What is the next best diagnostic step for suspected infective endocarditis?

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Last updated: June 29, 2025 • View editorial policy

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From the Guidelines

The next best diagnostic step for suspected infective endocarditis is to perform a transthoracic echocardiogram (TTE) promptly, as it is the most frequently used imaging study for confirming the diagnosis of infective endocarditis and can demonstrate vegetations on cardiac valves, valvular regurgitation, and paravalvular abscess. This approach is supported by the most recent and highest quality study, which recommends TTE as the initial imaging modality for suspected infective endocarditis 1.

Key Points to Consider:

  • The patient has already undergone blood cultures, which showed viridans group streptococci, indicating a possible infective endocarditis.
  • The patient's clinical presentation, including fever, malaise, and chills, along with the presence of a soft diastolic murmur, raises suspicion for infective endocarditis.
  • TTE is a non-invasive and widely available imaging modality that can provide valuable information on valvular function and potential complications of infective endocarditis.
  • If TTE is negative but clinical suspicion remains high, or if complications like valvular abscess are suspected, transesophageal echocardiography (TEE) may be considered as a next step, as it has higher sensitivity for detecting vegetations and complications compared to TTE 1.

Additional Recommendations:

  • Complete blood count, erythrocyte sedimentation rate, C-reactive protein, and renal function tests should be performed to assess the patient's overall condition and potential complications of infective endocarditis.
  • The patient's antibiotic therapy should be guided by the results of blood cultures and susceptibility testing, and adjusted as necessary to ensure effective treatment of the underlying infection.

Overall, the priority is to promptly diagnose and treat infective endocarditis to reduce morbidity, mortality, and improve quality of life, and TTE is a crucial step in this process.

From the Research

Diagnostic Approach for Suspected Infective Endocarditis

The patient's presentation with fevers, malaise, chills, and a soft diastolic murmur, along with the laboratory findings of viridans group streptococci in two separate blood cultures, suggests a diagnosis of infective endocarditis. Given this clinical context, the next best diagnostic step is crucial for confirming the diagnosis and guiding management.

Echocardiography in Infective Endocarditis

Echocardiography plays a pivotal role in the diagnosis of infective endocarditis, with both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) being utilized. The choice between TTE and TEE depends on several factors, including the patient's clinical presentation, the presence of prosthetic valves, and the suspicion of complications such as periannular abscesses.

Transthoracic Echocardiogram (TTE)

  • TTE is less sensitive than TEE for detecting valvular vegetations, especially smaller ones 2.
  • However, TTE can be useful as an initial screening test, particularly in patients with a low suspicion of infective endocarditis or those without prosthetic valves 3, 4.
  • A negative TTE can have a high negative predictive value, potentially ruling out infective endocarditis in certain patient populations 4, 5.

Transesophageal Echocardiogram (TEE)

  • TEE is more sensitive and specific than TTE for diagnosing infective endocarditis, especially in detecting smaller vegetations and periannular complications 6, 2.
  • TEE is recommended for patients with a high suspicion of infective endocarditis, those with prosthetic valves, or when TTE is inconclusive or suggests the presence of complications 6, 2.

Next Best Diagnostic Step

Given the patient's clinical presentation and the presence of viridans group streptococci in blood cultures, which is a common cause of infective endocarditis, the most appropriate next step would be to perform a Transthoracic Echocardiogram (TTE) as an initial evaluation. If the TTE is negative or inconclusive, or if there is a high clinical suspicion of infective endocarditis, a Transesophageal Echocardiogram (TEE) should be considered for its higher sensitivity and ability to detect complications 3, 6, 4, 5, 2.

Considerations

  • The decision to proceed directly to TEE or to start with TTE depends on the clinical context and the availability of resources.
  • It's also important to consider the patient's ability to undergo TEE, given its more invasive nature compared to TTE.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

5
Research

Diagnostic Accuracy of Transthoracic Echocardiography for Infective Endocarditis Findings Using Transesophageal Echocardiography as the Reference Standard: A Meta-Analysis.

Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography, 2017

6
Research

Echocardiography in infective endocarditis.

Southern medical journal, 1999

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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