Approach to managing infective endocarditis

Baddour, 2015Bayer, 2021Eleyan, 2021Habib, 2019Habib, 2015Saraste, 2019Satriano, 2020

Management of infective endocarditis requires a collaborative multidisciplinary approach.

Ideally, infective endocarditis should be managed by a dedicated endocarditis team because this dramatically reduces infective endocarditis mortality. At a minimum, this team should include the following members with expertise in infective endocarditis management:

  • an infectious diseases physician or clinical microbiologist
  • a cardiologist
  • a cardiac surgeon.

Involvement of other specialities including neurology, neurosurgery and radiology may be required, depending on the individual caseBaddour, 2015Cahill, 2017Chambers, 2014Habib, 2015Mestres, 2015Murphy, 2019.

If an endocarditis team is not available, consult with a cardiologist and an infectious diseases physician or clinical microbiologist as soon as infective endocarditis is suspected. Determining if early surgical intervention is required is critical to the management of infective endocarditis; early consultation with a cardiac surgeon is advised. However, patients with the following features should be discussed with an endocarditis team to determine whether early patient transfer to a centre with an endocarditis team is required:

  • prosthetic valves or cardiac implantable electronic devices
  • severe valvular regurgitation
  • symptoms or signs of heart failure
  • mobile vegetations larger than 10 mm
  • recurrent embolism
  • extravalvular complications (eg abscess, fistulas, heart block)
  • acute kidney injury
  • septic shock
  • requirement for intensive care support
  • neurological complications (including stroke)
  • endocarditis caused by organisms that are virulent or difficult to manage (eg staphylococcal endocarditis, endocarditis caused by other organisms and culture-negative endocarditis)
  • persistent infection (positive blood culture results or fever for longer than 7 days).

Patients who have had an episode of infective endocarditis are at risk of further episodes; see Prevention of infective endocarditis for further advice.

Infective endocarditis can occur after transcatheter aortic valve implantation (TAVI), also known as transcatheter aortic valve replacement (TAVR). TAVI is commonly used instead of surgical aortic valve replacement (SAVR), especially in older patients and those with major comorbidities. Notably, patients who have undergone TAVI will not have a sternotomy scar. Overall rates of prosthetic valve infective endocarditis are similar after TAVI and SAVR, but studies suggest thatAmat-Santos, 2015Bjursten, 2019Hassanin, 2022Prendergast, 2020Stortecky, 2020Tinica, 2020:

  • Staphylococcus, Streptococcus and Enterococcus species may be more likely pathogens in endocarditis associated with TAVI, especially late after insertion
  • echocardiography may be less sensitive in endocarditis associated with TAVI
  • overall outcomes for prosthetic valve endocarditis are worse for patients who have undergone TAVI than SAVR (although this may be confounded by the older average age of patients who have undergone TAVI).

Endocarditis with unique or unusual features may develop on any transcutaneous catheter-based implants, including valve replacements, mitral valve clips, pulmonary valve implants, septal defect occluder devices and left atrial appendage occlusion devices – for management, see Empirical therapy for prosthetic valve infective endocarditis.