Suspected Infective Endocarditis
Fever + new murmur, embolic phenomena, or risk factors (IVDU, prosthetic valve, prior IE)
All Pathways
Infectious DiseaseManagement
Infective Endocarditis Management (AHA/ESC 2023)
Infective Endocarditis Management (AHA/ESC 2023): Suspected Infective Endocarditis → Initial Workup → TTE or TEE? → Apply Modified Duke Criteria → Nativ...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Initial Workup
Blood cultures and imaging
- 3 sets blood cultures from separate sites before antibiotics
- CBC, BMP, ESR, CRP, urinalysis
- ECG (assess for conduction abnormalities)
- Chest X-ray
03Decision TTE or TEE?
Select appropriate echocardiography
- TTE first if: Native valve, good image quality expected
- TEE indicated if: Prosthetic valve, prior IE, poor TTE windows, high clinical suspicion with negative TTE
- TEE sensitivity ~90-100% vs TTE ~40-60% for vegetations
04Action Apply Modified Duke Criteria
Definite, Possible, or Rejected
- Major: Typical organisms from 2 blood cultures, echo findings (vegetation, abscess, dehiscence), new valvular regurgitation
- Minor: Predisposition, fever >38°C, vascular phenomena, immunologic phenomena, supportive microbiology
- Definite: 2 major OR 1 major + 3 minor OR 5 minor
05Decision Native or Prosthetic Valve?
Determines empiric therapy and duration
06Action Native Valve Empiric Therapy
Before culture results
- Ampicillin-sulbactam 12g/day IV divided q4h
- PLUS Gentamicin 3mg/kg/day IV divided q8h
- If MRSA risk: ADD Vancomycin 30mg/kg/day divided q12h
- Alternative: Vancomycin + Gentamicin + Ciprofloxacin
07Decision Blood Culture Results
Tailor therapy to organism
08Action Staphylococcus aureus
MSSA vs MRSA
- MSSA NVE: Nafcillin/Oxacillin 12g/day IV x6 weeks
- MRSA NVE: Vancomycin x6 weeks (consider adding rifampin)
- MSSA PVE: Nafcillin + Rifampin + Gentamicin x 6+ weeks
- MRSA PVE: Vancomycin + Rifampin + Gentamicin x 6+ weeks
09Warning Surgical Indications
Early surgery consultation
- Heart failure from valve dysfunction
- Uncontrolled infection (abscess, enlarging vegetation, persistent bacteremia >7 days)
- Prevention of embolism: Large mobile vegetation >10mm (especially after embolic event)
- PVE with Staph or fungal infection
- Timing: Within 24-48h for severe HF, within 1-2 weeks for others
10Action Monitoring & Follow-up
During and after treatment
- Daily assessment for complications
- Repeat blood cultures q48-72h until negative
- Weekly CBC, renal function, drug levels
- Repeat echo if clinical change or pre-surgery
- Post-treatment: Dental evaluation, surveillance cultures
11Outcome Successful Treatment
Resolution of infection
- Afebrile, negative cultures, no embolic events
- Complete antibiotic course
- Long-term follow-up for relapse
12Warning Complications/Failure
Poor outcome or relapse
- Mortality: 15-30% (higher with S. aureus, PVE)
- Relapse: Repeat cultures, consider resistance
- Embolic stroke, heart failure, renal failure
- Consider palliative care if not surgical candidate
13Action Viridans Strep / S. bovis
PCN-susceptible streptococci
- PCN-susceptible (MIC ≤0.12): Penicillin G or Ceftriaxone x4 weeks
- OR 2-week course with Gentamicin
- Relatively resistant (MIC 0.25-2): Add Gentamicin x2 weeks
- PVE: 6 weeks duration minimum
- Path rejoins step 09Shared downstream outcome
14Action Enterococcus
E. faecalis or E. faecium
- Ampicillin-susceptible: Ampicillin + (Ceftriaxone OR Gentamicin) x6 weeks
- Ampicillin-resistant: Vancomycin + Gentamicin x6 weeks
- VRE: Daptomycin 8-10mg/kg/day (consider linezolid)
- Gentamicin x4-6 weeks (monitor levels/renal function)
- Path rejoins step 09Shared downstream outcome
15Action HACEK / Culture-Negative
Fastidious organisms
- HACEK: Ceftriaxone 2g IV daily x4 weeks (6 weeks PVE)
- Culture-negative: Ampicillin-sulbactam + Gentamicin
- Consider Q fever (Coxiella): Doxycycline + Hydroxychloroquine
- Bartonella: Doxycycline + Gentamicin
- Path rejoins step 09Shared downstream outcome
16Action Prosthetic Valve Empiric Therapy
Broader coverage required
- Vancomycin 30mg/kg/day IV divided q12h
- PLUS Gentamicin 3mg/kg/day IV divided q8h
- PLUS Rifampin 900mg/day PO divided q8h
- De-escalate when culture/susceptibility available
- Path rejoins step 07Shared downstream outcome
Guideline Source
2023 ESC Guidelines for the management of endocarditis + AHA 2015 Scientific Statement
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Duke criteria sensitivity varies - clinical judgment essential
- Blood culture-negative endocarditis requires specialized testing
- Surgical timing decisions require multidisciplinary team
- Prosthetic valve endocarditis has different management considerations
- Local resistance patterns should guide empiric therapy
Applicable Regions
USEUInternational
EU: ESC 2023 guidelines include outpatient IV therapy options for stable patients
US: HACEK organisms common in culture-negative; consider TEE early
International: Q fever and Bartonella more common in certain regions
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Infective Endocarditis Management (AHA/ESC 2023)?
The Infective Endocarditis Management (AHA/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 + AHA 2015 Scientific Statement.
What guideline is the Infective Endocarditis Management (AHA/ESC 2023) based on?
This algorithm is based on 2023 ESC Guidelines for the management of endocarditis + AHA 2015 Scientific Statement (DOI: 10.1093/eurheartj/ehad193).
What are the limitations of the Infective Endocarditis Management (AHA/ESC 2023)?
Known limitations include: Duke criteria sensitivity varies - clinical judgment essential; Blood culture-negative endocarditis requires specialized testing; Surgical timing decisions require multidisciplinary team; Prosthetic valve endocarditis has different management considerations; Local resistance patterns should guide empiric therapy. Individual patient factors may require deviation from these recommendations.
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