Bacterial Endocarditis

Aka: Bacterial Endocarditis, Infective Endocarditis, Infectious Endocarditis, Subacute Bacterial Endocarditis, Acute Endocarditis, Osler Node, Osler's Node, Janeway Lesion, Roth Spot, Roth's Spot, Prosthetic Valve Endocarditis

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II. Epidemiology

  1. Incidence: 5-8 cases per 100,000 persons in U.S.
  2. Native valve affected in over 70-80% of cases
  3. Acute mortality in hospitalized patients is as high as 15-20% (and 5 year mortality approaches 40%)
  4. Hospital acquired cases (Nosocomial Infections) are increasing in Incidence
  5. Age
    1. Median age of onset: 58 years old
    2. Males older than 50 years are more commonly affected
    3. Increasing Incidence in those over age 65 years old
      1. Related to degenerative Heart Valve Disease and implanted devices
    4. Uncommon in children outside of specific risk factors (esp. Congenital Heart Disease, indwelling venous catheters)

III. Types: Infective Endocarditis

  1. Native Valve Infective Endocarditis
    1. Community Acquired
    2. Health-Care Associated (Nosocomial Infectious Endocarditis)
    3. IV Drug Abuse
  2. Prosthetic Valve Endocarditis
    1. Early infection (<2 months after Heart Valve Replacement)
      1. Intraoperative prosthetic contamination
      2. Postoperative Infection
    2. Mid-Term Infection (2-12 months after Heart Valve Replacement)
    3. Late infection (>12 months after Valve Replacement)
      1. Same bloodborne pathogen entry as with native valves
      2. Risk of perivalvular invasion (e.g. myocardial abscess, Pericarditis)

IV. Types: Noninfective Endocarditis

  1. Endocarditis is assumed to be infectious initially
    1. These non-Bacterial valvular lesions form part of the differential diagnosis of valvular vegetations
  2. Nonbacterial Thrombotic Endocarditis (NBTE)
    1. Small, sterile, non-inflammatory vegetations form on the surface of previously normal valves
    2. Associated with Hypercoagulable state (e.g. pregnancy) and with catheter-related valvular injury
  3. Libman-Sacks Lesions
    1. Associated with Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome
    2. May also be seen with HIV Infection, COVID-19, Granulomatosis with Polyangiitis
    3. Platelet and Fibrin vegetations form along valve leaflet closure
  4. Merantic Endocarditis
    1. Large thrombotic, non-Bacterial vegetations may form on abnormal valves with significant risk of embolic complications
    2. Associated with Disseminated Intravascular Coagulation, mucinous adenocarcinoma, chronic wasting or chronic infection
  5. References
    1. Ibrahim (2023) Libman Sacks Endocarditis, StatPearls, Treasure Island, FL, accessed 4/24/2023
    2. Hurrell (2020) Heart 106(13):1023-29 +PMID: 32376608 [PubMed]

V. Pathophysiology

  1. Two factor combination predisposes to the development of endocarditis
    1. Cardiac lesion: Intracardiac surface upon which the pathogens can adhere
      1. Prosthetic Heart Valve
      2. Native valve with congenital or acquired defect
    2. Bloodborne pathogen
      1. Bacteria
      2. Fungi
  2. Native Heart Valve Injury and Infection (80% of Infectious Endocarditis cases)
    1. Mitral valve and aortic valve are most likely to be involved
    2. Starts with endothelial damage
      1. Turbulent flow (e.g. valvular stenosis or valvular regurgitation)
      2. Intravascular device-related injury (e.g. catheters)
      3. Chronic inflammation (e.g. IVDA contaminated by particular matter)
    3. Injured endotholelium colonized with transient bacteremia (e.g. dental procedures, GI/GU surgery)
  3. Prosthetic Valve Infection (20% of Infectious Endocarditis cases)
    1. Infection types depend on timing from Prosthetic Valve Endocarditis (see above)
    2. Infection occurs at prosthetic valve sewing cuff or localized thrombus
      1. Unlike native valves, the prosthetic valve is inherently susceptible to infection

VI. Risk Factors

  1. Degenerative valvular disease (80% of native valve endocarditis cases)
    1. Primarily affect left sided Heart Valves (contrast with right sided involvement in IVDA)
    2. Mitral Regurgitation (43.4%)
    3. Aortic Regurgitation (26.3%)
    4. Calcific valvular heart disease
    5. Rheumatic Heart Disease (3.3%)
      1. Much higher Incidence in developing countries where Rheumatic Heart DiseaseIncidence still 10-15 per 1000
    6. Valve Replacement
      1. Risk 4% within first year of replacement, and 1% cumulative Incidence thereafter
  2. IV Drug Abuse (~10% of native valve endocarditis cases)
    1. Less than 50% of endocarditis in IV Drug Abuse is associated with a pre-existing structural cardiac defect
    2. IVDA and fever is associated with endocarditis in up to 15% (and bacteremia in up to 25-40%)
    3. Higher risk with Immunosuppression (e.g. HIV Infection)
    4. Staphylococcus Aureus infection is most common
    5. Tricuspid valve endocarditis is nearly pathognomonic for IV Drug Abuse
      1. Tricuspid valve is rarely involved in other causes of Bacterial Endocarditis
      2. Larger bloodborne particulate matter in IVDA typically deposits on the tricuspid valve
      3. Smaller particulate matter (<10 um) may pass through lung capillaries and deposit on aortic valve or mitral valve
    6. Atypical presentation due to primarily right sided involvement
      1. No murmur typically heard
      2. Associated with septic pulmonary emboli
      3. Not associated with Splinter Hemorrhages or Conjunctival Hemorrhage
  3. Hospitalization or long-term care stay (Nosocomial Infectious Endocarditis)
    1. Defined as endocarditis onset within 3-60 days of a health care facility admission
    2. Accounts for 20% of Infectious Endocarditis
    3. Typically associated with invasive procedures or Intravenous Access
  4. Other Major Risk Factors
    1. Hemodialysis (7.9%)
    2. Chronic Intravenous Access
    3. Immunosuppression

VII. Causes: Predisposing lesion (60-80% of patients)

  1. Prosthetic Heart Valve
  2. Rheumatic Heart Disease (30%)
    1. Mitral valve more affected than Aortic valve
  3. Congenital Heart Disease (10-20%)
    1. Bicuspid aortic valve
    2. Pulmonary stenosis
    3. Ventricular Septal Defect
  4. Mitral Valve Prolapse (10-33%)
  5. Calcific Aortic Stenosis
  6. Asymmetric septal hypertrophy
  7. Marfan's Syndrome

VIII. Causes: Infection Sources

  1. IV Drug Abuse or IV Catheter related phlebitis
    1. Staphylococcus Aureus
    2. Group A Streptococcus
    3. Gram Negative Rods
    4. Candida
  2. Dental procedures (including routine tooth cleaning)
    1. Viridans Streptococci
  3. Genitourinary procedures (includes Prostatic Massage)
    1. Enterococcus
    2. Gram Negative Rods
  4. Prosthetic Valve Recipient
    1. Staphylococcus Epidermidis
    2. Staphylococcus Aureus
    3. Diphtheroids
    4. Gram Negative Rods
    5. Candida
    6. Enterococcus
  5. Colonic neoplasm, villous adenoma or polyp
    1. Streptococcus bovis
  6. Homelessness or Alcoholism (and Body Lice)
    1. Bartonella Quintana
  7. Obstetric delivery
  8. Respiratory infection
  9. Skin Infection
  10. Cardiac surgery or cardiac catheterization

IX. Causes: Bacteria

  1. Staphylococcus Aureus (31%, esp. IV Drug Abuse)
  2. Viridans Streptococcus (17%)
  3. Coagulase negative staphylococci (11%)
  4. Enterococci (11%)
  5. Streptococcus bovis (7%)
  6. Other causes (<2-5% each)
    1. Miscellaneous Streptococcus
    2. Fungi
    3. Gram negative HACEK Bacilli (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella)
    4. Gram Negative non-HACEK Bacilli
    5. Bartonella (responsible for high number of culture negative endocarditis cases)
    6. Brucella
    7. Coxiella

X. History

  1. Recent hospitalizations
  2. Recent infections
  3. Indwelling catheters or devices
  4. Recent dental procedures
  5. Known murmur
  6. Structural heart disease (e.g. valvular stenosis, valvular regurgitation)
  7. Prosthetic Heart Valve
  8. Prior Infective Endocarditis
  9. Intravenous Drug Abuse
  10. Hemodialysis
  11. Immunosuppression (e.g. Diabetes Mellitus, HIV Infection)

XI. Symptoms: Typical Presentation

  1. Most endocarditis patients do not appear ill or septic
  2. Prodrome type symptoms
    1. Fever (>80-90% of cases)
      1. May be absent in elderly or immunosuppressed
    2. Chills
    3. Diaphoresis
    4. Myalgias (especially large Muscle groups)
    5. Fatigue
    6. Weight loss
    7. Anorexia
    8. Arthralgia
    9. Malaise
    10. Pallor
  3. Non-productive cough
    1. Present in up to 24% of cases
    2. Better when supine, worse when upright
  4. Cardiopulmonary symptoms (variably present)
    1. Chest Pain
    2. Shortness of Breath
  5. Classic endocarditis signs as below
    1. May only be present in severe Acute Endocarditis

XII. Signs: Classic Presentation (Osler)

  1. Precautions
    1. These classic findings are seen in late immunologic vascular complications
    2. Ideally, Infectious Endocarditis is diagnosed earlier, before these historically classic findings occur
    3. Careful evaluation may identify multiple foci of infection
      1. Skin findings (see below)
      2. Pneumonia
      3. Perinephric Abscess
      4. Cerebral emboli (focal Cerebrovascular Accident findings - see above)
  2. Cardiovascular Findings
    1. Congestive Heart Failure
      1. Present in severe cases
    2. Systolic Murmur from Heart Valve
      1. New murmur auscultated in 48% of careful examinations
      2. Most often a valve regurgitation murmur
      3. Characteristics change on serial exams
      4. Absent in tricuspid valve involvement (rare outside of IV Drug Abuse)
    3. Splenomegaly
  3. Skin Findings (uncommon, ~5% of cases)
    1. Petechiae on mucus membranes (mouth, Conjunctiva)
      1. Non-specific, but most common skin finding on presentation
    2. Splinter Hemorrhages
      1. Non-blanching linear lesions beneath nails
    3. Osler Nodes
      1. Painful, raised, violaceous Nodules affecting pulp of fingers and toes
    4. Janeway Lesions
      1. Blanching, erythematous, painless hemorrhagic Nodules on palms or soles
    5. Roth Spots
      1. Small Retinal Hemorrhages with central pallor
      2. Exudative, edematous Retinal lesions
    6. Digital Clubbing
  4. Neurologic Findings in 33% of cases (perform careful Neurologic Exam)
    1. Cerebrovascular Accident with focal neurologic changes
    2. Encephalopathy
    3. Meningitis
    4. Seizures

XIII. Presentations: Other

  1. Fever with Cerebrovascular Accident
    1. Consider endocarditis related embolic stroke
    2. Stroke is the initial presentation of endocarditis in 23% of cases
    3. Emboli to the brain account for 65% of endocarditis related embolic events
  2. Fever with Back Pain
    1. Consider septic emboli resulting in Vertebral Osteomyelitis or Spinal Epidural Abscess
  3. Fever with Acute Congestive Heart Failure
    1. Acute Aortic Regurgitation (Aortic Insufficiency) may result from endocarditis, leading to acute CHF
  4. Fever with a new Atrioventricular Block
    1. Perivalvular abscess is associated with new AV Block

XIV. Precautions

  1. Endocarditis Diagnosis is often missed initially due to non-specific symptoms and signs
    1. Typically presents as a viral-like syndrome
    2. Patients often appear non-toxic initially
    3. Fever may not be present at visit (but reported at home)
    4. Murmurs are often absent or only intermittently present
    5. Consider Blood Cultures and close interval follow-up in undifferentiated fever with myalgias
  2. Red Flags for which Endocarditis should be considered
    1. Endocarditis risk factors
      1. Prosthetic or malformed Heart Valve
      2. Intravenous Drug Abuse (IVDA)
      3. Hemodialysis
    2. Unexplained symptoms
      1. Fever
      2. Night Sweats
      3. Systemic illness

XV. Labs

  1. Blood Culture
    1. Obtain before starting empiric therapy
    2. Cultures should be obtained with careful antiseptic technique (not off IV lines)
    3. Obtain at least 3-5 ml for small children, 10 ml if older per culture (20 ml is preferred)
    4. Blood Culture timing need not coincide with fever (bacteremia is continuous)
    5. Obtain three cultures over at least one hour
      1. Three cultures are recommended as sufficient
      2. Test Sensitivity has been shown in the past to increase with additional cultures
        1. Four cultures: >90% sensitive
        2. Six cultures: 100% sensitive
    6. Repeat Blood Cultures (2 sets) are performed as part of the Antibiotic protocol below
      1. Repeated if suspected endocarditis if initial 3 Blood Cultures negative at 24-48 hours
      2. If positive and on Antibiotics, repeat every 24-48 hours until Blood Cultures are negative
    7. False Negative Rate: 10%
      1. Antibiotics prior to obtaining cultures
      2. Consider Serologic Testing for fastidious Bacteria (Bartonella, Coxiella, and Chlamydia)
  2. Urinalysis
    1. Proteinuria
    2. Microscopic Hematuria
  3. Complete Blood Count
    1. Leukocytosis (only present in 50% of cases)
    2. Normochromic, Normocytic Anemia (50% of cases)
  4. Acute phase reactants and other lab markers
    1. C-RP and ESR are recommended in suspected endocarditis, but they may add little to diagnosis
      1. Low Test Specificity
      2. Low Test Sensitivity (increased in 66% of cases)
    2. C-Reactive Protein (C-RP) elevated
    3. Sedimentation Rate (ESR) elevated
    4. Complement
      1. CH50 or C3 decreased
    5. Rheumatoid Factor positive
      1. Circulating immune complex
    6. Procalcitonin
      1. Not recommended routinely in endocarditis evaluation
      2. Yu (2013) Am J Emerg Med 31(6):935-41 [PubMed]
  5. Miscellaneous labs
    1. Comprehensive metabolic panel (all cases)
    2. Consider Coxiella and ChlamydiaSerology
    3. BartonellaSerology (Antibody titers >1:800) or tissue biopsy PCR
      1. Consider in culture negative cases, esp Alcoholism or Homelessness (or cat exposure)
  6. Markers of cardiac injury (consider as part of differential diagnosis depending on presentation)
    1. Serum Troponin
    2. Brain Natriuretic Peptide (BNP)

XVI. Diagnostics: Electrocardiogram (EKG)

  1. Evaluate for endocarditis complications as well as differential diagnosis
  2. Conduction abnormality in 26% of cases
  3. New AV nodal block (13% of cases)
    1. Periannular extension (valvular annulus, septum, Myocardium)
    2. Conduction abnormalities are seen in up to 26% of patients
    3. Associated with invasive infection and worse prognosis
    4. See complications below
    5. Meine(2001) Am Heart J 142(2):280-5 +PMID:11479467 [PubMed]
  4. Myocardial Ischemia or infarction
    1. Coronary emboli

XVII. Diagnosis

  1. See Duke Criteria for Infectious Endocarditis Diagnosis

XVIII. Imaging: Echocardiogram

  1. Transthoracic Echocardiogram
    1. Cornerstone of Duke Criteria for Infectious Endocarditis Diagnosis
    2. Recommended in all patients with suspected endocarditis
    3. Consider repeating Echocardiogram in 7-10 days in early cases, with high suspicion
    4. Findings
      1. Cannot differentiate active from healed lesion
      2. Vegetation in native valve endocarditis
        1. Test Sensitivity: 80% (range 50-90%), and very high in children
        2. Test Specificity: 90%
        3. Efficacy is much lower in Prosthetic Valve Endocarditis
      3. Other findings
        1. Systolic function
        2. Valvular function
        3. Endocarditis Complications
  2. Transesophageal Echocardiogram
    1. Efficacy
      1. Test Sensitivity for native valve Infective Endocarditis: 90-100%
      2. Efficacy is slightly lower for prosthetic valves
    2. Indications
      1. Staphylococcus bacteremia
      2. Thoracic views non-diagnostic or limited by Obesity
      3. Prosthetic valve (shadowing interferes with adequate valve viewing)
      4. Endocarditis prior history
      5. Structural valve abnormality

XIX. Imaging: Additional

  1. Chest XRay (all suspected Infectious Endocarditis cases)
    1. Evaluate differential diagnosis
    2. Lung Abscess
    3. Pulmonary Infarction
    4. Congestive Heart Failure
  2. Advanced imaging
    1. Imaging as needed for embolic events (e.g. MRI Brain)
    2. Cardiac Imaging (e.g. Cardiac MRI, ekg-gated Cardiac CT)
    3. PET/CT (18F-FDG) or SPECT/CT (Leukocyte labeled)
      1. Consider in suspected Prosthetic Valve Endocarditis

XX. Differential Diagnosis

  1. Viral syndrome
  2. Acute Rheumatic Fever
  3. Atrial Myxoma
  4. Libman-Sacks Endocarditis
    1. Non-Bacterial Endocarditis associated with Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome
  5. Marantic Endocarditis
    1. Nonbacterial thrombotic endocarditis (NBTE) associated with adenocarcinoma
  6. Primary neurologic disorder
  7. Occult neoplasm
  8. Myocarditis
  9. Fever of Unknown Origin (bacteremia from other occult causes)
  10. IV Drug Abuse
  11. Central catheter Sepsis
  12. Spinal Epidural Abscess

XXI. Management: General Measures

  1. Early multi-specialty Consultation (cardiology, cardiothoracic surgery, infectious disease)
  2. See ABC Management
  3. See Acute Pulmonary Edema Management
  4. See Septic Shock
  5. Remove implantable cardioverter Defibrillators and Pacemakers with evidence of device infection
  6. Other longterm measures
    1. Remove IV catheters as soon as Antibiotics are completed
    2. Repeat Echocardiogram at the end of Antibiotic therapy
      1. Documents new baseline echo

XXII. Management: Antibiotics

  1. Obtain Blood Cultures before starting empiric therapy (see above)
  2. In non-critically ill patients, delay treatment until Blood Culture and Echocardiogram confirm diagnosis
    1. If Septic Shock or other hemodynamic instability, Antibiotics must be started after cultures obtained
    2. Do not delay treatment beyond Blood Cultures in children (rapid decompensation may occur)
  3. Antibiotic Course
    1. Antibiotics IV for at least 4 weeks (native valves) to at least 6 weeks (prosthetic valves)
    2. Specific to organisms cultured
    3. Duration of therapy is based from the first day in which Blood Cultures are negative
      1. Obtain two sets of Blood Cultures every 24-48 until Blood Cultures are negative
    4. Antibiotics are initiated inpatient and then when clinically stable, at home via home care
      1. Re-evaluation in clinic following discharge should be within 7-14 days
      2. Obtain Complete Blood Count, Serum Creatinine and Antibiotic levels at follow-up
  4. Antibiotics: Initial Empiric Treatment
    1. Protocol 1 - Native Valve
      1. Vancomycin 15-20 mg/kg every 8-12 hours IV (max 2 g, target trough 15-20 mcg/ml) AND
      2. Ceftriaxone 2 grams every 24 hours IV
    2. Protocol 2 - Native Valve
      1. Vancomycin 15-20 mg/kg every 8-12 hours IV (max 2 g, target trough 15-20 mcg/ml) AND
      2. Gentamicin 1 mg/kg every 8 hours IV or IM
    3. Protocol 3 - Prosthetic Valve
      1. Vancomycin 15-20 mg/kg every 8-12 hours IV (max 2 g, target trough 15-20 mcg/ml) AND
      2. Gentamicin 1 mg/kg every 8 hours IV or IM AND
      3. Rifampin 300 mg PO/IV every every 8 to 12 hours
    4. Alternative agents
      1. Vancomycin alternative in native valve empiric therapy
        1. Daptomycin 6 mg/kg IV every 24 hours (every 48 hours if Creatinine Clearance <30 ml/min)
  5. Antibiotics: Viridans Streptococcus or Streptococcus bovis
    1. Penicillin Susceptible
      1. Penicillin G or Ceftriaxone for 4 weeks or
      2. Gentamicin AND (Penicillin G or Ceftriaxone) for 2 weeks or
      3. Vancomycin 15-20 mg/kg every 8-12 hours IV (target trough 15-20 mcg/ml) for 4 weeks
        1. Beta-lactams are preferred over Vancomycin, unless Antibiotic Resistance, allergy
    2. Penicillin Intermediate Sensitivity
      1. Gentamicin for 2 weeks AND (Penicillin G or Ceftriaxone) for 4 weeks or
      2. Vancomycin 15-20 mg/kg every 8-12 hours IV (target trough 15-20 mcg/ml) for 4 weeks
    3. Penicillin Resistant
      1. Gentamicin AND (Penicillin G or Ampicillin) for 4 to 6 weeks or
      2. Vancomycin 15-20 mg/kg every 8-12 hours IV (target trough 15-20 mcg/ml) for 6 weeks
  6. Antibiotics: Coagulase negative Staphylococcus
    1. Background
      1. Second most common endocarditis cause following Valve Replacement (and frequent Blood Culture contaminant)
      2. Staphylococcus lugdunensis is a virulent coagulase negative Staphylococcus that may also infect native valves
    2. Oxacillin-Susceptible (Coagulase negative Staphylococcus)
      1. Nafcillin or Oxacillin for 6 weeks AND
      2. Rifampin 300 mg IV/PO for 6 weeks AND
      3. Gentamicin 1 mg/kg every 8 hours IV or IM for 2 weeks
    3. Oxacillin-Resistant (Resistant coagulase negative Staphylococcus)
      1. Vancomycin 15-20 mg/kg every 8-12 hours IV (target trough 15-20 mcg/ml) for 6 weeks AND
      2. Rifampin 300 mg IV/PO for 6 weeks AND
      3. Gentamicin 1 mg/kg every 8 hours IV or IM for 2 weeks
  7. Antibiotics: Staphylococcus Aureus
    1. MSSA
      1. Nafcillin or Oxacillin for 6 weeks AND
      2. Rifampin 300 mg IV/PO (if prosthetic valve) for 6 weeks AND
      3. Gentamicin 1 mg/kg every 8 hours IV or IM (if prosthetic valve) for 2 weeks
    2. MRSA
      1. Vancomycin 15-20 mg/kg every 8-12 hours IV (target trough 15-20 mcg/ml) for 6 weeks AND
      2. Rifampin 300 mg IV/PO (if prosthetic valve) for 6 weeks AND
      3. Gentamicin 1 mg/kg every 8 hours IV or IM (if prosthetic valve) for 2 weeks
  8. Antibiotics: Enterococcus
    1. Penicillin, Ceftriaxone, Gentamicin, Vancomycin sensitive
      1. Ceftriaxone and Ampicillin for 6 weeks or
      2. Gentamicin and (Ampicillin or Penicillin G) for 4 to 6 weeks (4 weeks for native valve) or
      3. Gentamicin and Vancomycin for 6 weeks
    2. Penicillin, and Vancomycin (and Streptomycin) sensitive, but resistant to Gentamicin
      1. Streptomycin and (Ampicillin or Penicillin G) for 4 to 6 weeks or
      2. Streptomycin and Vancomycin for 6 weeks
    3. Gentamicin and Vancomycin sensitive, but resistant to Penicillin
      1. Gentamicin and Ampicillin-Sulbactam (Unasyn) for 6 weeks or more or
      2. Gentamicin and Vancomycin for 6 weeks
  9. Antibiotics: Gram Negatives
    1. Ceftriaxone for 4-6 weeks (6 weeks for prosthetic valves)
  10. Antibiotics: Bartonella
    1. Ceftriaxone 2 g IV every 24 hours for 6 weeks (or until Bartonella confirmed as causative) AND
    2. Gentamicin 1 mg/kg IV every 8 hours for first 2 weeks (or Rifampin 300 mg IV or oral) AND
    3. Doxycycline 100 mg oral or IV twice daily for 6 weeks (or Azithromycin 250 mg daily)
  11. Experimental
    1. Oral Antibiotics for endocarditis may be effective after using 2 weeks of IV Antibiotic therapy as above
      1. Stable patients with negative Blood Cultures
    2. May be indicated in left sided endocarditis native or prosthetic valve (mitral valve or aortic valve)
      1. Could be considered in non-compliant patients who refuse to continue IV medications
      2. Alternatively once weekly ParenteralAntibiotics may be considered (e.g. Dalbavancin, Oritavancin)
    3. Oral Protocols
      1. Streptococcus or Enterococcus
        1. Amoxicillin 1000 mg four times daily (high dose)
      2. Staphylococcus (MSSA)
        1. Dicloxacillin 1000 mg four times daily (high dose) AND Rifampin
      3. MRSA
        1. Linezolid
    4. References
      1. (2018) Presc Lett 25(11):62
      2. (2023) Presc Lett 30(1)
      3. Iversen (2018) N Engl J Med +PMID:30152252 [PubMed]
  12. References
    1. Gilbert (2016) Sanford Guide to Antibiotics, IOS app accessed 4/13/2016
    2. Bonow (2006) J Am Coll Cardiol 48(3): e1-e148 [PubMed]

XXIII. Management: Cardiovascular Surgery

  1. Indications (required in 50% of cases)
    1. Moderate to Severe Acute Heart Failure (Pulmonary Edema, Cardiogenic Shock)
      1. Most common indication (esp. for surgically treatable process, regardless of IE confirmation)
    2. Fungal endocarditis or other difficult to treat organisms
    3. Prosthetic Valve Endocarditis (higher risk of Heart Failure and invasive infection)
      1. Highest risk in first 3 months after surgery (as well as for the first year after surgery)
      2. May be compounded by other prosthetic valve complications (e.g. thrombosis, regurgitation, Hemolysis)
    4. Persistently positive Blood Culture despite therapy beyond the first week
    5. Recurrent emboli in the first 2 weeks of treatment
    6. Severe valvular regurgitation (Aortic Regurgitation, Mitral Regurgitation)
      1. Best outcomes with early surgery (regardless of Infective Endocarditis)
    7. Large vegetation
    8. Paravalvular extension of infection (persistent fevers or positive cultures despite Antibiotics, identified on TEE)
      1. Valve ring or myocardial abscess
      2. Valve dehiscence or fistula
      3. Heart Block or other EKG conduction defects
  2. Efficacy
    1. Based on retrospective study
    2. Early surgery improves survival over Antibiotic alone
      1. Surgery within first 2 days of admission
      2. Survival
        1. Surgery patient survival: 79% in hospital (60% at 8 year follow-up)
        2. Medical therapy (Antibiotics without surgery) survival: 55% in hospital (35% at 8 years)
    3. References
      1. Bishara (2001) Clin Infect Dis 33:1636-43 [PubMed]
      2. Murdoch (2009) Ann Intern Med 169(5): 463-73 [PubMed]

XXIV. Complications

  1. Cardiovascular complications (30-50% of cases)
    1. Precautions
      1. Cardiovascular complications are the most common cause for surgery and for death
    2. Heart Failure (right or left) typically due to Valvular Regurgitation
      1. See Cardiogenic Shock
      2. Associated with poor prognosis
      3. Valve perforation
      4. Mitral chordae rupture
      5. Valve obstruction (large vegetation)
    3. Perivalvular abscess (up to 30-40% of cases)
      1. Associated with worse prognosis (systemic embolization risk)
      2. Associated with conduction abnormalities (esp. when aortic valve involved)
      3. Consider when EKG abnormalities or persistent fever or bacteremia despite Antibiotics
    4. Periannular or Perivalvular extension of infection (myocardial abscess, valve ring, Valve dehiscence, septal fistula)
      1. May present as a new AV Nodal Block
      2. Increased mortality risk
      3. May require cardiac pacing
    5. Other cardiac complications
      1. Valvular destruction (valve cusps, leaflets or chordae tendinae)
      2. Pericarditis
      3. Aortic valve dissection
      4. Intracardiac fistula
  2. Renal complications
    1. Glomerulonephritis
    2. Renal Infarction
    3. Renal Abscess
  3. Musculoskeletal complications (esp. Staphylococcus aureus Infective Endocarditis)
    1. Vertebral Osteomyelitis
    2. Septic Arthritis
  4. Neurologic complications (33% of cases)
    1. Cerebrovascular Accident (CVA) or Transient Ischemic Attack (TIA)
      1. Typically affects the Middle Cerebral Artery distribution
    2. CNS emboli
      1. Stop Anticoagulation for 2 weeks in Staphylococcus aureus Prosthetic Valve Endocarditis with CNS emboli
    3. Mycotic aneurysm (rare)
    4. Meningitis
    5. Encephalitis or encephalopathy
    6. Cerebral mycotic aneurysm
    7. Cerebral Abscess
    8. Cerebral Hemorrhage
    9. Seizure Disorder
  5. Miscellaneous complications
    1. Septic Shock
    2. Splenic infarction
    3. Pulmonary Embolism and Lung Infarction

XXV. Prevention: Recurrent Endocarditis

  1. Obtain 3 Blood Culture sets at each subsequent febrile illness (prior to start of Antibiotics)
  2. Practice good Dental Hygiene with regular dental visits
  3. Endocarditis Prophylaxis
    1. See SBE Prophylaxis for indicated procedures

XXVI. Prognosis: Poor prognostic factors

  1. Advanced age
  2. Female gender
  3. Staphylococcus aureus Infective Endocarditis
  4. Healthcare-associated infection
  5. Heart Failure
  6. Prosthetic Valve Endocarditis
  7. Diabetes Mellitus
  8. Embolization complications
  9. Perivalvular Abscess
  10. Large vegetations
  11. Altered Mental Status
  12. Cardiac conduction abnormalities on EKG (see above)
  13. Other conditions associated with poor surgical candidacy

XXVII. References

  1. (2015) Presc Lett 22(12): 69
  2. Carr and Swaminathan in Herbert (2022) EM:Rap 22(2): 5-7
  3. Orman and Mattu in Herbert (2015) EM:Rap 15(1): 9-11
  4. Pacheco and Rawani-Patel (2019) Crit Dec Emerg Med 33(5): 3-11
  5. Pelletier (1991) in Harrison's Medicine, p. 972
  6. Vlasic (2015) Crit Dec Emerg Med 29(7): 12-9
  7. Vlasic (2021) Crit Dec Emerg Med 35(1): 17-24
  8. Baddour (2015) Circulation 132: 1435-86 +PMID: 26373316 [PubMed]
  9. Habib (2009) Eur Heart J 30(19): 2369-413 [PubMed]
  10. Hoen (2013) N Engl J Med 368(15):1425-33 +PMID:23574121 [PubMed]
  11. Murdoch (2009) Arch Intern Med 169(5): 463-73 [PubMed]
  12. Pierce (2012) Am Fam Physician 85(10): 981-6 [PubMed]

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Related Studies

Ontology: Bacterial Endocarditis (C0014121)

Definition (CSP) infection occuring when bacteria in the bloodstream (bacteremia) adhere to abnormal heart valves or other damaged heart tissue; characterized by growths, known as vegetations, on the valves or other areas of the heart which can break off, travel to other parts of the body, and cause serious complications; a common causative bacteria is staphylococcus, but any organism entering the bloodstream from any site of prior infection can result in the infection.
Definition (MSH) Inflammation of the ENDOCARDIUM caused by BACTERIA that entered the bloodstream. The strains of bacteria vary with predisposing factors, such as CONGENITAL HEART DEFECTS; HEART VALVE DISEASES; HEART VALVE PROSTHESIS IMPLANTATION; or intravenous drug use.
Concepts Disease or Syndrome (T047)
MSH D004697
SnomedCT 50194006, 194922003, 301183007
English Bacterial Endocarditides, Bacterial Endocarditis, Endocarditides, Bacterial, Endocarditis, Bacterial, ENDOCARDITIS BACT, BACT ENDOCARDITIDES, ENDOCARDITIDES BACT, BACT ENDOCARDITIS, bacterial endocarditis (diagnosis), bacterial endocarditis, Endocarditis bacterial NOS, Endocarditis infective, Endocarditis, Bacterial [Disease/Finding], Endocarditis;bacterial, bacterial infection of the heart valve, infective endocarditis, Endocarditis bacterial, Bacterial endocarditis, BE - Bacterial endocarditis, Bacterial endocarditis (disorder), bacterial; endocarditis, endocarditis; bacterial, Bacterial endocarditis, NOS, Bacterial endocarditis (disorder) [Ambiguous], Endocarditis, bacterial, Endocarditis, infective NOS
Dutch bacteriële endocarditis, endocarditis bacterieel NAO, endocarditis infectieus, bacterieel; endocarditis, endocarditis; bacterieel, endocarditis bacterieel, Bacteriële endocarditis, Endocarditis, bacteriële
French Endocardite infectieuse, Endocardite bactérienne SAI, Endocardite bactérienne
German Endokarditis bakteriell NNB, infektioese Endokarditis, Bakterielle Endokarditis, bakterielle Endokarditis, Endokarditis, bakterielle
Italian Endocardite batterica NAS, Endocardite infettiva, Endocarditi batteriche, Endocardite batterica
Portuguese Endocardite bacteriana NE, Endocardite infecciosa, Endocardite bacteriana, Endocardite Bacteriana
Spanish Endocarditis bacteriana NEOM, Endocarditis infecciosa, endocarditis bacteriana (trastorno), endocarditis bacteriana, Endocarditis bacteriana, Endocarditis Bacteriana
Japanese 細菌性心内膜炎ＮＯＳ, ｻｲｷﾝｾｲｼﾝﾅｲﾏｸｴﾝ, ｻｲｷﾝｾｲｼﾝﾅｲﾏｸｴﾝNOS, ｶﾝｾﾝｾｲｼﾝﾅｲﾏｸｴﾝ, 感染性心内膜炎, 心内膜炎-感染性, 心内膜炎-細菌性, 細菌性心内膜炎
Swedish Endokardit, bakteriell
Finnish Bakteeriendokardiitti
Russian ENDOKARDIT INFEKTSIONNYI, ENDOKARDIT BAKTERIAL'NYI, ЭНДОКАРДИТ БАКТЕРИАЛЬНЫЙ, ЭНДОКАРДИТ ИНФЕКЦИОННЫЙ
Czech Infekční endokarditida, Bakteriální endokarditida, Bakteriální endokarditida NOS, bakteriální endokarditida, endokarditida bakteriální
Croatian ENDOKARDITIS, BAKTERIJSKI, BAKTERIJSKI ENDOKARDITIS
Polish Zapalenie wsierdzia bakteryjne
Hungarian Bacterialis endocarditis, bacterialis endocarditis, bacterialis endocarditis k.m.n., Endocarditis infectiosa
Norwegian Bakteriell endokarditt, Endokarditt, bakteriell
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Subacute Bacterial Endocarditis (C0014122)

Definition (NCI) Subacute inflammation of the endocardium. Streptococcus viridans is the usual etiologic agent of SBE. The distinction between "acute" and "subacute" endocarditis has traditionally been made based on the pathogenic organism and clinical presentation.
Definition (MSH) ENDOCARDIUM infection that is usually caused by STREPTOCOCCUS. Subacute infective endocarditis evolves over weeks and months with modest toxicity and rare metastatic infection.
Concepts Disease or Syndrome (T047)
MSH D004698
SnomedCT 155334001, 194923008, 73774007, 50194006
English Bacterial Endocarditides, Subacute, Bacterial Endocarditis, Subacute, Endocarditides, Subacute Bacterial, Endocarditis Lenta, Endocarditis, Subacute Bacterial, Subacute Bacterial Endocarditides, Subacute Bacterial Endocarditis, SBE - Subacute bact endocard, Subacute bact endocarditis, ENDOCARDITIS SUBACUTE BACT, BACT ENDOCARDITIS SUBACUTE, SUBACUTE BACT ENDOCARDITIS, BACT ENDOCARDITIDES SUBACUTE, SUBACUTE BACT ENDOCARDITIDES, ENDOCARDITIDES SUBACUTE BACT, subacute bacterial endocarditis, subacute bacterial endocarditis (diagnosis), SBE (subacute bacterial endocarditis), Endocarditis, Subacute Bacterial [Disease/Finding], infectious endocarditis, endocarditis lenta, sbe, bacterial endocarditis subacute, endocarditis infectious, ie, SBE, Endocarditis lenta, Subacute bacterial endocarditis, SBE - Subacute bacterial endocarditis, Subacute bacterial endocarditis (disorder), endocarditis; lenta, infectious; endocarditis, lenta; endocarditis, Endocarditis, lenta, Subacute endocarditis, bacterial, Subacute endocarditis, lenta, Subacute bacterial endocarditi
Dutch subacute bacteriële endocarditis, endocarditis; lenta, infectieus; endocarditis, lenta; endocarditis, Endocarditis lenta, Bacteriële endocarditis, subacute, Endocarditis, subacute bacteriële, Subacute bacteriële endocarditis
French EBS, Endocardite bactérienne sous-aiguë, Endocardite bactérienne subaiguë, Endocardite bactérienne subaigüe, Endocardite maligne lente, Endocardite d'Osler, Endocardite lente, Maladie d'Osler, Maladie de Jaccoud-Osler
German SBE, subakute bakterielle Endokarditis, Subakute bakterielle Endokarditis, Endocarditis lenta, Endokarditis, subakute bakterielle
Portuguese Endocardite bacteriana subaguda, Endocardite Bacteriana Subaguda, Endocardite Lenta
Spanish Endocarditis bacteriana subaguda, EBS, endocarditis bacteriana subaguda, endocarditis infecciosa subaguda (trastorno), endocarditis infecciosa subaguda, Endocarditis Bacteriana Subaguda, Endocarditis Lenta
Swedish Endokardit, subakut bakteriell
Japanese ｱｷｭｳｾｲｻｲｷﾝｾｲｼﾝﾅｲﾏｸｴﾝ, 心内膜炎-亜急性細菌性, 亜急性細菌性心内膜炎, 亜急性心内膜炎, 遅延性心内膜炎, 遷延性心内膜炎, 心内膜炎-亜急性, 心内膜炎-細菌性-亜急性, 心内膜炎-遅延性, 心内膜炎-遷延性
Czech endokarditida bakteriální subakutní, SBE, Subakutní bakteriální endokarditida
Finnish Subakuutti bakteeriendokardiitti
Italian Endocarditi batteriche subacute, Endocardite lenta, Endocardite batterica subacuta
Russian ENDOKARDIT SEPTICHESKII PODOSTRYI, ENDOKARDIT INFEKTSIONNYI PODOSTRYI, ENDOKARDIT BASTERIAL'NYI PODOSTRYI, ЭНДОКАРДИТ БАСТЕРИАЛЬНЫЙ ПОДОСТРЫЙ, ЭНДОКАРДИТ ИНФЕКЦИОННЫЙ ПОДОСТРЫЙ, ЭНДОКАРДИТ СЕПТИЧЕСКИЙ ПОДОСТРЫЙ
Polish Zapalenie wsierdzia podostre bakteryjne
Hungarian Bacterialis subacut endocarditis, SBE
Norwegian Subakutt bakteriell endokarditt, Endokarditt, subakutt bakteriell, Endocarditis lenta
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Osler's node (C0240608)

Concepts Sign or Symptom (T184)
SnomedCT 63757006
Italian Noduli di Osler
Japanese オスラー結節, ｵｽﾗｰｹｯｾﾂ
Czech Oslerovy uzly
English Osler's nodes, Osler node, nodes osler, nodes oslers, osler's nodes, osler node, node oslers, osler's node, Osler's node, Osler's node (disorder), Osler; node, node; Osler
Hungarian Osler-csomók
Dutch Osler; nodus, nodus; Osler, nodi van Osler
Spanish nódulo de Osler (trastorno), nódulo de Osler, Nódulos de Osler
Portuguese Nódulos de Osler
French Nodules d'Osler
German Osler-Knoetchen
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Roth spots (C0240916)

Concepts Finding (T033)
SnomedCT 95688008
Dutch vlekken van Roth
French Taches de Roth
German Roth-Flecken
Italian Macchie di Roth
Portuguese Manchas de Roth
Spanish Manchas de Roth, manchas de Roth (trastorno), manchas de Roth, manchas de Roth (hallazgo)
Japanese ロート斑, ﾛｰﾄﾊﾝ
English Roth's spots were observed, Roth's spots (physical finding), roth's spot, roth spot, roths spots, roth spots, roth's spots, roths spot, Roth's spots, Roth spots, Roth's spots (disorder), Roth's spots (finding)
Czech Rothovy skvrny
Hungarian Roth-foltok
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Prosthetic valve endocarditis (C0340359)

Concepts Disease or Syndrome (T047)
SnomedCT 233853009
English PVE - Prosth valv endocarditis, prosthetic valve endocarditis (diagnosis), prosthetic valve endocarditis, endocarditis prosthetic valve, PVE - Prosthetic valve endocarditis, Prosthetic valve endocarditis, Prosthetic valve endocarditis (disorder)
Dutch kunstklependocarditis
French Endocardite sur prothèse valvulaire
German Endokarditis bei Herzklappenersatz
Italian Endocardite su valvola protesica
Portuguese Endocardite valvular prostética
Spanish Endocarditis de prótesis valvular, endocarditis de válvula protésica, endocarditis de válvula protésica (trastorno), endocarditis de prótesis valvular (trastorno), endocarditis de prótesis valvular
Japanese 人工弁心内膜炎, ｼﾞﾝｺｳﾍﾞﾝｼﾝﾅｲﾏｸｴﾝ
Czech Endokarditida chlopenní náhrady
Hungarian műbillentyű endocarditis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute endocarditis (C0375268)

Definition (NCI) Acute inflammation of the endocardium. Bacteria is the usual etiologic agent, and the distinction between "acute" and "subacute" has traditionally been made based on the pathogenic organism and clinical presentation.
Concepts Disease or Syndrome (T047)
ICD9 421.9
ICD10 I33.9
SnomedCT 194935007, 91357005
English Acute endocarditis, unspecified, acute endocarditis, acute endocarditis (diagnosis), Ac/subac endocardit NOS, Acute endocarditis NOS, Endocarditis;acute, endocarditis acute, Acute endocarditis NOS (disorder), Acute endocarditis, Acute endocarditis (disorder), acute; endocarditis, Acute endocarditis, NOS, Acute Endocarditis
Italian Endocardite acuta, Endocardite acuta non specificata
Dutch acute endocarditis, niet-gespecificeerd, acuut; endocarditis, Acute endocarditis, niet gespecificeerd, acute endocarditis
French Endocardite aiguë non précisée, Endocardite aiguë
German akute Endokarditis, unspezifisch, Akute Endokarditis, nicht naeher bezeichnet, akute Endokartitis
Portuguese Endocardite aguda NE, Endocardite aguda
Spanish Endocarditis aguda no especificada, endocarditis aguda, SAI, endocarditis aguda, SAI (trastorno), endocarditis aguda (trastorno), endocarditis aguda, Endocarditis aguda
Japanese 急性心内膜炎、詳細不明, 急性心内膜炎, ｷｭｳｾｲｼﾝﾅｲﾏｸｴﾝ, ｷｭｳｾｲｼﾝﾅｲﾏｸｴﾝｼｮｳｻｲﾌﾒｲ
Czech Akutní endokarditida, blíže neurčená, Akutní endokarditida
Korean 상세불명의 급성 심내막염
Hungarian acut endocarditis, k.m.n., acut endocarditis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Janeway lesion (C1532713)

Concepts Finding (T033)
SnomedCT 414550002
English Janeway lesion (finding), Janeway lesion
Spanish lesión de Janeway (hallazgo), lesión de Janeway
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Infective endocarditis (C1541923)

Definition (NCI) An infectious process involving the endocardial layer of the heart.
Definition (NCI_CTCAE) A disorder characterized by an infectious process involving the endocardial layer of the heart.
Concepts Disease or Syndrome (T047)
MSH D004696
SnomedCT 233850007, 50194006
English Endocarditides, Infective, Infective Endocarditides, Endocarditis, Infective, Infective Endocarditis, Endocarditis infective, infective endocarditis (diagnosis), IE - Infective endocarditis, Infective endocarditis (disorder), Infective endocarditis
French Endocardite infectieuse
German Infektiöse Endokarditis
Czech infekční endokarditida
Norwegian Endokarditt, infeksiøs, Infeksiøs hjerteklaffbetennelse, Infeksiøs endokarditt, Hjerteklaffbetennelse, infeksiøs
Spanish endocarditis infecciosa (concepto no activo), endocarditis infecciosa (trastorno), endocarditis infecciosa
Derived from the NIH UMLS (Unified Medical Language System)

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