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).
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.
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.
Findings on cardiac MRI suggestive of infective endocarditis include valvular vegetations, valvular and perivalvular damage, and vascular endothelial involvement.
Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk of infective endocarditis (DO NOT EDIT)
"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)
"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)"
"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)
"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)"
"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)"
"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)"
"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)
"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)"
"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)
"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)
"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)"
"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)
"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)"
"1. (In emergency situations, valvular surgery without pre-operative coronary anatomy assessment regardless of CAD risk should be considered.) (Level of Evidence: C)"
"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)
"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)
"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)"
"1. (Cardiac rehabilitation including physical exercise training should be considered in clinically stable patients based on an individual assessment.) (Level of Evidence: C)"
"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)
"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)
"1. (Complete system extraction without delay is recommended in patients with definite CIED-related IE under initial empirical antibiotic therapy.) (Level of Evidence: B)"
"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)"
"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)"
"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)"
"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)
"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)"
"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)"
"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)
"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)"
”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)"
"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)
"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)"
"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)"
”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)"
"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)
"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)"
"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)"
"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)
"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)
"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)"
"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)
"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 antibioticprophylaxis to high risk subjects who are undergoing high risk procedures. The choice of antibioticprophylaxis depends on whether the subject can tolerate oral intake or not, as well as on whether patient has allergy to penicillin or not.
