Consider performing surgery without delay in patients with IE requiring surgery for HF, uncontrolled infection, abscess, or persistent high embolic risk after a stroke as long as coma is absent and the presence of cerebral hemorrhage has been excluded by cranial CT or MRI. C Patients with neurological complications (IV alteplase): do not administer IV alteplase in patients with acute ischemic stroke and symptoms consistent with IE because of the increased risk of intracranial hemorrhage. D 8. Preventative measures Antibiotic prophylaxis, dental procedures: As per AHA/ACC 2021 guidelines, consider administering antibiotic prophylaxis against IE before dental procedures (involving manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa) in patients with VHD with any of the following: prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts prosthetic material used for cardiac valve repairs, such as annuloplasty rings, chords, or clips previous IE unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. C As per EANM/EACTS/ESC 2015 guidelines, consider administering antibiotic prophylaxis before high-risk procedures (dental procedures requiring the manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa) in patients at the highest risk for IE with any of the following: https://web.pathway.md/diseases/recmwGNF9ao69Drui 14/18 6/24/23, 2:35 PM Infective endocarditis Pathway prosthetic valve, including a transcatheter valve or any prosthetic material used for cardiac valve repair previous episode of IE any cyanotic congenital heart disease any congenital heart disease repaired with a prosthetic material, whether placed surgically or by percutaneous techniques, up to 6 months after the procedure or lifelong if residual shunt or valvular regurgitation remains. C Show 2 more Antibiotic prophylaxis, gastrointestinal procedures: As per AHA/ACC 2021 guidelines, do not administer antibiotic prophylaxis for non-dental procedures, including TEE, upper and lower gastrointestinal endoscopy, in patients with VHD at high risk of IE in the absence of active infection. D As per ESC 2021 guidelines, do not administer antibiotic prophylaxis before gastrointestinal procedures, including gastroscopy, colonoscopy, or transoesophageal echocardiogram. D As per ASGE 2015 guidelines, do not administer routine antibiotic prophylaxis before gastrointestinal endoscopy solely for the prevention of IE. D Consider administering antibiotics in patients with high-risk cardiac conditions and established gastrointestinal tract infections in which enterococci may be part of the infecting bacterial flora. D Show 10 more Antibiotic prophylaxis (mitral valve prolapse): avoid administering antibiotic prophylaxis against IE in patients with mitral valve prolapse. D Antibiotic prophylaxis (pregnancy termination): do not administer additional antibiotics for the prevention of IE in patients with high-risk cardiac conditions undergoing first-trimester medical abortion. D Antibiotic prophylaxis, Cesarean delivery: As per ESC 2021 guidelines, do not administer antibiotic prophylaxis before Cesarean delivery. D As per ACOG 2018 guidelines, do not administer IE prophylaxis for Cesarean delivery in females with acquired or congenital structural heart disease in the absence of infection, except possibly for the small subset of patients at the highest potential risk of adverse cardiac outcomes (such as with cyanotic cardiac disease, or prosthetic valves, or both). D Antibiotic prophylaxis, other procedures: As per AHA/ACC 2021 guidelines, do not administer antibiotic prophylaxis before cystoscopy in patients with VHD at high risk of IE in the absence of active infection. D As per ESC 2021 guidelines, do not administer antibiotic prophylaxis before respiratory tract procedures (including bronchoscopy or laryngoscopy, or transnasal or endotracheal intubation), genitourinary or obstetric procedures (including cystoscopy, vaginal delivery, or Cesarean delivery), or any skin and soft tissue procedure. D https://web.pathway.md/diseases/recmwGNF9ao69Drui 15/18 6/24/23, 2:35 PM Infective endocarditis Pathway 9. Follow-up and surveillance Monitoring for antibiotic toxicity: 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 Show 2 more Serial laboratory assessment: consider obtaining at least 2 sets of blood cultures every 24-48 hours until the bloodstream infection has cleared. C Show 2 more Serial imaging assessment: As per ACC 2021 guidelines: Obtain repeat TEE 1-3 days before completion of the oral antibiotic regimen that has been switched from parenteral therapy in stable patients. B Obtain TTE and/or TEE for re-evaluation in patients with IE experiencing a change in clinical signs or symptoms (such as new murmur, embolism, persistent fever, HF, abscess, or atrioventricular heart block) as well as in patients at high risk of complications (such as extensive infected tissue, large vegetation on initial echocardiogram, or staphylococcal, enterococcal, or fungal infections). B As per ESC 2021 guidelines, obtain repeat TTE and/or TEE within 5-7 days in case of initially negative examination when clinical suspicion of IE remains high. B Show 3 more As per AHA 2015 guidelines, obtain repeat TEE after an initially positive TEE if clinical features suggest a new development of intracardiac complications. B Show 2 more Surveillance for complications and recurrence (short-term): monitor for the development of IE complications, including IE relapse and HF, in the short-term follow-up. Monitor for developing or worsening HF during short-term follow-up. B Evaluate patients immediately for cardiac surgery if HF develops or worsens. B Show 3 more Surveillance for complications and recurrence (long-term): obtain ongoing observation for and provide education about recurrent infection and delayed onset of worsening valve dysfunction months to years after completion of medical therapy. B Show 4 more Likelihood Ratios Pertinent positives The following findings increase the probability of infective endocarditis in adults. 1 1 Finding LR+ Value Positive duke criteria 25.3 https://web.pathway.md/diseases/recmwGNF9ao69Drui 16/18 6/24/23, 2:35 PM Infective endocarditis Pathway Positive von Reyn criteria 8.6 Positive blood bacterial culture 2.6 Pertinent negatives The following findings decrease the probability of infective endocarditis in adults. 1 1 Finding LR- Value Negative duke criteria 0.2 Negative von Reyn criteria 0.3 Negative blood bacterial culture 0.3 References 1. Powers WJ, Rabinstein AA, Ackerson T et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49 3):e46-e110. Open 2. Baddour LM, Wilson WR, Bayer AS et al. 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