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Infective endocarditis

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Updated 2023 ESC guidelines for the diagnosis and management of infective endocarditis.

Background

Overview

Definition
IE is a disease characterized by infection and inflammation of the endocardium, the layer of endothelial cells that lines the chambers and valves of the heart.
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Pathophysiology
IE is most commonly caused by Streptococci and Staphylococci (80% cases), with S. aureus being the most common pathogen. Risk factors include the presence of cardiac prosthetic material (prosthetic valves, intracardiac devices) or abnormal valvular tissue (non-repaired cyanotic congenital heart diseases, chronic rheumatic heart disease, age-related degenerative valvular lesions), as well as intravenous drug use, and relative immunosuppression (including age ≥ 65 years, hemodialysis, diabetes, and HIV infection).
2
Epidemiology
The incidence of IE is approximately 15 cases per 100,000 person-years in the US.
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Disease course
The altered cardiac valve surface produces a suitable site for bacteria in the bloodstream to attach and proliferate, creating vegetations that can detach and disseminate. Septic emboli from vegetations result in clinical manifestations of ischemic stroke, mycotic aneurysms, infarcts, and abscesses at various sites. Pulmonary, splenic, neurovascular, renal, and cardiac manifestations can ultimately lead to death.
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Prognosis and risk of recurrence
IE is associated with 15-22% in-hospital mortality and 40% 5-year mortality in developed countries. The estimated risk of recurrence of IE is 1.3% per year.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of infective endocarditis are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2023), the French Society of Infectious Diseases (SPLIF 2023), the American Heart Association (AHA/ACC 2021), the American College of Obstetricians and Gynecologists (ACOG 2018), the American Heart Association (AHA/ASA 2018), the Society...
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Screening and diagnosis

Indication for testing: as per ESC 2023 guidelines, Obtain TTE/TEE to rule out IE in patients with spondylodiscitis and/or septic arthritis with positive blood cultures for typical IE microorganisms.
B
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  • Diagnostic criteria

Diagnostic investigations

Blood cultures
As per ACC/AHA 2021 guidelines:
Obtain blood culture in patients at risk of IE (such as patients with congenital or acquired valvular heart disease, previous IE, prosthetic heart valves, certain congenital or heritable heart malformations, immunodeficiency states, or injection drug use) having unexplained fever.
B
Obtain at least two sets of blood cultures in patients with a recent onset of left-sided valve regurgitation.
B

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  • TTE

  • TEE

  • Cardiac CTA

  • Cardiac CT/PET

  • Brain and whole-body imaging

  • Dental evaluation

Diagnostic procedures

Coronary angiography: as per ESC 2023 guidelines, Perform invasive coronary angiography in patients requiring heart surgery at high risk for coronary artery disease, in the absence of aortic valve vegetations.
B
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Medical management

General principles, setting of care: as per ESC 2023 guidelines, Evaluate and manage patients with complicated IE at an early stage in a heart valve center with immediate surgical facilities and an endocarditis team to improve the outcomes.
B
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  • General principles (guidance for antibiotic therapy)

  • Antibiotic therapy, initial empiric therapy

  • Antibiotic therapy, viridans streptococci and S. gallolyticus (NVE, penicillin-susceptible)

  • Antibiotic therapy, viridans streptococci and S. gallolyticus (NVE, penicillin-resistant)

  • Antibiotic therapy, viridans streptococci and S. gallolyticus (PVE)

  • Antibiotic therapy, A. defectiva and Granulicatella adiacens

  • Antibiotic therapy, S. pneumoniae, S. pyogenes, and beta-hemolytic streptococci

  • Antibiotic therapy, MSSA (NVE)

  • Antibiotic therapy, MSSA (PVE)

  • Antibiotic therapy, MRSA (NVE)

  • Antibiotic therapy, MRSA (PVE)

  • Antibiotic therapy, coagulase-negative staphylococci

  • Antibiotic therapy, enterococci (susceptible)

  • Antibiotic therapy, enterococci (resistant)

  • Antibiotic therapy, Gram-negative bacilli (HACEK group)

  • Antibiotic therapy, Gram-negative bacilli (non-HACEK group)

  • Antibiotic therapy, duration

  • Antibiotic therapy, removal of IV catheters

  • Management of antithrombotics

  • Thrombolytic therapy

Inpatient care

Monitoring for complications: as per AHA 2015 guidelines, Consider obtaining ongoing monitoring for IE complications, including perivalvular extension of infection and extracardiac foci of infection, in patients with staphylococcal endocarditis.
C
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Perioperative care

Epicardial pacemaker implantation: as per ESC 2023 guidelines, Consider performing immediate epicardial pacemaker implantation in patients undergoing surgery for valvular IE and complete AV block in the presence of any of the following predictors of persistent AV block:
preoperative conduction abnormality
S. aureus infection
aortic root abscess
tricuspid valve involvement
previous valvular surgery.
C

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  • Intraoperative echocardiogram

Surgical interventions

Timing of surgery: as per ESC 2023 guidelines, Perform cardiac surgery, if indicated, without delay after a TIA.
B
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  • Indications for surgery, left-sided endocarditis (NVE)

  • Indications for surgery, left-sided endocarditis (PVE)

  • Indications for surgery, right-sided endocarditis

Specific circumstances

Pediatric patients, antibiotic therapy, initial empiric therapy: as per ESC 2023 guidelines, Consider administering ampicillin in combination with ceftriaxone or with (flu)cloxacillin and gentamicin using the following doses in pediatric patients with community-acquired NVE or late PVE (≥ 12 months after surgery):
Situation
Guidance
Ampicillin
300 mg/kg/day IV in 4-6 equally divided doses
Ceftriaxone
100 mg/kg IV or IM in 1 dose
(flu)cloxacillin
200-300 mg/kg/day IV in 4-6 equally divided doses
Gentamicin
3 mg/kg/day IV or IM in 3 equally divided doses
C
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  • Pediatric patients (antibiotic therapy, streptococci)

  • Pediatric patients (antibiotic therapy, MSSA)

  • Pediatric patients (antibiotic therapy, MRSA)

  • Pediatric patients (antibiotic therapy, enterococci)

  • Patients with illicit drug use

  • Patients with device-related IE (prevention)

  • Patients with device-related IE (evaluation)

  • Patients with device-related IE (device removal)

  • Patients with device-related IE (antibiotic therapy)

  • Patients with device-related IE (device reimplantation)

  • Patients with culture-negative endocarditis

  • Patients with fungal endocarditis (general principles)

  • Patients with fungal endocarditis (Candida)

  • Patients with fungal endocarditis (Aspergillus endocarditis)

  • Patients with neurological complications (evaluation for intracranial aneurysms)

  • Patients with neurological complications (timing of valve surgery)

  • Patients with neurological complications (mechanical thrombectomy)

  • Patients with neurological complications (thrombolytic therapy)

  • Patients with neurological complications (neurosurgery)

  • Patients with musculoskeletal complications

Preventative measures

Antibiotic prophylaxis, cardiac surgery: as per ESC 2023 guidelines, Obtain preoperative screening for nasal carriage of S. aureus before elective cardiac surgery or transcatheter valve implantation to treat carriers.
A
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  • Antibiotic prophylaxis (dental procedures)

  • Antibiotic prophylaxis (gastrointestinal procedures)

  • Antibiotic prophylaxis (mitral valve prolapse)

  • Antibiotic prophylaxis (pregnancy termination)

  • Antibiotic prophylaxis (Cesarean delivery)

  • Antibiotic prophylaxis (genitourinary procedures)

  • Antibiotic prophylaxis (other procedures)

Follow-up and surveillance

Monitoring for antibiotic toxicity: as per AHA 2015 guidelines, Consider monitoring for antibiotic toxicity after the completion of treatment during short-term follow-up.
B
Consider obtaining evaluation after completing antibiotics in patients not having symptoms of systemic toxicity at the completion of therapy.
C
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  • Serial laboratory assessment

  • Serial imaging assessment

  • Cardiac rehabilitation

  • Surveillance for complications and recurrence (short-term)

  • Surveillance for complications and recurrence (long-term)