler's nodes]], [[janeway lesions]] and evidence of [[embolization]]. [[Aortic insufficiency]] with a [[wide pulse pressure]], [[mitral regurgitation]] or [[tricuspid regurgitation]] may be present depending upon the valve that is infected.


Shown below is a Janeway Lesion which is a flat, painless, erythematous lesions seen on the palm of this patient's hand:
===Laboratory Tests===
[[Image:Janeway lesion due to endocarditis.jpg|center|300px]]
Two [[blood culture]]s should be ordered when [[infective endocarditis]] is suspected. Laboratory findings consistent with the diagnosis of endocarditis include elevated [[white blood cell count]], [[erythrocyte sedimentation rate]], [[rheumatoid factor]], and elevated [[BUN]] and [[creatinine]] if [[glomerulonephritis]] is present.
----


Shown below is an Osler's Node:
===Chest x-ray===
[[Image:Oslers node.jpg|center|100px]]
On chest [[X-rays|x-ray]], right sided [[endocarditis]] is characterized by [[pleural effusion]]s, multiple round densities, and cavitary multilobar infiltrates.
 
===Laboratory Studies===
In endocarditis, the [[white blood cell count]] and [[erythrocyte sedimentation rate]] are elevated.  The [[rheumatoid factor]] is elevated in half of patients.  The [[BUN]] and [[Cr]] may be elevated in the presence of [[glomerulonephritis]].  


===Electrocardiography===
===Electrocardiography===
The EKG can show conduction abnormalities such as [[AV block]] in the presence of a [[myocardial abscess]]. The EKG can show [[ST elevation]] in the presence of embolization of a vegetation or clot down the coronary artery.
On [[EKG]], endocarditis may be characterized by conduction abnormalities, low [[QRS]] voltage, [[ST elevation]], [[heart block]], [[ventricular tachycardia]], and [[supraventricular tachycardia]]. The [[EKG]] may show [[ST elevation]] in the presence of [[embolization]] of a [[Vegetation (pathology)|vegetation]] or clot down the [[Coronary artery|coronary artery.]]


===Echocardiography===
===Cardiac MRI===
The goals of echocardiography in the patient with endocarditis include the following:
Findings on cardiac [[Magnetic resonance imaging|MRI]] suggestive of infective [[endocarditis]] include valvular vegetations, valvular and perivalvular damage, and vascular [[Endothelium|endothelial]] involvement.
# Determine the presence, location and size of vegetations
# Assess the damage to the valve apparatus and determine the magnitude of regurgitation, perforation or leak
# To assess the dimensions and function of the ventricle(s)
# To identify  any abscess formation
# To determine the need for surgical intervention
#Echocardiography may be useful for risk stratification. Although the data are inconsistent, some evidence suggests that vegetation size is associated with embolic complications.


==== Echocardiographic Features in Infective Endocarditis====
===CT Scan===
* Irregular [[echogenic mass]] attached to valve leaflet
[[Computed tomography|CT scans]] may be helpful in the diagnosis of [[endocarditis]]. CT scan findings suggestive of [[endocarditis]] include vegetations, paravalvular [[abscesses]], and [[pseudoaneurysm]]s.
* The attachment of the vegetation is on the upstream side of the valve leaflet
* There is chaotic independent movement of the mass relative to the valve
* The minimum size of a vegetation that is identifiable on trans thoracic echocardiography is 3 mm and by transoesophageal echocardiography route is 2 mm.
* With treatment and time, the vegetation shrinks and can become fibrosed or calcified. It may not disappear completely.
* Large vegetations occur with fungal endocarditis or [[staph. aureus]] endocarditis.
* The hemodynamic effects are mostly due to valvular regurgitation as a result of valve destruction.


The valve and the surrounding anatomy should be carefully inspected for the following complications:
===Echocardiography===
* Fistula
[[Echocardiography]] may be diagnostic of [[endocarditis]]. [[Echocardiography]] allows detection of microbial [[Vegetation (pathology)|vegetations]] and the degree of valvular dysfunction. Findings on [[Transthoracic echocardiography|transthoracic]] and [[Transesophageal echo cardiography|transesophageal]] echocardiogram diagnostic of [[endocarditis]] include vegetations, valvular [[regurgitation]], [[pseudoaneurysm]]s, paravalvular [[abscess]], and [[fistula]]s.
* Perforation
* Prosthetic dehiscence
* Aneurysm
* Vegetations
* Valve ulcers or erosions
* Rupture of chordaes
* Endocardial jet lesions
* Flail leaflets or cusps
* Abcess formation (annular and ring)
 
====Performance of Transesophageal Echocardiography (TEE) Versus Transthoracic Ehcocardiography (TTE)====
In general, transthoracic echocardiography (TTE) is often adequate for the diagnosis of infective endocarditis in cases where cardiac structures-of-interest are well visualized. The transthoracic echocardiogram has a sensitivity and specificity of approximately 65% and 95% if the echocardiographer believes there is 'probabable' or 'almost certain' evidence of endocarditis<ref name=Shively>{{cite journal | author = Shively B, Gurule F, Roldan C, Leggett J, Schiller N | title = Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. | journal = J Am Coll Cardiol | volume = 18 | issue = 2 | pages = 391-7 | year = 1991 | id = PMID 1856406}}</ref><ref name=Erbel>{{cite journal | author = Erbel R, Rohmann S, Drexler M, Mohr-Kahaly S, Gerharz C, Iversen S, Oelert H, Meyer J | title = Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study. | journal = Eur Heart J | volume = 9 | issue = 1 | pages = 43-53 | year = 1988 | id = PMID 3345769}}</ref>.
 
Specific situations where transesophageal echocardiography (TEE) is preferred over TTE include:
* The presence of a prosthetic valve
* Poor trans thoracic views
* Continuing sepsis despite adequate antibiotic therapy
* New [[PR prolongation]]
* No signs of endocarditis on trans thoracic echocardiography, but high clinical suspicion
* Suspected periannular complications
* Children with complex congenital cardiac lesions
* Patients with S. Aureus caused bacteremia and pre-existing valvular abnormalities that make TTE interpretation more difficult (e.g. calcific aortic stenosis).


==Treatment==
==Treatment==
High dose [[antibiotic]]s are administered by the intravenous route to maximize diffusion of antibiotic molecules into vegetation(s) from the blood filling the chambers of the heart. This is necessary because neither the heart valves nor the vegetations adherent to them are supplied by blood vessels.  [[Blood cultures]] should be drawn prior to instituting antibiotics to identify the etiologic agent and to determine its antimicrobial susceptibility.  Antibiotic therapy for subacute or indolent disease can be delayed until results of blood cultures are known; in fulminant infection or valvular dysfunction requiring urgent surgical intervention, begin empirical antibiotic therapy promptly after blood cultures have been obtained.Older antibiotics such as [[penicillin G]], [[ampicillin]], [[nafcillin]], [[cefazolin]], [[gentamycin]], [[ceftriaxone]], [[rifampin]] and [[vancomycin]] are the mainstays of therapy.  [[Fungal]] [[endocarditis]] requires specific anti-fungal treatment, such as [[amphotericin B]].<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
===Medical Therapy===
 
[[Antimicrobial]] therapy is the mainstay of therapy for [[endocarditis]]. [[Empiric therapy|Empiric]] antimicrobial therapy depends on the nature of the [[valve]] (native vs. [[Prosthesis|prosthetic]]) and the onset of [[endocarditis]] following valve implantation (less than 1 year vs. more than 1 year).  In patients with [[endocarditis]], [[Antithrombotic therapy|antithrombotic]] therapy may be administered when needed.  The [[prothrombin time]] must be carefully monitored as [[anticoagulant]]s may cause or worsen [[hemorrhage]] in patients with endocarditis. [[Heparin]] administration should be avoided if possible.
===Duration of Antibiotic Therapy===
The duration for native valve endocarditis is often 4 weeks. For prosthetic valve [[endocarditis]] (including the presence of a valve ring), treatment should be continued for 6 to 8 weeks. For each infective agent, the preferred antimicrobial agent, dose, and duration is listed below.
 
===Treatment Based Upon Infectious Agent<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>===


===Penicillin-Susceptible Strep Viridans and Other Nonenterococcal Streptococci===
==2023 ESC Guidelines for the management of endocarditis ESC Clinical Practice Guidelines (DO NOT EDIT)==
====[[Penicillin]] G====
===New recommendations (DO NOT EDIT)<ref name="pmid37622656">{{cite journal| author=Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H | display-authors=etal| title=2023 ESC Guidelines for the management of endocarditis. | journal=Eur Heart J | year= 2023 | volume= 44 | issue= 39 | pages= 3948-4042 | pmid=37622656 | doi=10.1093/eurheartj/ehad193 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=37622656  }} </ref>===
*If Minimum inhibitory concentration [MIC] <0.2 µg/ml.
===Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk of infective endocarditis (DO NOT EDIT)===
*'''Dose''': 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks.


====[[Penicillin]] G + [[gentamicin]]====
{|class="wikitable"
*'''Dose''': [[Penicillin]] G, 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks plus [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (General prevention measures are recommended in individuals at high and intermediate risk of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"<ref name="pmid31504413">{{cite journal| author=Habib G, Erba PA, Iung B, Donal E, Cosyns B, Laroche C | display-authors=etal| title=Clinical presentation, aetiology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study. | journal=Eur Heart J | year= 2019 | volume= 40 | issue= 39 | pages= 3222-3232 | pmid=31504413 | doi=10.1093/eurheartj/ehz620 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31504413  }} </ref>
|-
| bgcolor="LightGreen"|”'''2.''' (Antibiotic prophylaxis is recommended in patients with ventricular assist devices) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"<ref name="pmid35756779">{{cite journal| author=Maeda K, Hirai Y, Nashi M, Yamamoto S, Taniike N, Takenobu T| title=Clinical features and antimicrobial susceptibility of oral bacteria isolated from the blood cultures of patients with infective endocarditis. | journal=J Dent Sci | year= 2022 | volume= 17 | issue= 2 | pages= 870-875 | pmid=35756779 | doi=10.1016/j.jds.2021.09.023 | pmc=9201522 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35756779  }} </ref>
|-


====[[Ceftriaxone]]====
{|class="wikitable"
*'''Dose''': 2 g I.V. daily as a single dose for 2 weeks.
|-
| colspan="1" style="text-align:center; background:OrangeChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="OrangeChiffon"|"'''1.''' (Antibiotic prophylaxis may be considered in recipients of heart transplant) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
=== Recommendations for infective endocarditis prevention in high-risk patients (DO NOT EDIT)===


====[[Vancomycin]]====
{|class="wikitable"
*[[Vancomycin]] can be administered to patients with a history of [[penicillin]] [[hypersensitivity]].
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Systemic antibiotic prophylaxis may be considered for
high-risk patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for infective endocarditis prevention in cardiac procedures (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for the role of echocardiography in infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (TOE is recommended when the patient is stable before switching from intravenous to oral antibiotic therapy) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}


*'''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks.
=== Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis (DO NOT EDIT)===


===Relatively Penicillin-Resistant Streptococci===
{|class="wikitable"
====If MIC 0.2–0.5 µg/ml====
|-
=====[[Penicillin]] G + [[gentamicin]]=====
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
*'''Dose''': [[Penicillin]] G, 20–30 million units I.V. daily in divided doses q. 4 hour for 4 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr for 2 wk (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
|-
| bgcolor="LightGreen"|"'''1.'''  (Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  ([18F]FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:OrangeChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="OrangeChiffon"|"'''1.'''  ([18F]FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Brain and whole-body imaging (CT, [18F]FDG-PET/CT, and/or MRI) are recommended in symptomatic patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.''' (Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
=== Recommendations for outpatient antibiotic treatment of infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Outpatient parenteral antibiotic treatment should be considered in patients with left-sided IE caused by Streptococcus spp., E. faecalis, S. aureus, or CoNS who were receiving appropriate i.v. antibiotic treatment for at least 10 days (or at least 7 days after cardiac surgery), are clinically stable, and who do not show signs of abscess formation or valve abnormalities requiring surgery on TOE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  A]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Outpatient parenteral antibiotic treatment is not recommended in patients with IE caused by highly difficult-to-treat microorganisms, liver cirrhosis (Child–Pugh B or C), severe cerebral nervous system emboli, untreated large extracardiac abscesses, heart valve complications, or other severe conditions requiring surgery, severe post-surgical complications, and in PWID-related IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}


====If MIC > 0.5 µg/ml====
=== Recommendations for the treatment of neurological complications of infective endocarditis (DO NOT EDIT)===
=====[[Penicillin]] G + [[gentamicin]]=====
{|class="wikitable"
*'''Dose''' is [[penicillin]] G, 20–30 million units I.V. daily in divided doses q. 4 hour for 4 week; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 4 week (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
|-
=====[[Vancomycin]]=====
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
*Regimen for patients with history of [[penicillin]] [[hypersensitivity]].
|-
*'''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks.
| bgcolor="LemonChiffon"|"'''1.'''  (In embolic stroke, mechanical thrombectomy may be considered if the expertise is available in a timely manner) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Thrombolytic therapy is not recommended in embolic stroke due to IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for pacemaker implantation in patients with complete atrioventricular block and infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.''' (Immediate epicardial pacemaker implantation should be considered in patients undergoing surgery for valvular IE and complete AVB if one of the following predictors of persistent AVB is present: pre-operative conduction abnormality, S. aureus infection, aortic root abscess, tricuspid valve involvement, or previous valvular surgery) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for patients with musculoskeletal manifestations of infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (MRI or PET/CT is recommended in patients with suspected spondylodiscitis and vertebral osteomyelitis complicating IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (TTE/TOE is recommended to rule out IE in patients with spondylodiscitis and/or septic arthritis with positive blood cultures for typical IE microorganisms) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (More than 6-week antibiotic therapy should be considered in patients with osteoarticular IE-related lesions caused by difficult-to-treat microorganisms, such as S. aureus or Candida spp., and/or complicated with severe vertebral destruction or abscesses) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for pre-operative coronary anatomy assessment in patients requiring surgery for infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (In haemodynamically stable patients with aortic valve vegetations who require cardiac surgery and are high risk of CAD, a high-resolution multislice coronary CTA is recommended) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Invasive coronary angiography is recommended in patients requiring heart surgery who are high risk of CAD, in the absence of aortic valve vegetations.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.''' (In emergency situations, valvular surgery without pre-operative coronary anatomy assessment regardless of CAD risk should be considered.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Invasive coronary angiography may be considered despite the presence of aortic valve vegetations in selected patients with known CAD or at high risk of significant obstructive CAD.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Indications and timing of cardiac surgery after neurological complications in active infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (In patients with intracranial haemorrhage and unstable clinical status due to HF, uncontrolled infection, or persistent high embolic risk, urgent or emergency surgery should be considered weighing the likelihood of a meaningful neurological outcome.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}


===Enterococci===
=== Recommendations for post-discharge follow-up (DO NOT EDIT)===
In general, treatment of [[enterococcal]] endocarditis requires combination therapy with two antibiotics:
{|class="wikitable"
=====[[Penicillin]] G + [[gentamicin]]=====
|-
*'''Dose''' is [[penicillin]]  G, 20–30 million units I.V. daily in divided doses q. 4 hr for 4–6 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 4–6 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Patient education on the risk of recurrence and preventive measures, with emphasis on dental health, and based on the individual risk profile, is recommended during follow-up.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Addiction treatment for patients following PWID-related IE is recommended) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Cardiac rehabilitation including physical exercise training should be considered in clinically stable patients based on an individual assessment.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Psychosocial support may be considered to be integrated in follow-up care, including screening for anxiety and depression, and referral to relevant psychological treatment.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
=== Recommendations for prosthetic valve endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Surgery is recommended for early PVE (within 6 months of valve surgery) with new valve replacement and complete debridement) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
=== Recommendations for cardiovascular implanted electronic device-related infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.''' (Complete system extraction without delay is recommended in patients with definite CIED-related IE under initial empirical antibiotic therapy.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.''' (Extension of antibiotic treatment of CIED-related endocarditis to (4–)6 weeks following device extraction should be considered in the presence of septic emboli or prosthetic valves.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Use of an antibiotic envelope may be considered in select high-risk patients undergoing CIED reimplantation to reduce risk of infection) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|-
| bgcolor="LemonChiffon"|"'''1.'''  (In non-S. aureus CIED-related endocarditis without valve involvement or lead vegetations, and if follow-up blood cultures are negative without septic emboli, 2 weeks of antibiotic treatment may be considered following device extraction.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Removal of CIED after a single positive blood culture, with no other clinical evidence of infection, is not recommended) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for the surgical treatment of right-sided infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Tricuspid valve repair should be considered instead of valve replacement, when possible.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Surgery should be considered in patients with right-sided IE who are receiving appropriate antibiotic therapy and present persistent bacteraemia/sepsis after at least 1 week of appropriate antibiotic therapy.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|-
| bgcolor="LemonChiffon"|”'''3.'''  (Prophylactic placement of an epicardial pacing lead should be considered at the time of tricuspid valve surgical procedures) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Debulking of right intra-atrial septic masses by aspiration may be considered in select patients who are high risk of surgery.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}


=====[[Ampicillin]] + [[gentamicin]]=====
===2023  Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis (DO NOT EDIT)===
*'''Dose''' is [[ampicillin]], 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; [[gentamicin]], dose as above.


=====[[Vancomycin]] + [[gentamicin]]=====
{|class="wikitable"
*This regimen is for patients with history of [[penicillin]] [[hypersensitivity]].
|-
*'''Dose''': [[Vancomycin]], 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks; [[gentamicin]], dose as above.
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (General prevention measures are recommended in individuals at high and intermediate risk for IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Antibiotic prophylaxis is recommended in patients with previous IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Antibiotic prophylaxis is recommended in patients with surgically implanted prosthetic valves and with any material used for surgical cardiac valve repair.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Antibiotic prophylaxis is recommended in patients with transcatheter implanted aortic and pulmonary valvular prostheses.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|-
| bgcolor="LightGreen"|”'''2.'''  (Antibiotic prophylaxis is recommended in patients with untreated cyanotic CHD, and patients treated with surgery or transcatheter procedures with post-operative palliative shunts, conduits, or other prostheses. After surgical repair, in the absence of residual defects or valve prostheses, antibiotic prophylaxis is recommended only for the first 6 months after the procedure.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|-
| bgcolor="LightGreen"|”'''2.'''  (Antibiotic prophylaxis is recommended in patients with ventricular assist devices.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class Ila]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Antibiotic prophylaxis should be considered in patients with transcatheter mitral and tricuspid valve repair.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class Ilb]]
|-
| bgcolor="LemonChiffon"|"'''1.''' (Antibiotic prophylaxis may be considered in recipients of heart transplant.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Antibiotic prophylaxis is not recommended in other patients at low risk for IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|}
===2023 ESC Guidelines Recommendations for Prophylactic antibiotic regime for high-risk dental procedures===
[[Image:IMG 0918.jpeg|400px|left thumb|]]


===Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material===
===2023 ESC Guidelines Recommendations for Diagnostic Procedures of rare causes of blood culture-negative infective endocarditis ===
[[Image:IMG 1037.jpeg|400px|left thumb|]]


====[[Nafcillin]] or [[oxacillin]] + [[gentamicin]] (optional)====
=== Recommendations for infective endocarditis prevention in high-risk patients (DO NOT EDIT)===
*'''Dose''': [[Nafcillin]] or [[oxacillin]], 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr for 3–5 days (peak serum concentration should be ~ 3 µg/ml and trough concentrations <1 µg/ml).
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| bgcolor="LightGreen"|"'''1.'''  (Antibiotic prophylaxis is recommended in dental extractions, oral surgery procedures, and procedures requiring manipulation of the gingival or periapical region of the teeth.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Systemic antibiotic prophylaxis may be considered for high-riskc patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for infective endocarditis prevention in cardiac procedures (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.''' (Pre-operative screening for nasal carriage of S. aureus is recommended before elective cardiac surgery or transcatheter valve implantation to treat carriers.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: A]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Peri-operative antibiotic prophylaxis is recommended before placement of a CIED.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  A]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Periprocedural antibiotic prophylaxis is recommended in patients undergoing surgical or transcatheter implantation of a prosthetic valve, intravascular prosthetic, or other foreign material.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Elimination of potential sources of sepsis (including of dental origin) should be considered ≥2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, except in urgent procedures.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Systematic skin or nasal decolonization without screening for S. aureus is not recommended.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for the Endocarditis Team Recommendations (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Diagnosis and management of patients with complicated IE are recommended to be performed at an early stage in a Heart Valve Centre, with immediate surgical facilities and an Endocarditis Team’ to improve the outcomes.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (For patients with uncomplicated IE managed in a Referring Centre, early and regular communication between the local and the Heart Valve Centre endocarditis teams is recommended to improve the outcomes of the patients.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
===Recommendations for the role of echocardiography in infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (TTE is recommended as the first-line imaging modality in suspected IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (TOE is recommended in all patients with clinical suspicion of IE and a negative or non-diagnostic TTE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (TOE is recommended in patients with clinical suspicion of IE, when a prosthetic heart valve or an intracardiac device is present.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Repeating TTE and/or TOE within 5–7 days is recommended in cases of initially negative or inconclusive examination when clinical suspicion of IE remains high.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (TOE is recommended in patients with suspected IE, even in cases with positive TTE, except in isolated right-sided native valve IE with good quality TTE examination and unequivocal echocardiographic findings.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Performing an echocardiography should be considered in S. aureus, E. faecalis, and some Streptococcus spp. bacteraemia.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Repeating TTE and/or TOE is recommended as soon as a new complication of IE is suspected (new murmur, embolism, persisting fever and bacteraemia, HF, abscess, AVB) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (TOE is recommended when patient is stable before switching from intravenous to oral antibiotic therapy.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|”'''2.'''  (During follow-up of uncomplicated IE, repeat TTE and/ or TOE should be considered to detect new silent complications. The timing of repeat TTE and/or TOE depends on the initial findings, type of microorganism, and initial response to therapy.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Intra-operative echocardiography is recommended in all cases of IE requiring surgery) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (TTE and/or TOE are recommended at completion of antibiotic therapy for evaluation of cardiac and valve morphology and function in patients with IE who did not undergo heart valve surgery.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}


====[[Cefazolin]] + [[gentamicin]] (optional)====
===Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis (DO NOT EDIT)===
*Alternative regimen for patients with history of [[penicillin]] [[hypersensitivity]].
{|class="wikitable"
*'''Dose''': [[Cefazolin]], 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; [[gentamicin]], dose as above.
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  ( 18F FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Brain and whole-body imaging (CT, 18F FDG-PET/ CT, and/or MRI) are recommended in symptomaticc patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.''' (18F FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
==Definitions of the 2023 European Society of Cardiology modified diagnostic criteria of infective endocarditis (DO NOT EDIT)==
[[Image:IMG 1176.jpeg|400px]]
[[Image:IMG 1177.jpeg|400px]]


====[[Vancomycin]]====
== Recommendations for antibiotic treatment of infective endocarditis due to oral streptococci and Streptococcus gallolyticus group (DO NOT EDIT)==
*Alternative regimen for patients with history of [[penicillin]] [[hypersensitivity]].
*'''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hr for 4–6 weeks.


===Staphylococci (Methicillin Resistant) in the Absence of Prosthetic Material===
===Penicillin-susceptible oral streptococci and Streptococcus gallolyticus group (DO NOT EDIT)===
====[[Vancomycin]]====
*'''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks.


===Staphylococci (Methicillin Susceptible) in the Presence of Prosthetic Material===
===Standard treatment: 4-week duration in NVE or 6-week duration in PVE (DO NOT EDIT)===
====[[Nafcillin]] or [[oxacillin]] + [[rifampin]] + [[gentamicin]]====
*'''Dose''': [[Nafcillin]] or [[oxacillin]], 12 g I.V. daily in divided doses q. 4 hour for 6–8 weeks plus rifampin, 300 mg p.o., q. 8 hour for 6–8 weeks plus [[gentamicin]] (administer during the initial 2 weeks), 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks.


===Staphylococci (Methicillin Resistant) in the Presence of Prosthetic Material===
{|class="wikitable"
====[[Vancomycin]] + [[rifampin]] + [[gentamicin]]====
|-
*'''Dose''': [[Vancomycin]], 30 mg/kg I.V. daily in divided doses q. 12 hour for 6–8 weeks plus[[rifampin]], 300 mg p.o., q. 8 hour for 6–8 weeks plus [[gentamicin]] (administer during the initial 2 weeks), 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks.
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
 
|-
===[[HACEK organism|HACEK Organisms]]===
| bgcolor="LightGreen"|"'''1.'''  (In patients with IE due to oral streptococci and S. gallolyticus group, penicillin G, amoxicillin, or ceftriaxone are recommended for 4 (in NVE) or 6 weeks (in PVE), using the following doses: *Adult antibiotic dosage and route
These agents are more indolent and the infection is less complicated.
Penicillin G 12–18 millionc U/day i.v. either in 4–6 doses or continuously
====[[Ceftriaxone]] or another [[cephalosporin|third-generation cephalosporin]]====
Amoxicillin 100–200 mg/kg/day i.v. in 4–6 doses
*'''Dose''': 2 g I.V. daily as a single dose for 4 weeks.
Ceftriaxone 2 g/day i.v. in 1 dose
====[[Ampicillin]]-[[Sulbactam]]====
*Paediatric antibiotic dosage and route
====[[Ciprofloxacin]]====
Penicillin G 200 000 U/kg/day i.v. in 4–6 divided doses
*This is listed as an alternative, there is not a lot of data to support its regular use.
Amoxicillin 100–200c mg/kg/day i.v. in 4–6 doses
Ceftriaxone 100 mg/kg/day i.v. in 1 dose) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
===Standard treatment: 2-week duration (not applicable to PVE) (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.''' (2-week treatment with penicillin G, amoxicillin, ceftriaxone combined with gentamicin is recommended only for the treatment of non-complicated NVE due to oral streptococci and S. gallolyticus in patients with normal renal function using the following doses: *Adult antibiotic dosage and route
Penicillin G 12–18 millionc U/day i.v. either in 4–6 doses or continuously, Amoxicillin 100–200 mg/kg/day i.v. in 4–6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose.
*Pediatric antibiotic dosage and route
Penicillin G 200 000 U/kg/day i.v. in 4–6 divided doses, Amoxicillin 100–200 mg/kg/dayc i.v. in 4–6 doses , Ceftriaxone 100 mg/kg i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose or 3 equally divided doses) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
===Allergy to beta-lactams (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (In patients allergic to beta-lactams and with IE due to oral streptococci and S. gallolyticus, vancomycin for 4 weeks in NVE or for 6 weeks in PVE is recommended using the following doses: *Adult antibiotic dosage and route
Vancomycine 30 mg/kg/day i.v. in 2 doses.
*Pediatric antibiotic dosage and route
Vancomycine 30 mg/kg/day i.v. in 2 or 3 equally divided doses) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Oral streptococci and Streptococcus gallolyticus group susceptible, increased exposure or resistant to penicillin (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.''' (In patients with NVE due to oral streptococci and S. gallolyticus, penicillin G, amoxicillin, or ceftriaxone for 4 weeks in combination with gentamicin for 2 weeks is recommended using the following doses: *Adult antibiotic dosage and route
Penicillin G 24 million U/day i.v. either in 4–6 doses or continuously, Amoxicillin 12 g/day i.v. in 6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicin 3 mg/kg/day i.v. or i.m. in 1 dose) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (In patients with PVE due to oral streptococci and S. gallolyticus, penicillin G, amoxicillin, or ceftriaxone for 6 weeks combined with gentamicin for 2 weeks is recommended using the following doses:
*Adult antibiotic dosage and route
Penicillin G 24 million U/day i.v. either in 4–6 doses or continuously, Amoxicillin 12 g/day i.v. in 6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
==Sources==
* 2023 ESC Guidelines for the management of endocarditis
Developed by the task force on the management of endocarditis of the European Society of Cardiology (ESC)
Endorsed by the European Association for Cardio-Thoracic Surgery
(EACTS) and the European Association of Nuclear Medicine (EANM)


===Surgery===
===Surgery===
====Indications====
Indications for surgical debridement of vegetations and infected perivalvular tissue, with valve replacement or repair as needed are listed below:<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
# Moderate to severe [[congestive heart failure]] due to valve dysfunction
# Unstable valve prosthesis
# Uncontrolled infection for > 1–3 week despite maximal antimicrobial therapy
# Persistent [[bacteremia]]
#[[endocarditis|Fungal endocarditis]]
# Relapse after optimal therapy in a prosthetic valve
# Vegetation in Situ
# Prosthetic valve [[endocarditis]] with perivalvular invasion
# [[Endocarditis]] caused by [[Pseudomonas aeruginosa]] or other gram-negative bacilli that has not responded after 7–10 days of maximal antimicrobial therapy
# Perivalvular extension of infection and abscess formation
# [[Staphylococcal]] infection of prosthesis
# Persistent [[fever]] (culture negative)
# Large vegetation (>10 mm is associated with an increased risk of embolism)
# Relapse after optimal therapy in a native valve
# Vegetations that obstruct the valve orifice
# Onset of [[AV block]]
===Surgical Procedure===
Surgical removal of the valve is necessary in patients who fail to clear micro-organisms from their blood in response to antibiotic therapy, or in patients who develop cardiac failure resulting from destruction of a valve by infection. A removed valve is usually replaced with an artificial valve which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic valves.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
====Principles of Surgical Treatment of Endocarditis<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>====
*Excise all infected valve tissue
*Drain and debride abscess cavities
*Repair or replace damaged valves
*Repair associated pathology such as septal defect, fistulas


====Aortic Valve - Surgical Options====
Surgical removal of the [[valve]] is necessary for patients who fail to clear [[Microorganism|micro-organisms]] from their blood in response to [[antibiotic]] therapy, or in patients who develop [[cardiac failure]] resulting from destruction of a [[valve]] by [[infection]]. A removed valve is usually replaced with an artificial [[valve]] which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed [[Bioprosthetic valves|bioprosthetic]] valves. Surgical treatment of [[endocarditis]] involves excision of all infected [[valve]] tissue, drainage and debridement of [[abscess]] cavities, repair or replacement of damaged valves, and repair of any associated pathology such as [[fistula]]s or [[Septal defect|septal defects]].
If the infection limited is limited to the leaflets, then the aortic valve should be replaced. If the infection extends to the anulus or beyond, then the infected tissues should be debrided.  Any abscesses should be drained and the aortic root should be replaced.


====Atrioventricular Valve - Surgical Options====
==Prevention==
If the infection is limited to the leaflets, then the vegetations should be excised, perforations should be repaired, and a reduction annuloplasty should be performed.  If the infection extends to the anulus or beyond, then a valve replacement should be performed, and abscesses should be debrided and obliterated. In some cases the tricuspid valve may be excised.
Prevention of [[infective endocarditis]] can be achieved through the administration of [[antibiotic]] [[prophylaxis]] to high risk subjects who are undergoing high risk procedures. The choice of [[antibiotic]] [[prophylaxis]] depends on whether the subject can tolerate oral intake or not, as well as on whether patient has allergy to [[penicillin]] or not.
 
====Surgical Outcomes====
Operative mortality is 15 - 20%. The development of an infection of a prosthetic valve during operation for [[endocarditis|native valve endocarditis]] is 4%, it is higher (12 - 16%) if active [[endocarditis]] is present at the time of the surgery. Late survival at 5 years for [[endocarditis|native valve endocarditis]] is 70 - 80% and for [[endocarditis|prosthetic valve endocarditis]] is 50 - 80%.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
 
==Current AHA Recommendations Regarding Antibiotic Prophylaxis==
'''The AHA now recommends the administration of pre-endodontic procedural prophylactic antibiotics to patients with the highest risk of adverse outcomes subsequent to the development of endocarditis'''<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>:
:* '''Patients with a prosthetic cardiac valve'''
:* '''Patients with a prior history of [[infective endocarditis]]'''
:* '''[[Cardiac transplantation]] recipients who develop cardiac valvulopathy'''
:* '''Patients with [[congenital heart disease]]:'''
::*'''Patients with unrepaired cyanotic congenital heart disease in which shunts and conduits are present'''
::*'''Patients who have undergone complete repair of a congenital heart defect with prosthetic material or a device either by surgery or catheter repair within the past 6 months'''
::*'''Patient with repaired congenital heart disease with residual defects at the site of a prosthetic patch or device (which inhibits endothelialization)'''
 
The following endodontal procedures that involve manipulation of the gingival tissue or the periapical region of teeth or perforation of the oral mucosa require coverage in this high risk population:
:*'''Any type of dental extractions'''
:*'''Any type of periodontal procedures and gingival surgery'''
:**'''Placement of dental implants and avulsed teeth replantation'''
:**'''Dental canal or root surgery'''
:**'''Antibiotic fibres or strips placement at subgingival area'''
:**'''Initial placement of orthodontic brackets'''
:**'''Intraligamentous injection of local anesthetic drugs''' 
:**'''Bleeding during prophylactic cleaning of teeth or implants'''
 
Other scenarios that are not dental procedures and for which prophylaxis is not recommended include shedding of [[deciduous teeth]] and trauma to the lips and oral mucosa. Routine anesthetic injections through non-infected tissue, the taking of dental radiographs, placement of removable prosthodontic or orthodontic appliances, placement of orthodontic brackets, or adjustment of orthodontic appliances do not require prophylaxis.
 
In this high risk population, prophylactic antimicrobial therapy should be directed against [[Streptococcus viridans]]. Acknowledging an estimated 10-20 fold greater risk of single-dose fatal anaphylaxis with [[amoxicillin]] compared to single dose cephalosporin, macrolide and clindamycin regimens, the AHA believes prophylaxis with [[amoxicillin]] is a safe practice as there have been no reports of fatal [[anaphylaxis]] arising from a single-dose of pre-dental [[endocarditis]] prophylaxis using oral [[amoxicillin]]which  is well absorbed in the gastrointestinal tract and provides high and sustained serum concentrations.
 
For those patients who have an allergy to [[penicillin]]s or [[amoxicillin]], then the use of [[cephalexin]] or another first-generation oral [[cephalosporin]], [[clindamycin]], [[azithromycin]], or [[clarithromycin]] is recommended.  For those patients who cannot tolerate oral antibiotics, treatment with [[ampicillin]], [[ceftriaxone]], or [[cefazolin]] administered either intramuscularly or intravenously is recommended. Finally, for those patients who are [[ampicillin]] allergic and who are also unable to take an oral antibiotic, therapy with either parenteral [[cefazolin]], [[ceftriaxone]], or [[clindamycin]] is recommended.


==References==
==References==
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Infectious disease]]
 
[[Category:Intensive care medicine]]
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[[Category:Emergency medicine]]
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[[Category:Cardiology board review]]
[[Category:Up-To-Date]]
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[[Category:Cardiology board review]]
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Latest revision as of 23:17, 24 April 2024

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Endocarditis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Maliha Shakil, M.D. [2] Cafer Zorkun, M.D., Ph.D. [3] Kosar Doraghi, M.D.[4]

Overview

Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. While acute bacterial endocarditis is caused by an infection with a virulent organism such as Staphylococcus aureus, group A or other beta-hemolytic streptococci, subacute bacterial endocarditis is an indolent infection with less virulent organisms such as streptococcus viridans. Patients with unexplained fever for more than 48 hours and who are at high risk for infective endocarditis and patients among whom valve regurgitation is newly diagnosed should undergo a diagnostic workup to rule out endocarditis. The diagnosis of endocarditis depends on a thorough history and physical exam as well as on the results of the blood cultures and the findings on transthoracic echocardiogram or transesophageal echocardiogram. The modified Duke criteria is used to establish the diagnosis of endocarditis. Endocarditis is initially treated with empiric antibiotic therapy until the causative agent is identified.

Historical Perspective

Endocarditis was first described in 1554. The inflammatory process associated with endocarditis was discovered in 1799. Vegetations were first discovered to be associated with endocarditis in 1806.

Classification

Endocarditis may be classified based on the underlying pathophysiology of the process (infective vs. non-infective), the onset of the disease (acute vs. subacute or short incubation vs. long incubation), results of the cultures (culture-positive vs. culture-negative), the nature of the valve (native vs. prosthetic) and the valve affected (aortic, mitral, or tricuspid valve).

Pathophysiology

The pathogenesis of infective endocarditis includes valvular damage, altered and turbulent flow, bacteremia, and lack of blood supply to the valves. Damaged endothelium becomes a site for attachment of infectious agents in infectious endocarditis. Nonbacterial thrombotic endocarditis is related to hypercoagulable states such as pregnancy or systemic bacterial infection. The characteristic lesion of endocarditis is vegetation. Vegetations are composed of fibrin, inflammatory cells, platelets, and microorganisms.

Causes

The majority of cases of infective endocarditis are due to bacteria. Common causes of infective endocarditis include Streptococcus viridans, Staphylococci, and Enterococcus.

Differentiating Endocarditis From Other Diseases

Endocarditis must be differentiated from other causes of a fever of unknown origin (FUO) such as pulmonary embolism, deep vein thrombosis, lymphoma, drug fever, cotton fever, and disseminated granulomatosis.

Risk Factors

Common risk factors for endocarditis include prosthetic heart valves, valvular heart disease, congenital heart disease, intravenous drug use, age-related degenerative valvular lesions, immunosuppression, and colon cancer.

Epidemiology and Demographics

The incidence of native valve infective endocarditis is approximately 1.7-6.2 cases per 100,000 individuals per year in the United States and Europe. The prevalence of infective endocarditis among IV drug users ranges from 10 to 15%. The incidence of endocarditis increases with age; the median age of patients is 47 to 69 years. There is an increased incidence of infective endocarditis in persons 65 years of age and older. Males are more commonly affected with endocarditis than females. The male to female ratio is approximately 1.7:1.

Natural History, Complications, and Prognosis

If left untreated, patients with endocarditis may progress to develop congestive heart failure. Complications of endocarditis can occur as a result of the locally destructive effects of the infection. These complications include perforation of valve leaflets causing congestive heart failure, abscesses, and disruption of the heart's conduction system. Endocarditis may also cause embolization to the brain (causing a stroke), to the coronary artery (causing a heart attack), to the lung (causing pulmonary embolism), to the spleen (causing a splenic infarct), and to the kidney (causing a renal infarct). Prognosis of endocarditis is generally poor and the overall mortality rate for both native and prosthetic valve endocarditis ranges from 20-25%. The mortality rate for right-sided endocarditis in injection drug users is approximately 10%. The 5 year survival rate for native valve endocarditis is 70-80% and 50-80% for prosthetic valve endocarditis.

Diagnosis

Diagnostic Criteria

The Duke criteria can be used to establish the diagnosis of endocarditis. The Duke clinical criteria for infective endocarditis require either: Two major criteria, or one major and three minor criteria, or five minor criteria.

History and Symptoms

Common symptoms of endocarditis include fever, chills, new onset of murmur, anorexia, malaise, weight loss, and back pain.

Physical Examination

Common signs on physical examination of endocarditis include fever, rigors, osler's nodes, janeway lesions and evidence of embolization. Aortic insufficiency with a wide pulse pressure, mitral regurgitation or tricuspid regurgitation may be present depending upon the valve that is infected.

Laboratory Tests

Two blood cultures should be ordered when infective endocarditis is suspected. Laboratory findings consistent with the diagnosis of endocarditis include elevated white blood cell count, erythrocyte sedimentation rate, rheumatoid factor, and elevated BUN and creatinine if glomerulonephritis is present.

Chest x-ray

On chest x-ray, right sided endocarditis is characterized by pleural effusions, multiple round densities, and cavitary multilobar infiltrates.

Electrocardiography

On EKG, endocarditis may be characterized by conduction abnormalities, low QRS voltage, ST elevation, heart block, ventricular tachycardia, and supraventricular tachycardia. The EKG may show ST elevation in the presence of embolization of a vegetation or clot down the coronary artery.

Cardiac MRI

Findings on cardiac MRI suggestive of infective endocarditis include valvular vegetations, valvular and perivalvular damage, and vascular endothelial involvement.

CT Scan

CT scans may be helpful in the diagnosis of endocarditis. CT scan findings suggestive of endocarditis include vegetations, paravalvular abscesses, and pseudoaneurysms.

Echocardiography

Echocardiography may be diagnostic of endocarditis. Echocardiography allows detection of microbial vegetations and the degree of valvular dysfunction. Findings on transthoracic and transesophageal echocardiogram diagnostic of endocarditis include vegetations, valvular regurgitation, pseudoaneurysms, paravalvular abscess, and fistulas.

Treatment

Medical Therapy

Antimicrobial therapy is the mainstay of therapy for endocarditis. Empiric antimicrobial therapy depends on the nature of the valve (native vs. prosthetic) and the onset of endocarditis following valve implantation (less than 1 year vs. more than 1 year). In patients with endocarditis, antithrombotic therapy may be administered when needed. The prothrombin time must be carefully monitored as anticoagulants may cause or worsen hemorrhage in patients with endocarditis. Heparin administration should be avoided if possible.

2023 ESC Guidelines for the management of endocarditis ESC Clinical Practice Guidelines (DO NOT EDIT)

New recommendations (DO NOT EDIT)[1]

Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk of infective endocarditis (DO NOT EDIT)

Class I
"1. (General prevention measures are recommended in individuals at high and intermediate risk of IE) (Level of Evidence: C)"[2]
”2. (Antibiotic prophylaxis is recommended in patients with ventricular assist devices) (Level of Evidence: C)"[3]
Class IIb
"1. (Antibiotic prophylaxis may be considered in recipients of heart transplant) (Level of Evidence: C)"

Recommendations for infective endocarditis prevention in high-risk patients (DO NOT EDIT)

Class IIb
"1. (Systemic antibiotic prophylaxis may be considered for

high-risk patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems) (Level of Evidence: C)"

Recommendations for infective endocarditis prevention in cardiac procedures (DO NOT EDIT)

Class I
"1. (Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections.) (Level of Evidence: B)"
”2. (Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment) (Level of Evidence: C)"
Class II
"1. (Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures) (Level of Evidence: C)"

Recommendations for the role of echocardiography in infective endocarditis (DO NOT EDIT)

Class I
"1. (TOE is recommended when the patient is stable before switching from intravenous to oral antibiotic therapy) (Level of Evidence: B)"

Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis (DO NOT EDIT)

Class I
"1. (Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE) (Level of Evidence: B)"
”2. ([18F]FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE.) (Level of Evidence: B)"
Class IIb
"1. ([18F]FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE.) (Level of Evidence: B)"
Class I
"1. (Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive.) (Level of Evidence: B)"
”2. (Brain and whole-body imaging (CT, [18F]FDG-PET/CT, and/or MRI) are recommended in symptomatic patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria) (Level of Evidence: B)"
Class II
"1. (WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable) (Level of Evidence: C)"
Class IIb
"1. (Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients) (Level of Evidence: B)"

Recommendations for outpatient antibiotic treatment of infective endocarditis (DO NOT EDIT)

Class II
"1. (Outpatient parenteral antibiotic treatment should be considered in patients with left-sided IE caused by Streptococcus spp., E. faecalis, S. aureus, or CoNS who were receiving appropriate i.v. antibiotic treatment for at least 10 days (or at least 7 days after cardiac surgery), are clinically stable, and who do not show signs of abscess formation or valve abnormalities requiring surgery on TOE) (Level of Evidence: A)"
Class III
"1. (Outpatient parenteral antibiotic treatment is not recommended in patients with IE caused by highly difficult-to-treat microorganisms, liver cirrhosis (Child–Pugh B or C), severe cerebral nervous system emboli, untreated large extracardiac abscesses, heart valve complications, or other severe conditions requiring surgery, severe post-surgical complications, and in PWID-related IE.) (Level of Evidence: C)"

Recommendations for the treatment of neurological complications of infective endocarditis (DO NOT EDIT)

Class IIb
"1. (In embolic stroke, mechanical thrombectomy may be considered if the expertise is available in a timely manner) (Level of Evidence: C)"
Class III
"1. (Thrombolytic therapy is not recommended in embolic stroke due to IE) (Level of Evidence: C)"

Recommendations for pacemaker implantation in patients with complete atrioventricular block and infective endocarditis (DO NOT EDIT)

Class II
"1. (Immediate epicardial pacemaker implantation should be considered in patients undergoing surgery for valvular IE and complete AVB if one of the following predictors of persistent AVB is present: pre-operative conduction abnormality, S. aureus infection, aortic root abscess, tricuspid valve involvement, or previous valvular surgery) (Level of Evidence: C)"

Recommendations for patients with musculoskeletal manifestations of infective endocarditis (DO NOT EDIT)

Class I
"1. (MRI or PET/CT is recommended in patients with suspected spondylodiscitis and vertebral osteomyelitis complicating IE) (Level of Evidence: C)"
”2. (TTE/TOE is recommended to rule out IE in patients with spondylodiscitis and/or septic arthritis with positive blood cultures for typical IE microorganisms) (Level of Evidence: C)"
Class II
"1. (More than 6-week antibiotic therapy should be considered in patients with osteoarticular IE-related lesions caused by difficult-to-treat microorganisms, such as S. aureus or Candida spp., and/or complicated with severe vertebral destruction or abscesses) (Level of Evidence: C)"

Recommendations for pre-operative coronary anatomy assessment in patients requiring surgery for infective endocarditis (DO NOT EDIT)

Class I
"1. (In haemodynamically stable patients with aortic valve vegetations who require cardiac surgery and are high risk of CAD, a high-resolution multislice coronary CTA is recommended) (Level of Evidence: B)"
”2. (Invasive coronary angiography is recommended in patients requiring heart surgery who are high risk of CAD, in the absence of aortic valve vegetations.) (Level of Evidence: C)"
Class II
"1. (In emergency situations, valvular surgery without pre-operative coronary anatomy assessment regardless of CAD risk should be considered.) (Level of Evidence: C)"
Class IIb
"1. (Invasive coronary angiography may be considered despite the presence of aortic valve vegetations in selected patients with known CAD or at high risk of significant obstructive CAD.) (Level of Evidence: C)"

Indications and timing of cardiac surgery after neurological complications in active infective endocarditis (DO NOT EDIT)

Class II
"1. (In patients with intracranial haemorrhage and unstable clinical status due to HF, uncontrolled infection, or persistent high embolic risk, urgent or emergency surgery should be considered weighing the likelihood of a meaningful neurological outcome.) (Level of Evidence: C)"

Recommendations for post-discharge follow-up (DO NOT EDIT)

Class I
"1. (Patient education on the risk of recurrence and preventive measures, with emphasis on dental health, and based on the individual risk profile, is recommended during follow-up.) (Level of Evidence: C)"
”2. (Addiction treatment for patients following PWID-related IE is recommended) (Level of Evidence: C)"
Class II
"1. (Cardiac rehabilitation including physical exercise training should be considered in clinically stable patients based on an individual assessment.) (Level of Evidence: C)"
Class IIb
"1. (Psychosocial support may be considered to be integrated in follow-up care, including screening for anxiety and depression, and referral to relevant psychological treatment.) (Level of Evidence: C)"

Recommendations for prosthetic valve endocarditis (DO NOT EDIT)

Class I
"1. (Surgery is recommended for early PVE (within 6 months of valve surgery) with new valve replacement and complete debridement) (Level of Evidence: C)"

Recommendations for cardiovascular implanted electronic device-related infective endocarditis (DO NOT EDIT)

Class I
"1. (Complete system extraction without delay is recommended in patients with definite CIED-related IE under initial empirical antibiotic therapy.) (Level of Evidence: B)"
Class II
"1. (Extension of antibiotic treatment of CIED-related endocarditis to (4–)6 weeks following device extraction should be considered in the presence of septic emboli or prosthetic valves.) (Level of Evidence: C)"
Class IIb
"1. (Use of an antibiotic envelope may be considered in select high-risk patients undergoing CIED reimplantation to reduce risk of infection) (Level of Evidence: B)"
"1. (In non-S. aureus CIED-related endocarditis without valve involvement or lead vegetations, and if follow-up blood cultures are negative without septic emboli, 2 weeks of antibiotic treatment may be considered following device extraction.) (Level of Evidence: C)"
Class III
"1. (Removal of CIED after a single positive blood culture, with no other clinical evidence of infection, is not recommended) (Level of Evidence: C)"

Recommendations for the surgical treatment of right-sided infective endocarditis (DO NOT EDIT)

Class II
"1. (Tricuspid valve repair should be considered instead of valve replacement, when possible.) (Level of Evidence: B)"
”2. (Surgery should be considered in patients with right-sided IE who are receiving appropriate antibiotic therapy and present persistent bacteraemia/sepsis after at least 1 week of appropriate antibiotic therapy.) (Level of Evidence: C)"
”3. (Prophylactic placement of an epicardial pacing lead should be considered at the time of tricuspid valve surgical procedures) (Level of Evidence: C)"
Class II
"1. (Debulking of right intra-atrial septic masses by aspiration may be considered in select patients who are high risk of surgery.) (Level of Evidence: C)"

2023 Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis (DO NOT EDIT)

Class I
"1. (General prevention measures are recommended in individuals at high and intermediate risk for IE.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis is recommended in patients with previous IE.) (Level of Evidence: B)"
”3. (Antibiotic prophylaxis is recommended in patients with surgically implanted prosthetic valves and with any material used for surgical cardiac valve repair.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis is recommended in patients with transcatheter implanted aortic and pulmonary valvular prostheses.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis is recommended in patients with untreated cyanotic CHD, and patients treated with surgery or transcatheter procedures with post-operative palliative shunts, conduits, or other prostheses. After surgical repair, in the absence of residual defects or valve prostheses, antibiotic prophylaxis is recommended only for the first 6 months after the procedure.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis is recommended in patients with ventricular assist devices.) (Level of Evidence: C)"
Class Ila
"1. (Antibiotic prophylaxis should be considered in patients with transcatheter mitral and tricuspid valve repair.) (Level of Evidence: C)"
Class Ilb
"1. (Antibiotic prophylaxis may be considered in recipients of heart transplant.) (Level of Evidence: C)"
Class III
"1. (Antibiotic prophylaxis is not recommended in other patients at low risk for IE.) (Level of Evidence: C)"

2023 ESC Guidelines Recommendations for Prophylactic antibiotic regime for high-risk dental procedures

2023 ESC Guidelines Recommendations for Diagnostic Procedures of rare causes of blood culture-negative infective endocarditis

Recommendations for infective endocarditis prevention in high-risk patients (DO NOT EDIT)

Class I "1. (Antibiotic prophylaxis is recommended in dental extractions, oral surgery procedures, and procedures requiring manipulation of the gingival or periapical region of the teeth.) (Level of Evidence: B)"
Class IIb
"1. (Systemic antibiotic prophylaxis may be considered for high-riskc patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems.) (Level of Evidence: C)"

Recommendations for infective endocarditis prevention in cardiac procedures (DO NOT EDIT)

Class I
"1. (Pre-operative screening for nasal carriage of S. aureus is recommended before elective cardiac surgery or transcatheter valve implantation to treat carriers.) (Level of Evidence: A)"
”2. (Peri-operative antibiotic prophylaxis is recommended before placement of a CIED.) (Level of Evidence: A)"
”3. (Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections.) (Level of Evidence: B)"
”3. (Periprocedural antibiotic prophylaxis is recommended in patients undergoing surgical or transcatheter implantation of a prosthetic valve, intravascular prosthetic, or other foreign material.) (Level of Evidence: B)"
”3. (Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment.) (Level of Evidence: C)"
Class IIa
”2. (Elimination of potential sources of sepsis (including of dental origin) should be considered ≥2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, except in urgent procedures.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures.) (Level of Evidence: C)"
Class III
"1. (Systematic skin or nasal decolonization without screening for S. aureus is not recommended.) (Level of Evidence: C)"

Recommendations for the Endocarditis Team Recommendations (DO NOT EDIT)

Class I
"1. (Diagnosis and management of patients with complicated IE are recommended to be performed at an early stage in a Heart Valve Centre, with immediate surgical facilities and an Endocarditis Team’ to improve the outcomes.) (Level of Evidence: B)"
”2. (For patients with uncomplicated IE managed in a Referring Centre, early and regular communication between the local and the Heart Valve Centre endocarditis teams is recommended to improve the outcomes of the patients.) (Level of Evidence: B)"

Recommendations for the role of echocardiography in infective endocarditis (DO NOT EDIT)

Class I
"1. (TTE is recommended as the first-line imaging modality in suspected IE.) (Level of Evidence: B)"
”2. (TOE is recommended in all patients with clinical suspicion of IE and a negative or non-diagnostic TTE.) (Level of Evidence: B)"
”3. (TOE is recommended in patients with clinical suspicion of IE, when a prosthetic heart valve or an intracardiac device is present.) (Level of Evidence: B)"
”3. (Repeating TTE and/or TOE within 5–7 days is recommended in cases of initially negative or inconclusive examination when clinical suspicion of IE remains high.) (Level of Evidence: C)"
”3. (TOE is recommended in patients with suspected IE, even in cases with positive TTE, except in isolated right-sided native valve IE with good quality TTE examination and unequivocal echocardiographic findings.) (Level of Evidence: C)"
Class IIa
”2. (Performing an echocardiography should be considered in S. aureus, E. faecalis, and some Streptococcus spp. bacteraemia.) (Level of Evidence: C)"
Class I
"1. (Repeating TTE and/or TOE is recommended as soon as a new complication of IE is suspected (new murmur, embolism, persisting fever and bacteraemia, HF, abscess, AVB) (Level of Evidence: B)"
”2. (TOE is recommended when patient is stable before switching from intravenous to oral antibiotic therapy.) (Level of Evidence: B)"
Class IIa
”2. (During follow-up of uncomplicated IE, repeat TTE and/ or TOE should be considered to detect new silent complications. The timing of repeat TTE and/or TOE depends on the initial findings, type of microorganism, and initial response to therapy.) (Level of Evidence: B)"
Class I
"1. (Intra-operative echocardiography is recommended in all cases of IE requiring surgery) (Level of Evidence: C)"
”2. (TTE and/or TOE are recommended at completion of antibiotic therapy for evaluation of cardiac and valve morphology and function in patients with IE who did not undergo heart valve surgery.) (Level of Evidence: C)"

Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis (DO NOT EDIT)

Class I
"1. (Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE) (Level of Evidence: B)"
”2. ( 18F FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE) (Level of Evidence: B)"
”3. (Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive.) (Level of Evidence: B)"
”3. (Brain and whole-body imaging (CT, 18F FDG-PET/ CT, and/or MRI) are recommended in symptomaticc patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria) (Level of Evidence: B)"
Class IIa
"1. (WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable.) (Level of Evidence: C)"
Class IIb
"1. (18F FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE) (Level of Evidence: B)"
”2. (Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients) (Level of Evidence: B)"

Definitions of the 2023 European Society of Cardiology modified diagnostic criteria of infective endocarditis (DO NOT EDIT)

Recommendations for antibiotic treatment of infective endocarditis due to oral streptococci and Streptococcus gallolyticus group (DO NOT EDIT)

Penicillin-susceptible oral streptococci and Streptococcus gallolyticus group (DO NOT EDIT)

Standard treatment: 4-week duration in NVE or 6-week duration in PVE (DO NOT EDIT)

Class I
"1. (In patients with IE due to oral streptococci and S. gallolyticus group, penicillin G, amoxicillin, or ceftriaxone are recommended for 4 (in NVE) or 6 weeks (in PVE), using the following doses: *Adult antibiotic dosage and route

Penicillin G 12–18 millionc U/day i.v. either in 4–6 doses or continuously Amoxicillin 100–200 mg/kg/day i.v. in 4–6 doses Ceftriaxone 2 g/day i.v. in 1 dose

  • Paediatric antibiotic dosage and route

Penicillin G 200 000 U/kg/day i.v. in 4–6 divided doses Amoxicillin 100–200c mg/kg/day i.v. in 4–6 doses Ceftriaxone 100 mg/kg/day i.v. in 1 dose) (Level of Evidence: B)"

Standard treatment: 2-week duration (not applicable to PVE) (DO NOT EDIT)

Class I
"1. (2-week treatment with penicillin G, amoxicillin, ceftriaxone combined with gentamicin is recommended only for the treatment of non-complicated NVE due to oral streptococci and S. gallolyticus in patients with normal renal function using the following doses: *Adult antibiotic dosage and route

Penicillin G 12–18 millionc U/day i.v. either in 4–6 doses or continuously, Amoxicillin 100–200 mg/kg/day i.v. in 4–6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose.

  • Pediatric antibiotic dosage and route

Penicillin G 200 000 U/kg/day i.v. in 4–6 divided doses, Amoxicillin 100–200 mg/kg/dayc i.v. in 4–6 doses , Ceftriaxone 100 mg/kg i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose or 3 equally divided doses) (Level of Evidence: B)"

Allergy to beta-lactams (DO NOT EDIT)

Class I
"1. (In patients allergic to beta-lactams and with IE due to oral streptococci and S. gallolyticus, vancomycin for 4 weeks in NVE or for 6 weeks in PVE is recommended using the following doses: *Adult antibiotic dosage and route

Vancomycine 30 mg/kg/day i.v. in 2 doses.

  • Pediatric antibiotic dosage and route

Vancomycine 30 mg/kg/day i.v. in 2 or 3 equally divided doses) (Level of Evidence: C)"

Oral streptococci and Streptococcus gallolyticus group susceptible, increased exposure or resistant to penicillin (DO NOT EDIT)

Class I
"1. (In patients with NVE due to oral streptococci and S. gallolyticus, penicillin G, amoxicillin, or ceftriaxone for 4 weeks in combination with gentamicin for 2 weeks is recommended using the following doses: *Adult antibiotic dosage and route

Penicillin G 24 million U/day i.v. either in 4–6 doses or continuously, Amoxicillin 12 g/day i.v. in 6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicin 3 mg/kg/day i.v. or i.m. in 1 dose) (Level of Evidence: B)"

”2. (In patients with PVE due to oral streptococci and S. gallolyticus, penicillin G, amoxicillin, or ceftriaxone for 6 weeks combined with gentamicin for 2 weeks is recommended using the following doses:
  • Adult antibiotic dosage and route

Penicillin G 24 million U/day i.v. either in 4–6 doses or continuously, Amoxicillin 12 g/day i.v. in 6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose) (Level of Evidence: B)"

Sources

  • 2023 ESC Guidelines for the management of endocarditis

Developed by the task force on the management of endocarditis of the European Society of Cardiology (ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Nuclear Medicine (EANM)

Surgery

Surgical removal of the valve is necessary for patients who fail to clear micro-organisms from their blood in response to antibiotic therapy, or in patients who develop cardiac failure resulting from destruction of a valve by infection. A removed valve is usually replaced with an artificial valve which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic valves. Surgical treatment of endocarditis involves excision of all infected valve tissue, drainage and debridement of abscess cavities, repair or replacement of damaged valves, and repair of any associated pathology such as fistulas or septal defects.

Prevention

Prevention of infective endocarditis can be achieved through the administration of antibiotic prophylaxis to high risk subjects who are undergoing high risk procedures. The choice of antibiotic prophylaxis depends on whether the subject can tolerate oral intake or not, as well as on whether patient has allergy to penicillin or not.

References

  1. ↑ Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H; et al. (2023). "2023 ESC Guidelines for the management of endocarditis". Eur Heart J. 44 (39): 3948–4042. doi:10.1093/eurheartj/ehad193. PMID 37622656 Check |pmid= value (help).
  2. ↑ Habib G, Erba PA, Iung B, Donal E, Cosyns B, Laroche C; et al. (2019). "Clinical presentation, aetiology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study". Eur Heart J. 40 (39): 3222–3232. doi:10.1093/eurheartj/ehz620. PMID 31504413.
  3. ↑ Maeda K, Hirai Y, Nashi M, Yamamoto S, Taniike N, Takenobu T (2022). "Clinical features and antimicrobial susceptibility of oral bacteria isolated from the blood cultures of patients with infective endocarditis". J Dent Sci. 17 (2): 870–875. doi:10.1016/j.jds.2021.09.023. PMC 9201522 Check |pmc= value (help). PMID 35756779 Check |pmid= value (help).

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