What are the guideline sources, guidelines and references for Infective endocarditis ?
Guideline sources The following summarized guidelines for the evaluation and management of infective endocarditis (IE) are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2021), the American Heart Association (AHA/ACC 2021), the American Heart Association (AHA/ASA 2018), the American College of Obstetricians and Gynecologists (ACOG 2018), the Infectious Diseases Society of America (IDSA 2016; 2015; 2011), the American Heart Association (AHA 2015), the European Association of Nuclear Medicine (EANM/ESC/EACTS 2015), the American Society for Gastrointestinal Endoscopy (ASGE 2015), the Society of Family Planning (SFP 2012), and the American College of Chest Physicians (ACCP 2012). 1 2 3 4 5 6 7 8 9 10 11 12 14 15 15 16 17 17 17 18 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. 15 E id i l https://web.pathway.md/diseases/recmwGNF9ao69Drui 1/18 6/24/23, 2:35 PM Infective endocarditis Pathway Epidemiology 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 human immunodeficiency virus infection). 17 17 Pathophysiology The incidence of IE is approximately 15 cases per 100,000 person-years in the United States. 16 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. 15 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. 17 18 Calculator2023 Duke-ISCVID criteria for in CalculatorCardiac Anesthesia Risk Evaluati CalculatorInfective e Guidelines 1. Screening and diagnosis Diagnostic criteria: use the current Duke Criteria for the diagnosis of suspected IE. B 2. Diagnostic investigations Blood cultures: Obtain blood culture in patients at risk of IE (such as patients with congenital or acquired VHD, previous IE, prosthetic heart valves, certain congenital or heritable heart malformations, immunodeficiency states, or injection drug use) having unexplained fever. B https://web.pathway.md/diseases/recmwGNF9ao69Drui 2/18 6/24/23, 2:35 PM Infective endocarditis Pathway Obtain at least two sets of blood cultures in patients with a recent onset of left-sided valve regurgitation. B Transthoracic echocardiogram: As per ACC 2021 guidelines, obtain TTE to identify vegetations, characterize the hemodynamic severity of valvular lesions, assess ventricular function and pulmonary pressures, and detect complications in patients with suspected IE. B As per ESC 2021 guidelines: Obtain TTE as the first-line imaging modality in patients with suspected IE. B Obtain repeat TTE and/or TEE within 5-7 days in case of initially negative examination when clinical suspicion of IE remains high. B Consider obtaining echocardiography in patients with S. aureus bacteremia. C Transesophageal echocardiogram: As per AHA 2021 guidelines, obtain a TEE in all patients with known or suspected IE and nondiagnostic TTE results when complications have developed or are clinically suspected or when intracardiac device leads are present. B Show 4 more As per ESC 2015 guidelines, obtain a TEE in all patients with clinical suspicion of IE and a negative or nondiagnostic TTE. B Show 3 more Cardiac CT/PET: Consider obtaining cardiac CT if the anatomy cannot be clearly delineated by echocardiography in the setting of suspected paravalvular infections. C Consider obtaining 18F-FDG-positron emission tomography/CT as adjunct diagnostic imaging in patients classified by modified Duke Criteria as having possible IE. C Evaluation for intracranial mycotic aneurysms: As per ESC 2021 guidelines, evaluate for infectious intracranial aneurysms in patients with IE and neurological symptoms. Consider obtaining CT or MRA for diagnosis. Consider obtaining conventional angiography if noninvasive techniques are negative and the suspicion of intracranial aneurysm remains. B As per AHA 2015 guidelines, obtain cerebrovascular imaging to detect intracranial mycotic aneurysms or CNS bleeding in all patients with IE or contiguous spread of infection with severe, localized headache, neurological deficits, or meningeal signs. B Show 2 more Evaluation for extracranial mycotic aneurysms: Obtain CT or multislice CT angiography with 3D reconstruction to evaluate for extracranial (such as thoracic or intra-abdominal) mycotic aneurysms. B Obtain TEE to identify mycotic aneurysms of the sinus of Valsalva and thoracic aorta. B Dental evaluation: consider obtaining a thorough dental evaluation, especially in patients deemed likely to require valve replacement, with all active sources of oral infection eradicated. C https://web.pathway.md/diseases/recmwGNF9ao69Drui 3/18 6/24/23, 2:35 PM Infective endocarditis Pathway Show 3 more 3. Medical management General principles, setting of care: As per AHA/ACC 2021 guidelines, evaluate and manage patients with IE in consultation with a multispecialty heart valve team, including: infectious disease specialist, cardiologist, and cardiac surgeon cardiac anesthesiologist for surgically managed patients neurologist for patients with neurological events. B As per ESC 2021 guidelines: Evaluate and manage patients with complicated IE at an early stage in a reference center with immediate surgical facilities and the presence of a multidisciplinary endocarditis team, including an infectious disease specialist, a microbiologist, a cardiologist, imaging specialists, a cardiac surgeon, and if needed, a specialist in congenital heart disease. B Ensure early and regular communication with the reference center and, when needed, visits to the reference center in patients with uncomplicated IE managed in a non-reference center. B As per AHA 2015 guidelines: Evaluate and stabilize patients in the inpatient setting before offering outpatient therapy. B Consider offering outpatient antibiotic therapy only in patients at low risk for complications of IE, including HF and systemic emboli. B General principles, guidance for antibiotic therapy: As per AHA/ACC 2021 guidelines: Initiate appropriate antibiotic therapy and continue after obtaining blood cultures, with guidance from antibiotic sensitivity data and the infectious disease experts on the multidisciplinary heart valve team. B Do not initiate antibiotics before obtaining blood cultures for unexplained fever in patients with known VHD. D As per AHA 2015 guidelines, obtain infectious diseases consultation to define an optimal empirical treatment regimen at the time of initiation of antimicrobial therapy. B General principles (removal of IV catheters): remove all indwelling IV catheters used to infuse antimicrobial treatment promptly at the end of therapy. B Antibiotic therapy, viridans streptococci and S. gallolyticus, NVE, penicillin-susceptible: As per ESC 2021 guidelines, administer any of the following regimens for 4 weeks in patients with native valve IE caused by penicillin-susceptible (MIC 0.125 mg/L) oral and digestive streptococci: Situation Guidance Penicillin G https://web.pathway.md/diseases/recmwGNF9ao69Drui 4/18 6/24/23, 2:35 PM Infective endocarditis Pathway 12-18 million U/day IV in 4-6 doses or continuously 100-200 mg/kg/day IV in 4-6 doses Amoxicillin 2 g/day IV or intramuscularly in 1 dose. B Ceftriaxone Show 2 more As per AHA 2015 guidelines, consider administering aqueous crystalline penicillin G or ceftriaxone for 4 weeks in patients with native valve IE caused by highly penicillin-susceptible (MIC 0.12 g/mL) viridans group streptococci or S. gallolyticus (bovis). C Show 2 more Antibiotic therapy, viridans streptococci and S. gallolyticus, NVE, penicillin-resistant: As per ESC 2021 guidelines, administer any of the following regimens for 4 weeks (for 6 weeks for prosthetic valve IE) in patients with IE with relatively penicillin-resistant (MIC 0.250-2 mg/L) strains: Situation Guidance 24 million U/day IV in 4-6 doses or continuously for 4 weeks Penicillin G 200 mg/kg/day IV in 4-6 doses for 4 weeks Amoxicillin Ceftriaxone 2 g/day IV or intramuscularly in 1 dose for 4 weeks combined with gentamicin 3 mg/kg/day IV or intramuscularly in 1 dose for 2 weeks. B Ceftriaxone plus gentamicin Show 2 more As per AHA 2015 guidelines, consider administering penicillin for 4 weeks with single daily-dose gentamicin for the first 2 weeks of therapy in patients with native valve IE caused by relatively penicillin-resistant (MIC > 0.12 but < 0.5 g/mL) viridans group streptococci or S. gallolyticus (bovis). C Show 5 more Antibiotic therapy, viridans streptococci and S. gallolyticus (PVE): consider administering aqueous crystalline penicillin G or ceftriaxone for 6 weeks with or without gentamicin for the first 2 weeks in patients with IE of prosthetic valves or other prosthetic material Caused by viridans group streptococci or S. gallolyticus (bovis). C Show 2 more Antibiotic therapy, Abiotrophia defectiva and Granulicatella adiacens: Consider administering ampicillin or penicillin plus gentamicin in patients with native valve endocarditis caused by A. defectiva or Granulicatella species. C Do not use gentamicin if vancomycin is used in patients intolerant to ampicillin or penicillin. D https://web.pathway.md/diseases/recmwGNF9ao69Drui 5/18 6/24/23, 2:35 PM Infective endocarditis Pathway Antibiotic therapy, S. pneumoniae, S. pyogenes, and beta-hemolytic streptococci: consider administering penicillin, cefazolin, or ceftriaxone for 4 weeks in patients with IE caused by S. pneumoniae. Consider administering vancomycin in patients intolerant to -lactam therapy. Consider continuing treatment for 6 weeks in patients with prosthetic valve IE caused by S. pneumoniae. C Show 6 more Antibiotic therapy, methicillin-susceptible S. aureus, NVE: As per AHA 2015 guidelines, administer antistaphylococcal -lactam antibiotics rather than aqueous crystalline penicillin G because in patients with IE caused by penicillin-susceptible staphylococci. B Show 9 more As per EANM/EACTS/ESC 2015 guidelines, administer (flu)cloxacillin or oxacillin 12 g/day IV in 4-6 doses for 4-6 weeks in patients with native valve IE caused by methicillin-susceptible staphylococci. B Show 3 more Antibiotic therapy, methicillin-susceptible S. aureus, PVE: As per AHA 2015 guidelines, administer a combination antimicrobial therapy in patients with IE of prosthetic valves or other prosthetic material caused by S. aureus. Administer gentamicin for the initial 2 weeks of therapy with either -lactam or vancomycin-containing regimens. B As per EANM/EACTS/ESC 2015 guidelines, administer the following combination antibiotic regimen in patients with prosthetic valve IE caused by methicillin-susceptible staphylococci: (flu)cloxacillin or oxacillin 12 g/day IV in 4-6 doses for 6 weeks, and rifampin 900-1,200 mg IV or PO in 2-3 divided doses for 6 weeks, and gentamicin 3 mg/kg/day IV or intramuscularly in 1-2 doses for 2 weeks. B Antibiotic therapy, methicillin-resistant S. aureus, NVE: As per ESC 2021 guidelines, administer vancomycin 30-60 mg/kg/day IV in 2-3 doses for 4-6 weeks in patients with native valve IE caused by methicillin-resistant staphylococci. B Show 2 more As per AHA 2015 guidelines: Consider administering daptomycin as an alternative to vancomycin in patients with left-sided IE caused by MRSA. C Do not use gentamicin in patients with native valve IE caused by MRSA. D As per IDSA 2011 guidelines, administer vancomycin IV B or daptomycin 6 mg/kg/dose IV once daily, A up to 8-10 mg/kg/dose once daily, B for 6 weeks in adult patients with IE caused by MRSA. B Show 6 more Antibiotic therapy, methicillin-resistant S. aureus, PVE: As per EANM/EACTS/ESC 2015 guidelines, administer the following combination antibiotic regimen in patients with prosthetic valve IE caused by methicillin-resistant staphylococci and in penicillin-allergic patients: https://web.pathway.md/diseases/recmwGNF9ao69Drui 6/18 6/24/23, 2:35 PM Infective endocarditis Pathway vancomycin 30-60 mg/kg/day IV in 2-3 doses for 6 weeks, and rifampin 900-1,200 mg IV or PO in 2-3 divided doses for 6 weeks, and gentamicin 3 mg/kg/day IV or intramuscularly in 1-2 doses for 2 weeks. B As per IDSA 2011 guidelines: Administer vancomycin IV plus rifampin 300 mg PO/IV every 8 hours for at least 6 weeks plus gentamicin 1 mg/kg/dose IV every 8 hours for 2 weeks in patients with prosthetic valve IE caused by MRSA. B Obtain early evaluation for valve replacement surgery. B Antibiotic therapy, coagulase-negative staphylococci: administer vancomycin and rifampin for a minimum of 6 weeks, with the use of gentamicin limited to the first 2 weeks of therapy, in patients with IE of prosthetic valves or other prosthetic material caused by coagulase-negative staphylococci. B Show 2 more Antibiotic therapy, enterococci, susceptible: As per AHA 2015 guidelines, obtain enterococcal in vitro for susceptibility to penicillin and vancomycin (MIC determination) and high-level resistance to gentamicin to predict synergistic interactions. A Show 5 more As per EANM/EACTS/ESC 2015 guidelines, administer any of the following regimens in patients with IE caused by -lactam- and gentamicin-susceptible Enterococcus species: amoxicillin 200 mg/kg/day IV in 4-6 doses for 4-6 weeks with gentamicin 3 mg/kg/day IV or intramuscular in 1 dose for 2-6 weeks B ampicillin 200 mg/kg/day IV for 4-6 doses for 6 weeks with ceftriaxone 4 g/day IV or intramuscularly in 2 doses for 6 weeks B vancomycin 30 mg/kg/day IV in 2 doses for 6 weeks with gentamicin 3 mg/kg/day IV or intramuscularly in 1 dose for 6 weeks. B Antibiotic therapy, enterococci, resistant: As per AHA 2015 guidelines, consider administering ceftriaxone-ampicillin combination therapy in patients with IE caused by aminoglycoside-resistant Enterococcus species. C Show 4 more As per EANM/EACTS/ESC 2015 guidelines, replace gentamicin with streptomycin 15 mg/kg/day in 2 equally divided doses in patients with IE caused by streptomycin-susceptible Enterococcus species highly resistant to gentamicin (MIC > 500 mg/L). Show 2 more Antibiotic therapy, Gram-negative bacilli (HACEK group): regard Haemophilus species, Aggregatibacter actinomycetemcomitans, C. hominis, E. corrodens, and K. kingae microorganisms as resistant to ampicillin, therefore, do not use penicillin and ampicillin for the treatment of IE unless growth is adequate in vitro to obtain susceptibility testing results. B Show 5 more https://web.pathway.md/diseases/recmwGNF9ao69Drui 7/18 6/24/23, 2:35 PM Infective endocarditis Pathway Antibiotic therapy, Gram-negative bacilli (non-HACEK group): Consult with an infectious disease specialist for the management of patients with IE caused by non-Haemophilus species, Aggregatibacter actinomycetemcomitans, C. hominis, E. corrodens, K. kingae Gram-negative aerobic bacilli. B Consider administering combination antibiotic therapy with a -lactam (penicillins, cephalosporins, or carbapenems) and either an aminoglycoside or fluoroquinolone for 6 weeks in patients with IE caused by non-Haemophilus species, Aggregatibacter actinomycetemcomitans, C. hominis, E. corrodens, K. kingae Gram-negative aerobic bacilli. C Antibiotic therapy, acute severely ill patients: Administer the following combination antibiotic regimen as initial empirical therapy in acute severely ill patients with early prosthetic valve endocarditis (< 12 months post-surgery) or nosocomial and non-nosocomial healthcare- associated endocarditis: vancomycin 30 mg/kg/day IV in 2 doses, and gentamicin 3 mg/kg/day IV or intramuscularly in 1 dose, and rifampin 900-1,200 mg IV or PO in 2-3 divided doses. B Show 2 more Antibiotic therapy, duration: consider beginning the counting of days for the duration of antimicrobial therapy on the first day of negative blood cultures if they were initially positive. C Show 4 more Management of antithrombotics: As per AHA 2021 guidelines: Consider discontinuing vitamin K antagonists temporarily in patients receiving vitamin K antagonist therapy at the time of IE diagnosis. C Consider discontinuing anticoagulant therapy temporarily in patients with IE and with evidence of cerebral embolism or stroke, regardless of the other indications for anticoagulation. C As per ESC 2021 guidelines, interrupt antiplatelet therapy in the presence of major bleeding. B Interrupt all anticoagulants in case of intracranial hemorrhage. B Show 4 more As per AHA 2015 guidelines, consider discontinuing all forms of anticoagulation in patients with mechanical valve IE experiencing a CNS embolic event for at least 2 weeks. C Show 2 more As per ACCP 2012 guidelines, do not initiate anticoagulant D or antiplatelet therapy routinely in patients with IE unless a specific indication is present. D Show 2 more 4. Inpatient care Monitoring for complications: consider obtaining ongoing monitoring for IE complications, including perivalvular extension of infection and extracardiac foci of infection, in patients with staphylococcal endocarditis. C https://web.pathway.md/diseases/recmwGNF9ao69Drui 8/18 6/24/23, 2:35 PM Infective endocarditis Pathway Show 2 more 5. Perioperative care Preoperative antibiotic prophylaxis: obtain preoperative screening of nasal carriage of S. aureus to treat carriers before elective cardiac surgery. A Show 4 more Intraoperative echocardiogram: As per ACC 2021 guidelines, obtain intraoperative TEE in patients undergoing valve surgery for IE. B As per ESC 2021 guidelines, obtain intraoperative echocardiography in all patients with IE requiring surgery. B 6. Surgical interventions Timing of surgery: As per ACC 2021 guidelines, decide on the timing of surgical intervention for IE by a heart valve team. B Show 2 more As per ESC 2021 guidelines: Perform cardiac surgery without delay in patients with IE requiring surgery after a silent embolism or TIA. B Postpone surgery for 1 month following intracranial hemorrhage. B 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 As per AHA 2015 guidelines: Consider performing valve surgery without delay in patients with IE with stroke or subclinical cerebral emboli with non-severe neurological damage and residual vegetation, after the exclusion of intracranial hemorrhage by imaging. C Consider delaying valve surgery for at least 4 weeks in patients with major ischemic stroke or intracranial hemorrhage. C Indications for surgery, left-sided endocarditis, NVE: As per AHA/ACC 2021 guidelines: Perform early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics) in patients with IE and any of the following: valve dysfunction resulting in symptoms of HF heart block, annular or aortic abscess, or destructive penetrating lesions evidence of persistent infection as manifested by persistent bacteremia or fevers lasting > 5 days after onset of appropriate antimicrobial therapy https://web.pathway.md/diseases/recmwGNF9ao69Drui 9/18 6/24/23, 2:35 PM Infective endocarditis Pathway IE caused by S. aureus, a fungal organism, or other highly resistant organisms. B Consider performing early surgery in patients with IE and any of the following: recurrent emboli and persistent vegetations despite appropriate antibiotic therapy C mobile vegetations > 10 mm in length, with or without clinical evidence of embolic phenomenon. C As per AHA 2015 guidelines: Perform early surgery (during initial hospitalization and before completion of a full course of antibiotics) in patients with left-sided native valve IE and any of the following: valve dysfunction resulting in symptoms or signs of HF heart block, annular or aortic abscess, or destructive penetrating lesions evidence of persistent infection (manifested by persistent bacteremia or fever lasting > 5-7 days and provided that other sites of infection and fever have been excluded) after the start of appropriate antimicrobial therapy evidence of persistent infection (manifested by persistent bacteria or fevers lasting > 5-7 days and provided that infections of other sites and fever have been excluded) after the initiation of appropriate antimicrobial therapy. B Consider performing early surgery in patients with left-sided native valve IE and any of the following: IE caused by fungi or highly resistant organisms, such as VRE, multidrug-resistant Gram- negative bacilli B recurrent emboli and persistent or enlarging vegetations despite appropriate antibiotic therapy C severe valve regurgitation and mobile vegetations > 10 mm C mobile vegetations > 10 mm, particularly when involving the anterior leaflet of the mitral valve and associated with other relative indications for surgery. C As per EANM/EACTS/ESC 2015 guidelines, perform emergency surgery in patients with aortic or mitral native valve IE with severe acute regurgitation, obstruction, or fistula causing refractory pulmonary edema or cardiogenic shock. B Show 4 more Indications for surgery, left-sided endocarditis, PVE: As per AHA/ACC 2021 guidelines: Perform early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics) in patients with left-sided IE caused by S. aureus, a fungal organism, or other highly resistant organisms. B Perform surgery in patients with relapsing (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequent negative blood culture results) prosthetic valve IE and relapsing infection without other identifiable sources of infection. B As per AHA 2015 guidelines: Perform early surgery in patients with left-sided prosthetic valve IE and any of the following: https://web.pathway.md/diseases/recmwGNF9ao69Drui 10/18 6/24/23, 2:35 PM Infective endocarditis Pathway symptoms or signs of HF resulting from valve dehiscence, intracardiac fistula, or severe prosthetic valve dysfunction persistent bacteremia despite appropriate antibiotic therapy for 5-7 days, after excluding infections of other sites heart block, annular or aortic abscess, or destructive penetrating lesions IE caused by fungi or highly resistant organisms. B Consider performing early surgery in patients with left-sided prosthetic valve IE and any of the following: recurrent emboli despite appropriate antibiotic treatment C relapsing left-sided prosthetic valve IE C mobile vegetations > 10 mm. C As per EANM/EACTS/ESC 2015 guidelines, perform emergency surgery in patients with aortic or mitral prosthetic valve IE with severe acute regurgitation, obstruction, or fistula causing refractory pulmonary edema or cardiogenic shock. B Show 5 more Indications for surgery, right-sided endocarditis: As per ESC 2021 guidelines, consider performing surgical treatment in patients with right-sided IE in the following scenarios: microorganisms difficult to eradicate (such as persistent fungi) or bacteremia for > 7 days (such as S. aureus, P. aeruginosa) despite adequate antimicrobial therapy persistent tricuspid valve vegetations > 20 mm after recurrent pulmonary emboli with or without concomitant right HF right HF secondary to severe tricuspid regurgitation with poor response to diuretic therapy. C As per AHA 2015 guidelines, consider performing surgical intervention in patients with certain complications (such as right HF secondary to severe tricuspid regurgitation with poor response to medical therapy, sustained infection caused by difficult-to-treat organisms such as fungi or multidrug resistant bacteria or lack of response to appropriate antimicrobial therapy, and tricuspid valve vegetations 20 mm in diameter and recurrent pulmonary embolism despite antimicrobial therapy). C Show 2 more 7. Specific circumstances Pediatric patients (streptococci): Administer any of the following regimens for 4 weeks in pediatric patients with IE caused by penicillin-susceptible (MIC 0.125 mg/L) oral and digestive streptococci: Situation Guidance 12-18 million U/day IV in 4-6 doses or continuously Penicillin G https://web.pathway.md/diseases/recmwGNF9ao69Drui 11/18 6/24/23, 2:35 PM Infective endocarditis Pathway 100-200 mg/kg/day IV in 4-6 doses Amoxicillin 2 g/day IV or intramuscularly in 1 dose. B Ceftriaxone Show 5 more Pediatric patients (MSSA): administer (flu)cloxacillin or oxacillin 200-300 mg/kg/day IV in 4-6 equally divided doses in pediatric patients with native valve IE caused by methicillin-susceptible staphylococci. B Show 5 more Pediatric patients, MRSA: As per EANM/EACTS/ESC 2015 guidelines, administer vancomycin 40 mg/kg/day IV in 2-3 equally divided doses in pediatric patients with native valve IE caused by methicillin-resistant staphylococci. B Show 2 more As per IDSA 2011 guidelines, administer vancomycin 15 mg/kg/dose IV every 6 hours for 2-6 weeks, depending on the source, presence of endovascular infection, and metastatic foci of infection, in pediatric patients with bacteremia and IE caused by MRSA. B Consider administering daptomycin 6-10 mg/kg/dose IV once daily as an alternative option. B Do not use clindamycin or linezolid in pediatric patients with IE. B Show 2 more Pediatric patients (enterococci): Administer any of the following regimens in pediatric patients with IE caused by -lactam- and gentamicin-susceptible Enterococcus species: ampicillin 300 mg/kg/day IV in 4-6 equally divided doses with gentamicin 3 mg/kg/ day IV or intramuscularly in 3 equally divided doses B ampicillin 200 mg/kg/day IV with ceftriaxone 100 mg/kg/12 hour IV or intramuscularly B vancomycin 40 mg/kg/day IV in 2-3 equally divided doses with gentamicin 3 mg/kg/day IV or intramuscularly in 1 dose. B Patients with illicit drug use: As per ACC 2021 guidelines: Refer patients with suspected or confirmed IE associated with drug use to addiction treatment for opioid substitution therapy. B Consider consulting with an addiction medicine specialist to discuss the long-term prognosis for the patient's refraining from actions risking re-infection before repeat surgical intervention in patients with recurrent endocarditis and continued IV drug use. B As per AHA 2015 guidelines, refer patients using IV drugs to a program to assist in the cessation of drug use. B Patients with device-related IE (prevention): Administer routine antibiotic prophylaxis before device implantation. B Eliminate potential sources of sepsis 2 weeks before implantation of an intravascular/cardiac foreign material, except in urgent procedures. B https://web.pathway.md/diseases/recmwGNF9ao69Drui 12/18 6/24/23, 2:35 PM Infective endocarditis Pathway Patients with device-related IE (evaluation): obtain 3 sets of blood cultures before prompt initiation of antimicrobial therapy in patients with cardiac implantable electronic device infection. Obtain lead-tip culture when the cardiac implantable electronic device is explanted. B Show 3 more Patients with device-related IE, device removal: As per AHA/ACC 2021 guidelines, perform complete removal of the pacemaker or defibrillator systems, including all leads and the generator, in all patients with definite endocarditis and an implanted cardiac electronic device. B As per EANM/EACTS/ESC 2015 guidelines, initiate prolonged (before and after extraction) antibiotic therapy and perform complete hardware (device and leads) removal in patients with definite cardiac device-related IE, as well as in presumably isolated pocket infection. B Show 3 more Patients with device-related IE (device reimplantation): reassess the need for reimplantation after device extraction. B Show 3 more Patients with culture-negative endocarditis: obtain an evaluation of epidemiological factors, history of prior infections including cardiovascular infections, exposure to antimicrobials, clinical course, severity, and extracardiac sites of infection of the current infection in all culture-negative endocarditis cases. B Show 5 more Patients with fungal endocarditis (general principles): Perform valve surgery for most cases of fungal IE. B Consider initiating life-long suppressive therapy with an oral azole after completion of initial parenteral therapy. C Patients with fungal endocarditis (Candida): administer a lipid formulation of amphotericin B 3-5 mg/kg/day, with or without flucytosine 25 mg/kg QID, or high-dose echinocandin (caspofungin 150 mg/day, micafungin 150 mg/day, or anidulafungin 200 mg/day) as initial therapy in patients with native valve endocarditis. B Show 7 more Patients with fungal endocarditis (Aspergillus endocarditis): perform early surgical intervention and administer antifungal therapy in patients with Aspergillus endocarditis to prevent embolic complications and valvular decompensation. B Show 2 more Patients with neurological complications, evaluation for intracranial aneurysms: As per ESC 2021 guidelines: Evaluate for infectious intracranial aneurysms in patients with IE and neurological symptoms. Consider obtaining CT or MRA for diagnosis. Consider obtaining conventional angiography if noninvasive techniques are negative and the suspicion of intracranial aneurysm remains. B Perform neurosurgery or endovascular therapy for very large, enlarging, or ruptured infectious intracranial aneurysms. B https://web.pathway.md/diseases/recmwGNF9ao69Drui 13/18 6/24/23, 2:35 PM Infective endocarditis Pathway As per AHA 2015 guidelines, obtain cerebrovascular imaging to detect intracranial mycotic aneurysms or CNS bleeding in all patients with IE or contiguous spread of infection with severe, localized headache, neurological deficits, or meningeal signs. B Show 2 more Patients with neurological complications, timing of valve surgery: As per AHA/ACC 2021 guidelines: Consider performing surgery without delay in patients with IE with an indication for surgery and having a stroke without evidence of intracranial hemorrhage or extensive neurological damage. C Consider delaying valve surgery for at least 4 weeks in hemodynamically stable patients with IE and major ischemic stroke with extensive neurological damage or intracranial hemorrhage. C As per ESC 2021 guidelines: Perform cardiac surgery without delay in patients with IE requiring surgery after a silent embolism or TIA. B Postpone surgery for 1 month following intracranial hemorrhage. B 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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