01Approach to the Critical Patient/attcp64

Immediate priorities

›Hemodynamic and cardiac threats

›Cardiogenic shock from acute valvular regurgitation

›SBP < 90 mmHg

›MAP < 65 mmHg

›New aortic or mitral regurgitation murmur

›Septic shock physiology

›Lactate >= 2 mmol/l

›Organ dysfunction markers

›If hemodynamically unstable, IV access and fluid resuscitation immediately

›Class I recommendation

›Blood cultures before antibiotics if feasible

›Acute heart failure from valvular destruction

›Pulmonary edema signs

›Rapid surgical evaluation trigger

›Neurologic and embolic threats

›Embolic stroke in up to 20-40% of left-sided IE

›Sudden focal neurologic deficits

›Altered mental status

›Intracranial hemorrhage from mycotic aneurysm

›Severe headache

›Meningismus

›If new focal deficit or hemorrhage, emergent neuroimaging

›CT head without contrast first

›Neurology or neurosurgery consult

Monitoring and targets

›Monitoring bundle

›Continuous cardiac monitoring

02History/hx90

Presentation pattern

›Cardinal symptoms

›Fever

›Present in approximately 78% of cases

›Acute IE: sudden high fever with rigors

›Subacute IE: low-grade fever over weeks to months

›Chills and rigors

›Associated with S. aureus bacteremia

›Night sweats and diaphoresis

›Constitutional symptoms

›Fatigue and malaise

›Weight loss and anorexia

Tempo and onset

›Acute versus subacute distinction

›Acute presentation

›S. aureus most common cause

›Rapid deterioration over days

›Subacute presentation

›Viridans streptococci or enterococci

›Evolves over weeks to months

›Timing of precipitating events

›Recent dental procedures within prior weeks

›Recent invasive procedures or hospitalization

›IV line placement or catheter insertion

Cardiovascular symptoms

›Heart failure symptoms

›Dyspnea

›Exertional then rest dyspnea

›Orthopnea

›Peripheral edema

›New bilateral lower extremity edema

›Rapid onset suggests acute valve destruction

›Palpitations

›Atrial fibrillation from valvular regurgitation

›Conduction abnormality symptoms

Embolic and neurologic symptoms

›Embolic manifestations

›Neurologic symptoms in left-sided IE

›Focal weakness or speech difficulty

›Vision changes

›Severe headache suggesting mycotic aneurysm

›Peripheral emboli

›Painful finger or toe nodules

›Painless palmar or plantar lesions

›Hematuria from renal emboli or glomerulonephritis

›Right-sided IE emboli

›Cough and pleuritic chest pain

›Hemoptysis from septic pulmonary emboli

Risk factors

›Cardiac predispositions

›Prior infective endocarditis

›Strongest risk factor for recurrence

›Recurrence risk 2-6% per year

›Prosthetic heart valve

›Early PVE < 12 months: coagulase-negative staphylococci, S. aureus

›Late PVE > 12 months: similar to native valve IE

›Valvular heart disease

›Degenerative disease

›Rheumatic disease

›Bicuspid aortic valve

›Congenital heart disease

›Unrepaired cyanotic lesions highest risk

›VSD and complex congenital lesions

›Cardiac implantable electronic devices

›Pacemakers and defibrillators

›Ventricular assist devices

›Non-cardiac predispositions

›IV drug use

›Tricuspid valve predominantly affected

›S. aureus most common organism

›Chronic hemodialysis

›Vascular access infection risk

›High S. aureus bacteremia risk

›Indwelling intravascular catheters

›Nosocomial IE source

›Healthcare-associated IE

›Immunosuppression and comorbidities

›Diabetes mellitus

›Chronic liver disease

›HIV and malignancy

›Poor dentition

›Periodontal disease and dental abscess

›Viridans streptococcal bacteremia source

Collateral and social history

›Social and exposure history

›IV drug use practices

›Frequency and injection sites

›Needle sharing and water source

›Animal and environmental exposures

›Farm animal contact suggesting Coxiella burnetii

›Homelessness suggesting Bartonella quintana

›Recent antibiotic use

›Affects blood culture yield

›May indicate prior treated bacteremia

›Medication adherence history

›Critical for OPAT or oral step-down planning

03Physical Exam/exam65

Vitals

›Vital sign assessment

›Temperature

›Fever >= 38 degrees C in approximately 78% of cases

›Afebrile presentation possible in elderly or immunocompromised

›Heart rate

›Tachycardia from fever or heart failure

›Bradycardia or irregular rate suggesting conduction block

›Blood pressure

›SBP < 90 mmHg indicating shock physiology

›Wide pulse pressure suggesting aortic regurgitation

›Respiratory rate

›Tachypnea from heart failure or sepsis

›Oxygen saturation on room air

Cardiac exam

›Murmur assessment

›New or changing cardiac murmur in 64.5% of cases

›New aortic regurgitation murmur is highly significant

›Mitral regurgitation from leaflet destruction or chordal rupture

›Signs of heart failure

›Elevated jugular venous distension

›Third heart sound

›Pulmonary crackles

›Peripheral edema

Peripheral stigmata

›Embolic and immunologic skin findings

›Janeway lesions

›Painless erythematous macules on palms and soles

04Differential Diagnosis/ddx50

Life-threatening mimics

›Cardiac emergencies

›Acute valvular rupture without IE

›ICD-10 I34.1 nonrheumatic mitral valve prolapse

›Differentiated by culture results and vegetation on echo

›Acute myocardial infarction with septic embolism

›ICD-10 I21

›Coronary embolization from vegetation

›Type A aortic dissection with aortic regurgitation

›ICD-10 I71.0

›CT angiography differentiates

›Sepsis from other sources

›Pneumonia-associated sepsis

›ICD-10 A41.9 sepsis unspecified

›Echocardiographic findings absent

›Intra-abdominal sepsis

›Urinary tract infection-associated bacteremia

›Persistent bacteremia uncommon without IE

Non-bacterial cardiac masses

›Intracardiac masses

›Atrial myxoma

›ICD-10 D15.1

›Constitutional symptoms and embolic events

›Differentiated by tissue pathology and absence of bacteremia

›Non-bacterial thrombotic endocarditis

›Associated with malignancy and SLE Libman-Sacks

›Culture-negative without fever

›Papillary fibroelastoma

05Laboratory Tests/lt67

Blood cultures

›Culture collection protocol

›Three sets from separate venipuncture sites

›Ideally collected 30 minutes apart

›Before starting antibiotics whenever possible

›Yield and interpretation

›90-95% of native valve IE is culture-positive

›S. aureus in any blood culture is a major Duke criterion

›Viridans streptococci in 2 separate cultures is a major criterion

›Repeat blood cultures

›Every 24-48 hours until clearance confirmed

›Persistent bacteremia > 5-7 days on appropriate antibiotics triggers surgical evaluation

Hematologic and inflammatory markers

›Complete blood count

›Leukocytosis in acute IE

›Leukopenia as severe sepsis marker

›Thrombocytopenia suggesting DIC

›Normocytic anemia

›Anemia of chronic disease in subacute IE

›Hemolysis from mechanical valve dysfunction

›Inflammatory markers

›Erythrocyte sedimentation rate elevated in subacute IE

›ESR > 50 mm/hour is a minor Duke criterion

›C-reactive protein

›Non-specific but monitors treatment response

›Procalcitonin adjunct

›Bacterial infection support

›Not a rule-out test for IE

06Diagnostic Tests/dt98

Scoring Systems

›2023 Duke-ISCVID Criteria

›Major criteria

›Positive blood cultures with typical IE organisms in 2 separate cultures

›Echocardiographic evidence: vegetation, abscess, pseudoaneurysm, fistula, valve perforation

›Coxiella burnetii phase I IgG titer >= 1:800

›Bartonella IgG titer >= 1:800

›Positive FDG-PET/CT around prosthetic valve

›Intraoperative inspection of endocardial involvement (new 2023 criterion)

›Minor criteria

›Predisposing cardiac condition or IV drug use

›Fever >= 38 degrees C

›Vascular phenomena: arterial emboli, septic pulmonary infarcts, mycotic aneurysm, Janeway lesions

›Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, positive rheumatoid factor

›Supportive microbiology: positive culture not meeting major criterion

›Classification thresholds

›Definite IE: 2 major, or 1 major and 3 minor, or 5 minor criteria

›Possible IE: 1 major and 1 minor, or 3 minor criteria

›Rejected IE: firm alternative diagnosis or resolution with antibiotics < 4 days

›Surgical risk stratification

›EuroSCORE II for operative risk assessment

›Guides timing and urgency of surgery

›Combined with clinical urgency indicators

MRI

›Brain MRI indications

›Neurologic symptoms in left-sided IE

›Detection of silent cerebral emboli in up to 60-80% of left-sided IE

›Can change management and surgical timing

›Asymptomatic screening role

›Silent emboli detected in majority even without symptoms

›Microbleeds associated with higher hemorrhagic transformation risk

›Mycotic aneurysm evaluation

›MR angiography for intracranial aneurysm detection

›CT angiography as alternative

›Spine MRI indications

›Spondylodiscitis assessment

›Back pain in IE patient requires spine imaging

›Present in 5-15% of IE cases

›Changes antibiotic duration and surgery timing

›Limitations

›Unstable patient: contraindicated

›Non-compatible implants: CIEDs require device-specific clearance

›Availability constraints in emergency setting

CT

›Cardiac CT indications

›Perivalvular abscess detection

›Sensitivity superior to TTE for paravalvular complications

›Pseudoaneurysm and fistula visualization

›Pre-surgical anatomic planning

›Aortic root involvement mapping

›Coronary anatomy in surgical candidates

›Less sensitive for small vegetations < 4 mm

›Does not replace echocardiography for vegetation diagnosis

›CT chest indications

›Right-sided IE evaluation

›Septic pulmonary emboli detection

›Cavitary lesions and pleural effusion

›ACEP Level B recommendation for CT in suspected pulmonary complications

›CT abdomen and pelvis

›Splenic abscess and infarct detection

›Renal infarct assessment

›Mycotic aneurysm of mesenteric or renal vessels

›CT head

›Hemorrhagic transformation of embolic stroke

›Guides anticoagulation decisions

›Subarachnoid hemorrhage from mycotic aneurysm rupture

›FDG-PET/CT

›Incorporated into 2023 Duke-ISCVID major criteria

›Particularly valuable for prosthetic valve IE

›CIED infections and culture-negative cases

›Abnormal FDG uptake around prosthetic valve is a major criterion

Ultrasound

›Transthoracic echocardiography

›First-line imaging for all suspected IE cases

›Sensitivity approximately 70% for native valves

›Sensitivity approximately 50% for prosthetic valves

›Specificity approximately 94%

›Findings sought

›Vegetation: oscillating intracardiac mass on valve or supporting structure

›Abscess: thickened perivalvular region with heterogeneous echo density

›New valvular regurgitation

›Partial dehiscence of prosthetic valve

›Class I recommendation for initial evaluation

›Transesophageal echocardiography

›Sensitivity 90-96% for native and prosthetic valves

›Specificity > 90%

›Class I recommendation when TTE non-diagnostic

›Indications for TEE

›TTE negative or equivocal with high clinical suspicion

›Prosthetic valve or intracardiac device

›Suspected complications: abscess, fistula, perforation

›S. aureus bacteremia evaluation

›Class I recommendation in all S. aureus bacteremia cases

›Intraoperative TEE

›Surgical planning and assessment of repair adequacy

›Point-of-care ultrasound

›Large vegetation detection at bedside in ED

›Pericardial effusion screen

›Gross valvular dysfunction assessment

›Hemodynamic assessment

›LV function estimate for shock stratification

›IVC assessment for fluid responsiveness

07Disposition/dispo49

Admission criteria

›All suspected and confirmed IE require hospital admission

›Observation or outpatient management is not appropriate

›All cases require IV antibiotics and monitoring

›Echocardiographic assessment required early

›Admission level of care

›Telemetry minimum for monitoring conduction changes

›ICU for hemodynamic instability or cardiac decompensation

ICU admission indications

›Critical illness criteria

›Septic shock

›Vasopressor requirement

›Lactate > 2 mmol/l persisting despite resuscitation

›Cardiogenic shock from acute valvular regurgitation

›Mechanical circulatory support consideration

›Emergency surgical evaluation

›Acute heart failure requiring intensive management

›Pulmonary edema with respiratory failure

›HFNC or intubation

›New neurologic deficits

›Embolic stroke with significant disability

›Intracranial hemorrhage from mycotic aneurysm

Transfer criteria

›Tertiary center transfer indications

›Surgical capability not available locally

›Confirmed or suspected surgical indication

›Prosthetic valve IE at center without cardiac surgery

›Transfer timing

08Treatment/t117

Initial stabilization

›Resuscitation priorities

›Vascular access and hemodynamic monitoring

›Two large-bore peripheral IV lines

›Arterial line if hemodynamically unstable

›Blood cultures before antibiotics in subacute presentations

›At least 3 sets from separate sites

›Do not delay antibiotics > 1 hour in septic shock

›Fluid resuscitation for septic shock

›30 ml/kg IV crystalloid in first 3 hours

›Reassess volume responsiveness frequently

›Vasopressors if MAP < 65 mmHg despite fluids

›Norepinephrine first-line

›Titrate to MAP >= 65 mmHg

Empiric antibiotic therapy

›Native valve empiric regimen

›Vancomycin IV plus ceftriaxone IV

›Vancomycin: target AUC 400-600 mg·h/l

›Ceftriaxone 2 g IV every 24 hours

›Covers streptococci, enterococci, and staphylococci

›Alternative if GI or odontogenic source

›Ampicillin-sulbactam 3 g IV every 6 hours

›Provides anaerobic and gram-negative coverage

›Prosthetic valve empiric regimen

›Vancomycin IV plus cefepime IV or piperacillin-tazobactam IV

›Cefepime 2 g IV every 8 hours for antipseudomonal coverage

›Piperacillin-tazobactam 4.5 g IV every 6 hours as alternative

›Vancomycin target AUC 400-600 mg·h/l

Definitive organism-directed therapy

›MSSA native valve IE

›Nafcillin or oxacillin IV preferred

›12 g/day IV divided every 4-6 hours

›Duration 4-6 weeks

›Beta-lactams preferred over vancomycin for higher cure rates

›Cefazolin alternative

›6 g/day IV divided every 8 hours

›Equivalent efficacy with better tolerability

›Duration 4-6 weeks

›MRSA IE

›Vancomycin IV

›Target AUC/MIC ratio 400-600 mg·h/l

›Duration 6 weeks

›Daptomycin alternative

›10 mg/kg/day IV

›Duration 6 weeks

›Do not use for concurrent pulmonary infection: inactivated by surfactant

›Viridans streptococci penicillin-susceptible IE

›Penicillin G IV or ceftriaxone IV

›Penicillin G 12-18 million units/day IV continuous or divided every 4-6 hours

›Ceftriaxone 2 g IV every 24 hours as alternative

›Duration 4 weeks

›Two-week short course option in select patients

›Ceftriaxone plus gentamicin for 2 weeks

›Only uncomplicated native valve IE in patients without renal impairment

›Enterococcal IE

›Ampicillin plus ceftriaxone preferred

›Ampicillin 12 g/day IV divided every 4 hours

›Ceftriaxone 2 g IV every 12 hours

›Duration 6 weeks for native valve, >= 6 weeks for prosthetic

›Preferred when high-level aminoglycoside resistance or renal risk

›Ampicillin plus gentamicin alternative

›Gentamicin 3 mg/kg/day IV divided every 8 hours

›Limit aminoglycoside to <= 2 weeks due to nephrotoxicity

›Monitor renal function every 48-72 hours

›HACEK organisms

›Ceftriaxone 2 g IV every 24 hours

›Duration 4 weeks for native valve

›Duration 6 weeks for prosthetic valve

›First-line per AHA guidelines

Antibiotic duration principles

›Duration by valve type

›Native valve IE

›>= 4 weeks for most organisms

›6 weeks for enterococcal IE and complicated cases

›Prosthetic valve IE

›>= 6 weeks for all organisms

›Rifampin added to prosthetic valve staphylococcal IE

›Rifampin 300 mg PO every 8 hours after culture clearance

›Do not start rifampin empirically or before culture clearance

›Aminoglycoside limitation

›Avoid in elderly and renal disease

›Limit total duration to <= 2 weeks

Surgical treatment

›Class I surgical indications

›Heart failure from valve dysfunction

›Acute severe aortic or mitral regurgitation with heart failure

›Emergency surgery within 24 hours if refractory pulmonary edema or cardiogenic shock

›Uncontrolled infection

›Perivalvular abscess, fistula, or destructive penetrating lesion

›Persistent fever or bacteremia > 5-7 days on appropriate antibiotics

›Fungal or highly resistant organism

›Prevention of embolism

›Vegetation > 10 mm with embolic event despite antibiotics

›Very large vegetation > 15 mm on anterior mitral leaflet

›Recurrent emboli with persistent vegetations

›Surgical timing

›Emergency within 24 hours

›Refractory pulmonary edema or cardiogenic shock from valve regurgitation

›Class I recommendation

›Urgent within 3-5 days

›Uncontrolled infection with perivalvular abscess

›Large vegetation with embolic event

›Elective after 1-2 weeks of antibiotics

›Stable patients meeting surgical indications

Source control and adjuncts

›Device and catheter management

›Remove infected intravascular catheters and lines

›All implicated foreign bodies removed when feasible

›CIED extraction when device-related IE confirmed

›Abscess drainage evaluation

›Splenic abscess: percutaneous drainage or splenectomy

›Renal or metastatic abscess drainage guided by interventional radiology

›Anticoagulation considerations

›No routine anticoagulation for IE vegetations

›Does not reduce embolism risk

›Increases hemorrhagic transformation risk in embolic stroke

›Existing anticoagulation for mechanical valves

›Continue if no hemorrhagic stroke

›Bridge decisions individualized with neurology

›Multidisciplinary team involvement

›ID, cardiology, and cardiothoracic surgery early involvement

›Associated with improved survival

›Class I recommendation per 2015 AHA guidelines

09Special Populations/sp87

Pregnancy

›Pregnancy-specific considerations

›Physiologic changes affecting presentation

›Physiologic flow murmur may obscure new pathologic murmur

›Normal tachycardia and increased cardiac output

›Delayed fever response from altered immune state

›Maternal and fetal risks

›Maternal mortality approximately 11% in IE during pregnancy

›Preterm labor and fetal loss risk from sepsis

›Embolic stroke risk to mother and fetus

›Echocardiography safety

›TTE preferred and safe in all trimesters

›TEE generally safe with obstetric monitoring

›Antibiotic selection in pregnancy

›Beta-lactams preferred and safe in all trimesters

›Penicillins: category B, preferred first-line

›Cephalosporins: generally safe

›Vancomycin

›Use when MRSA or beta-lactam allergy

›Crosses placenta: fetal monitoring required

›AUC-guided dosing essential

›Aminoglycosides

›Avoid when possible: ototoxicity and nephrotoxicity risk

›Use only when no alternative with close monitoring

›Daptomycin

›Limited data: use only when benefit outweighs risk

›Avoid rifampin in first trimester

›Surgical considerations in pregnancy

›Surgery may be required for life-threatening valve destruction

›Cardiopulmonary bypass carries fetal mortality risk 15-33%

›Multidisciplinary team decision with maternal-fetal medicine

Geriatric

›Atypical presentation in older adults

›Afebrile presentation common

›Delirium or confusion as primary presenting symptom

›Unexplained functional decline

›S. bovis bacteremia association

›Streptococcus gallolyticus in older adults

›Mandates colorectal cancer screening

›Higher prevalence of degenerative valvular disease

›Calcific aortic stenosis as risk factor

›Degenerative mitral valve disease

›Medication risk management in elderly

›Aminoglycosides

›Significant nephrotoxicity and ototoxicity risk in elderly

›Avoid or limit to <= 2 weeks with close renal monitoring

›Vancomycin

›AUC-guided monitoring essential

›Reduced renal clearance prolongs half-life

›Renal dosing adjustment required for most antibiotics

›Calculate eGFR at baseline and monitor weekly

›Frailty and disposition considerations

›Higher surgical mortality in frail elderly

›EuroSCORE II may underestimate risk in frailty

›Palliative approach discussion when operative risk prohibitive

›OPAT feasibility

›Home nursing support and PICC care capability

›Oral step-down attractive option in stable elderly patients

Pediatrics

›Pediatric epidemiology and risk factors

›Congenital heart disease as primary risk factor

›Unrepaired cyanotic congenital heart disease highest risk

›VSD and other defects with turbulent flow

›S. aureus and viridans streptococci most common organisms

›Similar microbiology to adults

›Coagulase-negative staphylococci in neonates with catheters

›In pediatric IE, right-sided more common than adults

›Often catheter-related in neonates and infants

›Antibiotic dosing in children

›Nafcillin for MSSA

›150-200 mg/kg/day IV divided every 4-6 hours

›Maximum 12 g/day

›Vancomycin for MRSA or allergy

›60 mg/kg/day IV divided every 6 hours

›Adjust by AUC monitoring in children

›Ampicillin for enterococcal IE

›200-300 mg/kg/day IV divided every 4-6 hours

›Maximum 12 g/day

›Ceftriaxone for streptococcal IE

›100 mg/kg/day IV once daily

›Maximum 4 g/day

›Pediatric surgical and monitoring considerations

›Surgical indications similar to adults

›Heart failure, uncontrolled infection, large vegetations

›Growth and valve considerations

›Bioprosthetic valves avoided in children when possible

›Reoperation planning required as child grows

›Prophylaxis after pediatric IE

›Antibiotic prophylaxis before dental procedures recommended

›Lifelong prophylaxis for congenital heart disease history

10Background/b82

Epidemiology

›Incidence and burden

›Annual incidence 3-10 cases per 100,000 population

›Rising incidence attributed to aging population and device use

›Healthcare-associated IE accounts for 25-30% of cases

›Demographics

›Male sex predominance

›Mean age of onset approximately 50-60 years

›Increasing in persons who inject drugs

›Mortality

›In-hospital mortality approximately 15-20% overall

›S. aureus IE carries 25-40% in-hospital mortality

›Prosthetic valve IE has higher mortality than native valve IE

›One-year mortality approximately 30%

›Valve distribution

›Left-sided IE: 75-80% of cases

›Mitral valve most common native valve affected

›Tricuspid valve predominant in IV drug users

›Right-sided IE has lower mortality than left-sided

Pathophysiology

›Mechanisms of infection

›Endothelial damage and vegetation formation

›Turbulent flow from structural defect damages endothelium

›Sterile platelet-fibrin thrombus forms on damaged surface

›Transient bacteremia seeds thrombus

›Bacteria proliferate in vegetation protected from phagocytosis

›Organism-specific virulence

›S. aureus: adhesins bind directly to intact endothelium

›Viridans streptococci: dextran promotes adherence to fibrin-platelet thrombus

›Enterococci: tolerate bile and urinary tract reservoirs

›Cardiac complications

›Local destruction

›Valve leaflet perforation and regurgitation

›Chordal rupture causing acute mitral regurgitation

›Perivalvular abscess extending into adjacent structures

›Fistula formation between cardiac chambers

›Conduction system involvement

›Aortic root abscess extending into AV node

›New PR prolongation or heart block

›Embolic and immunologic complications

›Embolic events

›Left-sided IE: stroke, renal infarct, splenic infarct, coronary embolism

›Right-sided IE: septic pulmonary emboli

›Vegetation size > 10 mm associated with higher embolic risk

›Immune-mediated injury

›Circulating immune complexes cause Osler nodes and glomerulonephritis

›Rheumatoid factor produced in subacute IE

›Complement activation and consumption

Therapeutic Considerations

›Antibiotic strategy principles

›Prolonged IV therapy rationale

›Vegetation is avascular: antibiotics must achieve high concentrations by diffusion

›Bacteria in biofilm phase of growth are less susceptible

›Bactericidal antibiotics required: beta-lactams and vancomycin preferred

›Synergy considerations

›Aminoglycoside synergy with penicillin for viridans streptococci limited to 2-week short course

›Combination nafcillin plus aminoglycoside for MSSA NVE does not improve outcomes

›Ampicillin plus ceftriaxone exploits different PBP saturation for enterococcal IE

›Oral step-down evidence

›POET trial: oral step-down non-inferior to continued IV in stable left-sided IE

›Requires afebrile status, cleared blood cultures, and no surgical indication

›Surgical decision-making principles

›Risk-benefit framework

›Active IE with systemic inflammation increases operative risk

›Delay to allow antibiotic treatment must be weighed against hemodynamic deterioration

›Emergency surgery mortality higher than elective but necessary when life-threatening

›Stroke and surgical timing

›Hemorrhagic stroke: delay surgery >= 4 weeks when feasible

›Ischemic stroke: surgery within 1-2 weeks acceptable if no hemorrhagic transformation

›Large infarct increases cardiopulmonary bypass hemorrhagic risk

›Recurrence prevention

›Antibiotic prophylaxis before dental procedures for all with prior IE history

›Oral hygiene optimization

›Harm reduction and addiction treatment for PWID

›Microbiology-driven approach

›Staphylococcal IE prognosis

›Beta-lactam preferred over vancomycin for MSSA: lower treatment failure rate

›Daptomycin for MRSA when vancomycin MIC elevated or toxicity

›HACEK group

›Historically beta-lactam susceptible

›Ceftriaxone preferred over ampicillin as some HACEK now produce beta-lactamase

›Culture-negative IE approach

›Empiric coverage while awaiting serology

›PCR and next-generation sequencing on valve tissue at surgery

›Never withhold therapy pending culture results in unstable patient

11Patient Discharge Instructions/pdi45

copy discharge instructions

›Home care instructions for bacterial endocarditis

›Complete the full antibiotic course exactly as directed

›Never stop early even if feeling better

›Intravenous antibiotics at home require PICC line care as instructed by your nurse

›Daily PICC line care

›Inspect site daily for redness, swelling, or drainage

›Keep site dry and covered as instructed

›Rest and activity

›Gradual return to activities as energy allows

›Avoid strenuous exercise until cleared by your cardiologist

›Warning signs to return to ER immediately

›Fever or new shaking chills

›Temperature > 38 degrees C

›May indicate treatment failure or new infection

›Sudden weakness, numbness, or speech difficulty

›Signs of stroke require emergency evaluation

›New or worsening shortness of breath

›Worsening at rest or with minimal activity

›New leg swelling

›Severe headache unlike any before

›May indicate brain aneurysm or bleed

›Redness, pain, or discharge at PICC line site

›Confusion or unusual drowsiness

›Chest pain or heart pounding

›Medications and antibiotic prophylaxis

›Always tell your dentist about your history of heart infection

›You require antibiotics before dental procedures for life

12References/r24

Guidelines and key sources

›Primary guidelines

›Baddour LM et al. AHA Scientific Statement: Infective Endocarditis in Adults. Circulation 2015

›Comprehensive antimicrobial therapy and management of complications

›Fowler VG et al. 2023 Duke-ISCVID Criteria for Infective Endocarditis. Clinical Infectious Diseases 2023

›Updated diagnostic criteria incorporating FDG-PET/CT and intraoperative inspection

›McDonald EG et al. WikiGuidelines Consensus Statement on IE Diagnosis and Management. JAMA Network Open 2023

›ESC Guidelines on Infective Endocarditis 2023

›European Society of Cardiology comprehensive management guidance

›Key trials and landmark studies

›Chambers HF, Bayer AS. Native-Valve Infective Endocarditis. NEJM 2020

›Clinical review of diagnosis, microbiology, and management

›Wang A, Gaca JG, Chu VH. Management Considerations in IE: A Review. JAMA 2018

›Comprehensive management framework and surgical indications

›Li M et al. Infective Endocarditis. Lancet 2024

›Updated global epidemiology and management

›POET trial: Oral antibiotics non-inferior to IV in stable left-sided IE

›Supports oral step-down after >= 10 days IV in selected patients

›Yucel E et al. IE in People Who Inject Drugs. JACC State-of-the-Art 2022

›Coding standards

›ICD-10 I33.0 acute and subacute infective endocarditis

›ICD-10 I33.9 acute endocarditis unspecified

›ICD-10 I38 endocarditis valve unspecified

›ICD-10 T82.6 infection of cardiac prosthetic device

›SNOMED CT infective endocarditis disorder concept

Evidence & Review