Suspected infective endocarditis (adult)
Fever with a new regurgitant murmur, embolic events, or a risk factor (prosthetic valve, previous IE, injecting drug use, intracardiac device, rheumatic heart disease).
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Infectious DiseaseManagement
Infective Endocarditis Management (ESC 2023)
Infective Endocarditis Management (ESC 2023): Suspected infective endocarditis (adult) → Blood cultures before antibiotics, then first tests → Echocardi...
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Action Blood cultures before antibiotics, then first tests
Refer early to the Endocarditis Team (cardiology, infectious diseases, microbiology, cardiac surgery). Stroke signs: urgent brain imaging; no thrombolysis.
- 3 blood culture sets from separate venepunctures, 30 min apart, before antibiotics
- Septic or unstable: take the cultures quickly, then give empirical antibiotics without delay
- Transfer early to a hospital with cardiac surgery if: unstable, severe valve regurgitation, prosthetic valve or device IE, stroke, embolism, abscess or fistula, cultures positive >7 days, or S. aureus, Gram-negative or fungal IE
- ECG (new AV block suggests perivalvular abscess) and chest X-ray
- FBC, UEC, CRP, LFT, urinalysis
- Uncomplicated IE in a hospital without cardiac surgery: early and regular contact with the surgical centre's Endocarditis Team
03Action Echocardiography and imaging
TTE first in all patients. Then TOE in most patients, even if TTE is positive.
- TOE always if prosthetic valve or intracardiac device, or if TTE is negative or non-diagnostic
- TOE not needed only in isolated right-sided native valve IE with a clear, good-quality TTE
- Still suspected after negative imaging: repeat TTE/TOE within 5-7 days
- Possible NVE: cardiac CT angiography. Possible PVE: cardiac CT angiography and [18F]FDG-PET/CT
- Symptoms of emboli: brain and whole-body imaging (CT, MRI or PET/CT)
04Action Apply ESC 2023 diagnostic criteria
Definite: 2 major, or 1 major + 3 minor, or 5 minor. Possible: 1 major + 1-2 minor, or 3-4 minor.
- Major: typical organism in 2 separate blood cultures, or persistently positive cultures, or C. burnetii culture or phase I IgG >1:800
- Major: lesion typical of IE on echo, cardiac CT, [18F]FDG-PET/CT or WBC SPECT/CT
- Minor: predisposition, fever >38°C, embolic lesions (also on imaging only), immunological phenomena, other microbiology
- Possible IE: repeat blood cultures and TTE/TOE within 5-7 days; add cardiac CT and brain or whole-body imaging
05Warning Child, pregnancy or cardiac device? Specialist pathway first
This pathway is for adults with valve endocarditis. The doses below are adult doses.
- Child: use paediatric weight-based doses with paediatric ID and cardiology
- Pregnancy: add obstetric and neonatal teams to the Endocarditis Team; do not delay indicated surgery; check each drug for fetal risk; do not use doxycycline (ID advice for Q fever or Bartonella)
- Pacemaker or ICD lead IE: complete device system extraction without delay
06Warning Penicillin allergy, kidney or hearing problems, or anticoagulant? Check first
Gentamicin: once daily, maximum 240 mg/day, maximum 2 weeks. Check creatinine and levels at least weekly.
- Penicillin allergy: cefazolin only if the reaction was non-immediate; otherwise vancomycin. Get ID advice.
- Renal impairment, hearing or balance problems, older age: prefer regimens without gentamicin (ID advice)
- Warfarin or a DOAC: rifampicin lowers their effect. Warfarin: check INR often. DOAC: usually change to another anticoagulant. Pharmacist review of all drugs
07Action Choose the empirical regimen by type of IE
Use one of the next two steps. Change to targeted therapy as soon as the organism is known (usually 24-48 h).
08Action Community native valve IE or late PVE (>=12 months): empirical antibiotics
Adult doses (ESC 2023). Give after blood cultures. Australia: follow eTG or local ID advice.
- Ampicillin 12 g/day IV in 4-6 doses (e.g. 2 g 4-hourly)
- PLUS flucloxacillin 12 g/day IV in 4-6 doses (e.g. 2 g 4-hourly)
- PLUS gentamicin 3 mg/kg IV once daily (maximum 240 mg/day)
- Or ampicillin + ceftriaxone 2 g IV 12-hourly (no gentamicin)
- Known MRSA carriage or high local MRSA rates: include vancomycin (ID advice)
- Penicillin allergy: cefazolin 2 g IV 8-hourly (non-immediate reaction only) or vancomycin, each + gentamicin
09Action Early PVE (<12 months) or healthcare-associated IE: empirical antibiotics
Adult doses (ESC 2023). Rifampicin: start only after 3-5 days of effective therapy, once blood cultures are clear. It lowers warfarin effect.
- Vancomycin 30 mg/kg/day IV in 2 doses (adult); over 2 g/day only with level monitoring (local protocol)
- PLUS gentamicin 3 mg/kg IV once daily (maximum 240 mg/day; maximum 2 weeks)
- PLUS rifampicin 900-1200 mg/day IV or oral in 2-3 doses, from day 3-5 once cultures are clear
- On warfarin: check INR often after rifampicin starts and after it stops; pharmacist review
- Vancomycin not suitable: ID advice (daptomycin-based option)
10Action Organism identified: change to targeted therapy
Use the step for the organism below. Count the course from the first negative blood culture, not from surgery.
11Action If staphylococci (S. aureus or CoNS): targeted therapy
Adult doses. Native valve: no gentamicin and no rifampicin. Prosthetic valve: add rifampicin, and gentamicin for 2 weeks.
- MSSA, native valve: flucloxacillin 2 g IV 4-hourly (12 g/day) or cefazolin 2 g IV 8-hourly (6 g/day), 4-6 weeks
- MRSA, native valve: vancomycin 30-60 mg/kg/day IV in 2-3 doses, 4-6 weeks; over 2 g/day only with level monitoring
- MSSA, prosthetic valve: flucloxacillin or cefazolin + rifampicin 900 mg/day in 3 doses for at least 6 weeks + gentamicin 3 mg/kg once daily (max 240 mg/day) for the first 2 weeks
- MRSA, prosthetic valve: vancomycin + rifampicin 900-1200 mg/day in 2-3 doses for at least 6 weeks + gentamicin for the first 2 weeks
- Rifampicin only after 3-5 days of effective therapy, once cultures are clear
- Immediate penicillin allergy or vancomycin failure: ID advice (daptomycin combination)
12Action If oral streptococci or S. gallolyticus (bovis): targeted therapy
Adult doses. Regimen depends on the penicillin susceptibility category on the lab report.
- Penicillin-susceptible: benzylpenicillin 12-18 million units/day IV (7.2-10.8 g/day) in 4-6 doses, or ceftriaxone 2 g IV daily; 4 weeks native valve, 6 weeks prosthetic valve
- 2-week option (penicillin or ceftriaxone + gentamicin 3 mg/kg once daily, max 240 mg/day): only uncomplicated native valve IE with normal renal function
- Not the 2-week option if: prosthetic valve, abscess, extracardiac infection, hearing or balance problems, Abiotrophia, Granulicatella or Gemella
- Reduced susceptibility or resistant: benzylpenicillin 24 million units/day IV (14.4 g/day) or ceftriaxone 2 g IV daily, 4 weeks (6 weeks if prosthetic) + gentamicin for the first 2 weeks
- Beta-lactam allergy: vancomycin, 4 weeks native valve or 6 weeks prosthetic valve (ID advice)
- Find the source: S. gallolyticus needs colonoscopy for colon neoplasm; oral streptococci need a dental review
13Action If Enterococcus: targeted therapy
Adult doses. Gentamicin, if used, for 2 weeks only. Ampicillin + ceftriaxone avoids gentamicin.
- E. faecalis, ampicillin-susceptible: ampicillin 2 g IV 4-hourly (12 g/day) + ceftriaxone 2 g IV 12-hourly for 6 weeks (preferred; also for high-level aminoglycoside resistance)
- Or ampicillin + gentamicin 3 mg/kg IV once daily (max 240 mg/day), gentamicin for the first 2 weeks only (ampicillin duration per ID advice)
- Ampicillin-resistant (usually E. faecium): vancomycin 6 weeks + gentamicin for the first 2 weeks (ID advice)
- Vancomycin-resistant: daptomycin combined with a beta-lactam or fosfomycin. Dose: see ESC 2023 Recommendation Table 9 (ID advice)
- Creatinine and gentamicin levels at least weekly
14Action If HACEK, culture-negative or another organism: targeted therapy
Get ID advice for all of these. Adult doses.
- HACEK: ceftriaxone 2 g IV daily, 4 weeks native valve or 6 weeks prosthetic valve
- Culture-negative: continue the empirical regimen; test for Coxiella, Bartonella and Brucella (serology, PCR); send valve tissue for PCR if surgery
- Q fever (C. burnetii): doxycycline 200 mg/day + hydroxychloroquine 200-600 mg/day, both oral, for more than 18 months; serology guides stopping
- Bartonella: doxycycline 100 mg oral 12-hourly for 4 weeks + gentamicin 3 mg/kg IV once daily (max 240 mg/day) for 2 weeks
- Fungal or non-HACEK Gram-negative IE: cardiac surgery review; surgery is usually needed
15Warning Stroke or new neurological signs: no thrombolysis
Urgent brain CT or MRI. Neurology and cardiac surgery input. Intracranial haemorrhage: stop all anticoagulant and antiplatelet drugs; mechanical valve: restart unfractionated heparin as soon as possible after team discussion. No bleeding: continue a needed anticoagulant; consider changing warfarin or a DOAC to heparin early if surgery is likely.
- Thrombolysis is not recommended for embolic stroke in IE; mechanical thrombectomy may be considered
- Ischaemic stroke or TIA without haemorrhage or coma: do not delay indicated cardiac surgery
- Intracranial haemorrhage: delay surgery >1 month if possible; if unstable (heart failure, uncontrolled infection, high embolic risk), the team may still operate urgently
16Warning Surgery: emergency <24 h if shock or pulmonary oedema; urgent 3-5 days if other
Fungal or multiresistant organisms: urgent or in-hospital surgery, by haemodynamic state. The Endocarditis Team and cardiac surgeon decide; reassess if the course changes.
- Emergency (<24 h): severe acute regurgitation, obstruction or fistula with refractory pulmonary oedema or cardiogenic shock
- Urgent (3-5 days): heart failure symptoms from valve dysfunction; abscess, false aneurysm, fistula, enlarging vegetation, prosthetic dehiscence or new AV block; positive cultures >1 week or persistent sepsis despite therapy; PVE with S. aureus or non-HACEK Gram-negative
- Urgent (3-5 days): vegetation >=10 mm after an embolic event, or >=10 mm with another surgical indication
17Action Monitoring during treatment
Repeat blood cultures until negative. Repeat echo when a new complication is suspected.
- Repeat TTE/TOE if new murmur, embolism, persistent fever or bacteraemia, heart failure or AV block
- Creatinine at least weekly; gentamicin and vancomycin levels by local protocol
- Oral step-down or outpatient IV therapy: consider after >=10 days IV (>=7 days after surgery) if stable, left-sided IE due to streptococci, E. faecalis, S. aureus or CoNS, and TOE shows no abscess or valve lesion needing surgery
- TOE before switching from IV to oral therapy
- No outpatient IV therapy if: PWID-related IE, cirrhosis (Child-Pugh B/C), severe CNS emboli, untreated large abscess, or surgery needed
18Decision Responding to treatment?
Afebrile, blood cultures negative, no new embolic events or heart failure.
- If Yes
19Outcome Yes: complete the course and follow up
Complete the full course. Echo (TTE and/or TOE) at the end of therapy as a new baseline.
- Complete the full antibiotic course
- Teach symptoms of relapse and good dental hygiene; dental review
- Addiction treatment after PWID-related IE
- Cardiac rehabilitation if stable
If No20Warning No: persistent infection, relapse or complications
Re-discuss with the Endocarditis Team.
- Persistent fever or positive cultures: look for abscess or metastatic infection; urgent surgery review
- Relapse: repeat blood cultures and echo; IV antibiotics for another 4-6 weeks; consider surgery
- New stroke, heart failure or AV block: see surgery and neurology steps; not a surgical candidate: palliative care input
Guideline Source
2023 ESC Guidelines for the management of endocarditis (Delgado et al., Eur Heart J 2023;44:3948-4042)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults with valve endocarditis only: children, pacemaker/ICD lead IE and pregnancy need specialist-led care
- Doses are ESC 2023 adult doses; in Australia follow eTG Antibiotic and local ID advice for empirical and targeted choices
- Right-sided IE in people who inject drugs has different regimens and surgical criteria
- Surgical timing and all changes to therapy need the Endocarditis Team
- Local resistance patterns guide empirical therapy
Contraindicated Populations
Children under 18 years (adult doses only)Pacemaker or ICD lead (CIED-related) endocarditis: device extraction pathwayPregnancy: specialist-led Endocarditis Team care with obstetric input
Applicable Regions
AUEUUSInternational
AU: Empirical and targeted choices: Therapeutic Guidelines (eTG Antibiotic) and local ID advice. Flucloxacillin is the anti-staphylococcal penicillin (nafcillin and oxacillin are US drugs). Benzylpenicillin is dosed in mg: 600 mg = 1 million units. Q fever is endemic; test for it in culture-negative IE. Rheumatic heart disease is a common predisposition in Aboriginal and Torres Strait Islander people.
EU: ESC 2023 is the source for doses, criteria and surgical timing.
US: AHA 2015 statement uses nafcillin or oxacillin in place of flucloxacillin and older aminoglycoside durations; ESC 2023 limits gentamicin to 2 weeks.
International: Q fever, Bartonella and Brucella are more common in some regions; test for them in culture-negative IE.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Infective Endocarditis Management (ESC 2023)?
The Infective Endocarditis Management (ESC 2023) is a management clinical algorithm for Infectious Disease. It provides a structured decision tree to guide clinical decision-making, based on 2023 ESC Guidelines for the management of endocarditis (Delgado et al., Eur Heart J 2023;44:3948-4042).
What guideline is the Infective Endocarditis Management (ESC 2023) based on?
This algorithm is based on 2023 ESC Guidelines for the management of endocarditis (Delgado et al., Eur Heart J 2023;44:3948-4042) (DOI: 10.1093/eurheartj/ehad193).
What are the limitations of the Infective Endocarditis Management (ESC 2023)?
Known limitations include: Adults with valve endocarditis only: children, pacemaker/ICD lead IE and pregnancy need specialist-led care; Doses are ESC 2023 adult doses; in Australia follow eTG Antibiotic and local ID advice for empirical and targeted choices; Right-sided IE in people who inject drugs has different regimens and surgical criteria; Surgical timing and all changes to therapy need the Endocarditis Team; Local resistance patterns guide empirical therapy. Individual patient factors may require deviation from these recommendations.
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