What is the recommended management for infective endocarditis?

Management of Infective Endocarditis

The recommended management of infective endocarditis requires a multidisciplinary "Endocarditis Team" approach with appropriate antibiotic therapy and early surgical intervention for complications such as heart failure, uncontrolled infection, or prevention of embolism. 1

Diagnostic Approach

• Transthoracic echocardiography (TTE) is the first-line imaging modality for all suspected cases of infective endocarditis 1
• Transesophageal echocardiography (TOE) is mandatory when clinical suspicion remains high despite negative TTE, or when a prosthetic heart valve or intracardiac device is present 1
• Three or more sets of blood cultures should be obtained before initiating antimicrobial therapy 2
• Repeat echocardiography within 5-7 days is necessary if initial examination is negative but clinical suspicion remains high 1
• Immediate repeat imaging is required when complications are suspected (new murmur, embolism, persistent fever, heart failure, abscess, atrioventricular block) 1

Antimicrobial Therapy

Empirical Treatment

• For community-acquired native valve or late prosthetic valve endocarditis:

  • Ampicillin (12 g/day IV in 4-6 doses) plus (flu)cloxacillin/oxacillin (12 g/day IV in 4-6 doses) plus gentamicin (3 mg/kg/day IV or IM in 1 dose) 2
  • For penicillin-allergic patients: vancomycin (30-60 mg/kg/day IV in 2-3 doses) plus gentamicin (3 mg/kg/day IV or IM in 1 dose) 2

• For early prosthetic valve endocarditis or healthcare-associated endocarditis:

  • Vancomycin (30 mg/kg/day IV in 2 doses) plus gentamicin (3 mg/kg/day IV or IM in 1 dose) plus rifampin (900-1200 mg IV or orally in 2-3 divided doses) 2

Specific Therapy Based on Pathogen

• For staphylococcal endocarditis:

  • Native valve: penicillinase-resistant penicillin (oxacillin) 2g IV every 4 hours for 4-6 weeks plus gentamicin 1.0 mg/kg IV every 8 hours for 1 week 3
  • For methicillin-resistant strains: vancomycin 30 mg/kg/day IV in 2-4 doses for 4-6 weeks 3
  • Prosthetic valve: three-drug regimen (oxacillin or vancomycin, plus gentamicin and rifampin) for 6 weeks or more 3

• For enterococcal endocarditis:

  • Vancomycin has been reported to be effective only in combination with an aminoglycoside 4

Surgical Management

Indications for Surgery

1. Heart Failure:

   • Emergency surgery (within 24h) for aortic or mitral endocarditis with severe acute regurgitation, obstruction or fistula causing refractory pulmonary edema or cardiogenic shock 2
   • Urgent surgery (within days) for aortic or mitral endocarditis with severe regurgitation or obstruction causing symptoms of heart failure 2

2. Uncontrolled Infection:

   • Urgent surgery for locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation) 2
   • Urgent/elective surgery for infection caused by fungi or multiresistant organisms 2
   • Urgent surgery for persisting positive blood cultures despite appropriate antibiotic therapy 2
   • Urgent/elective surgery for prosthetic valve endocarditis caused by staphylococci or non-HACEK gram-negative bacteria 2

3. Prevention of Embolism:

   • Urgent surgery for aortic or mitral endocarditis with persistent vegetations >10 mm after one or more embolic episodes despite appropriate antibiotic therapy 2
   • Urgent surgery for aortic or mitral endocarditis with vegetations >10 mm, associated with severe valve stenosis or regurgitation, and low operative risk 2
   • Urgent surgery for aortic or mitral endocarditis with isolated very large vegetations (>30 mm) 2

Cardiac Device-Related Infective Endocarditis (CDRIE)

• Prolonged antibiotic therapy and complete hardware (device and leads) removal are recommended in definite CDRIE and in presumably isolated pocket infection 2
• Percutaneous extraction is recommended in most patients with CDRIE, even those with vegetations >10 mm 2
• After device extraction, reassessment of the need for reimplantation is necessary 2
• When indicated, definite reimplantation should be postponed to allow a few days or weeks of antibiotic therapy 2

Outpatient Parenteral Antibiotic Therapy (OPAT)

• During the critical phase (first 2 weeks), inpatient treatment is preferred 2
• OPAT may be considered after 2 weeks if the patient is medically stable 2
• OPAT should not be considered if the patient has heart failure, concerning echocardiographic features, neurological signs, or renal impairment 2
• Regular post-discharge evaluation is essential (nurses daily, physician in charge 1-2 times/week) 2

Special Considerations

Intensive Care Management

• Patients with severe sepsis or septic shock should be managed according to protocolized international guidelines 2
• Emergency/salvage surgery carries the highest mortality rates in registry data 2
• Decision-making for critically ill patients should involve the multidisciplinary Endocarditis Team 2

Right-Sided Infective Endocarditis

• Common in patients with pacemakers, ICDs, central venous catheters, congenital heart disease, and intravenous drug users 2
• Staphylococcus aureus is the predominant organism (60-90% of cases) 2
• The frequency of polymicrobial infections is increasing 2

Prevention

• Routine antibiotic prophylaxis is recommended before cardiac device implantation 2
• Potential sources of sepsis should be eliminated ≥2 weeks before implantation of an intravascular/cardiac foreign material, except in urgent procedures 2

Pitfalls and Caveats

• Delayed diagnosis and treatment significantly worsen prognosis 5
• Inadequate use of diagnostic tools (blood cultures and echocardiography) can lead to poor outcomes 5
• Methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci pose significant clinical challenges 6
• For patients with S. bovis/S. gallolyticus IE, investigation for occult colorectal cancer is recommended 1
• Early consultation with a cardiac surgeon is essential to determine the best therapeutic approach 2