Management of

Infective Endocarditis

 The major goals of therapy for infective endocarditis (IE)

are to eradicate the infectious agent from the thrombus
and to address the complications of valvular infection.
Treatment is guided by presentation,clinical findings,
native or prosthetic valves and organism virulence.
Indications for surgery include the following: heart
failure, uncontrolled infection and large vegetations.

General measures
Treatment of congestive heart failure
Oxygen
Hemodialysis (may be required in patients with renal
failure)

 If suspected IE, before C+S results available,

Abx must be started.
TDM monitoring.
Native valves:

The viridans group streptococci have remained the primary

cause of native valve endocarditis.

S aureus is the most common cause of endocarditis on native

valves of intravenous drug users. In intravenous drug users
with right-sided endocarditis, gentamicin has been shown to
increase the rate of microbial killing when used in
combination with a beta-lactam.

Prosthetic valves

Viridans species are a primary cause of endocarditis of prosthetic

valves. Organisms are generally penicillin-sensitive though some
have a relatively high minimum inhibitory concentration (MIC) and
are therefore relatively penicillin-resistant.

Staphylococcal endocarditis is becoming an increasingly recognised

entity, owing to high rates of hospital exposure and the development
of resistant organisms. Infections caused byS aureusare often
rapidly progressive and carry a high mortality rate.

 Once C+S results available, change Abx course

accordingly.

Enterococcus and HACEK

Native and prosthetic valves infected with
enterococci
Enterococci, unlike the viridans group streptococci, are not
usually killed by antimicrobials but merely inhibited.
Vancomycin-resistant faecium species have emerged in recent
years and require treatment with either linezolid or
quinupristin/dalfopristin.

Native and prosthetic valves infected with gramnegative organisms

Increasingly, the gram-negative
organismsHaemophilus,Actinobacillus,Cardiobacterium,Eiken
ella, andKingella(HACEK) have become ampicillin-resistant,
and this should never be used as first-line therapy for HACEKorganism endocarditis. These strains are susceptible to thirdand fourth-generation cephalosporins and ampicillin/sulbactam.

Antibiotic allergies
Penicillin allergy is commonly self-reported.
It is important to determine the timing, extent, and nature of any previous
reaction
In general, patients with type I hypersensitivity anaphylactoid reactions or
severe excoriating rashes should not receive penicillin or cephalosporins
(10% to 15% cross-reactivity). In this sub-group of patients, vancomycin is
an alternative drug.
In patients unable to recollect their reaction, or who developed mild rash, it
is often necessary to obtain an allergy consultation for de-sensitisation
therapy or pre-treat with an antihistamine (e.g., diphenhydramine) prior to
administration.
In patients with methicillin-sensitive S aureus endocarditis, it becomes
crucial to define the nature of the allergic reaction clearly, as nafcillin has
been found to be superior in the treatment of these patients when
compared with vancomycin.

Surgical Indications

Haemodynamic embarrassment/severe heart failure

Overwhelming sepsis despite conventional antibiotic therapy
Patients who have large vegetations on echocardiogram or embolic
phenomenon following 2 weeks of medical therapy would be candidates
for valve surgery as well.

Perivalvular abscess
Intracardiac fistulae
Valve perforation or dehiscence
Recurrent embolic episodes despite antibiotic therapy
Prosthetic valve endocarditis
Fungal endocarditis.
Generally, however, the decision to proceed with surgical intervention should be avoided as long as
the patient remains stable. Prolonged antimicrobial therapy prior to surgery is recommended based on
anecdotal expert opinion; however, there currently are no prospective data to support this
recommendation.

Anticoagulation and antiplatelets

Although the majority of complications of IE occur as a
result of embolisation, there is no evidence that
anticoagulation or antiplatelet therapy reduce this risk.
In fact, data suggest that patients already on
anticoagulants who develop prosthetic valve
endocarditis are at higher risk of haemorrhagic
transformation.
Current European guidelines indicate that antiplatelet
therapy can be continued if there is no evidence of
bleeding, that oral anticoagulants should be switched to
unfractionated heparin if an ischaemic stroke occurs,
and that anticoagulation should be withheld entirely if
an intracranial bleed occurs.

Prophylaxis to IE
Antibiotic prophylaxis is largely reserved for patients with the
highest lifetime risk of developing infective endocarditis. The
American Heart Association lists the following high-risk features:
A history of previous infective endocarditis
Prosthetic valves or prosthetic material used for cardiac valve repair
Congenital heart diseases, including: unrepaired cyanotic congenital
heart disease (including palliative shunts and conduits); and completely
repaired congenital heart disease with prosthetic material or device,
whether placed by surgery or catheter intervention, during the first 6
months after the procedure
Repaired congenital heart disease with residual defects at the site or
adjacent to the site of a prosthetic patch or prosthetic device (which
inhibit endothelialisation)
Cardiac transplant patients who develop a cardiac valvulopathy.