Infective endocarditis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected infective endocarditis

1st line – supportive care

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1st line –

supportive care

Initial management is aimed at controlling airway, breathing, and circulation. Patients may require resuscitation, oxygen therapy, and other supportive measures.

Acutely ill patients presenting with decompensated heart failure generally require surgery and pulmonary edema should be managed with intravenous diuretics prior to the surgery.

Blood cultures should be taken prior to the initiation of antimicrobial therapy, and urgent echocardiography is required.[6][7][20][62][63]

US guidelines recommend temporarily discontinuing anticoagulation in patients with IE who have evidence of cerebral embolism or stroke. In patients receiving warfarin or other vitamin K antagonists at the time of IE diagnosis, temporary discontinuation of the anticoagulation should be considered. These guidelines state that decisions about continued anticoagulation and antiplatelet therapy should ultimately be made by the cardiologist and cardiothoracic surgeon, in consultation with a neurology specialist if neurologic findings are present clinically or on imaging.[20] 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 ischemic stroke occurs, and that anticoagulation should be withheld entirely if an intracranial bleed occurs.[7]

All cases of suspected or confirmed IE should include multidisciplinary evaluation by infectious disease, cardiology, and cardiac surgery specialists.[6][7][20][91]

Plus – empiric broad-spectrum antibiotic therapy

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Plus –

empiric broad-spectrum antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Appropriate antimicrobial therapy should be started and continued after blood cultures are obtained, with guidance from antibiotic sensitivity data and the infectious disease experts on the multidisciplinary team.[20] It is vital to obtain blood cultures prior to the initiation of antimicrobial therapy, as one dose often masks an underlying bacteremia and delays appropriate therapy. Broad-spectrum antimicrobial therapy is required empirically in patients with septic shock, or in those who show high-risk signs on presentation.[20]

Consideration of the following factors influences the choice of empiric treatment: previous antibiotic therapy received; native or prosthetic valve involvement; local epidemiology and knowledge of antibiotic-resistant and culture-negative pathogens; and community, nosocomial, or non-nosocomial healthcare-associated infection.[6]

Recommended antibiotic regimens may differ between countries and local guidance should be consulted.[94]

Consider – surgery

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Consider –

surgery

Treatment recommended for SOME patients in selected patient group

The aims of surgery are to remove infected tissue completely and to repair or replace the affected valves, thus restoring cardiac anatomy.

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

2) Uncontrolled infection with local complications (e.g., abscess, false aneurysm, fistula, and enlarging vegetation); persistent positive blood cultures (despite appropriate antibiotic therapy for more than one week and control of septic emboli); resistant bacteria or fungi; or prosthetic valve endocarditis caused by Staphylococcus aureus or non-HACEK gram-negative bacilli.

3) High risk of embolism or established embolism with vegetation ≥10 mm and emboli despite appropriate antibiotic therapy, vegetation ≥10 mm and another reason for surgery (e.g., patients with significant valvular dysfunction [whether a direct result of endocarditis process or not]) or vegetation ≥10 mm and no evidence of embolus.

The 2023 European Society of Cardiology guidelines and the 2020 American Heart Association/American College of Cardiology guideline recommend that the timing of surgical intervention should be decided by the multidisciplinary endocarditis team.[7][20] In addition to antibiotic therapy, early surgical intervention will be needed in around 50% of patients.[20] Early surgical intervention (during initial hospitalization and before completion of the full course of antibiotics) is recommended for patients with any of the following: heart failure symptoms; left-sided IE caused by S aureus, fungal organism, or other highly-resistant pathogen; IE complicated by heart block, annular or aortic abscess or destructive penetrating lesions; persistent bacteremia or fever for >5 days despite appropriate antimicrobial therapy. Early surgery should also be considered for patients with: recurrent emboli and persistent vegetation; native left-sided valve IE with a mobile vegetation >10 mm in length.[20]

ACUTE

native valve: confirmed endocarditis

penicillin-susceptible viridans group streptococci or Streptococcus gallolyticus

1st line – beta-lactam ± gentamicin; or vancomycin

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1st line –

beta-lactam ± gentamicin; or vancomycin

Highly penicillin-sensitive streptococci are often treated based on minimum inhibitory concentration (MIC).

For patients with an MIC ≤0.12 micrograms/mL, treatment consists of either beta-lactam (e.g., penicillin G, ampicillin, or ceftriaxone) monotherapy for 4 weeks or a beta-lactam plus gentamicin for 2 weeks. The 2-week regimen is only recommended in patients with noncomplicated native valve endocarditis and normal renal function. The 4-week regimen should be used in patients >65 years of age or patients with renal impairment or cranial nerve VIII impairment.[6]

Amoxicillin may be considered as an alternative beta-lactam in some countries. Also, netilmicin may be used as an alternative to gentamicin in some countries; however, it is not available in all locations.[7]

Vancomycin only (for 4 weeks) is recommended in patients unable to tolerate penicillin (type I hypersensitivity reaction).[6]

The 2020 American Heart Association/American College of Cardiology guideline states that stable patients with left-sided IE caused by streptococcus, E faecalis, S aureus, or coagulase-negative staphylococci, and who have no evidence of paravalvular infection on transesophageal echocardiogram (TEE), can be considered for switching to oral antibiotic therapy after initial intravenous therapy.[20][104] Frequent follow-up from the multidisciplinary team is required, and a follow-up TEE is recommended 1-3 days prior to completion of the antibiotic course.[20]

Primary options

penicillin G sodium: 12-18 million units/day intravenously given in divided doses every 4-6 hours for 4 weeks

ampicillin: 2 g intravenously every 4 hours for 4 weeks

ceftriaxone: 2 g intravenously/intramuscularly once daily for 4 weeks

amoxicillin: 100-200 mg/kg/day intravenously given in divided doses every 4-6 hours for 4 weeks

penicillin G sodium: 12-18 million units/day intravenously given in divided doses every 4-6 hours for 2 weeks

ceftriaxone: 2 g intravenously/intramuscularly once daily for 2 weeks

amoxicillin: 100-200 mg/kg/day intravenously given in divided doses every 4-6 hours for 2 weeks

-- AND --

gentamicin: 3 mg/kg intravenously/intramuscularly once daily for 2 weeks

Secondary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 4 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

The 2023 European Society of Cardiology guidelines and the 2020 American Heart Association/American College of Cardiology guideline recommend that the timing of surgical intervention should be decided by the multidisciplinary endocarditis team.[7][20][108] In addition to antibiotic therapy, early surgical intervention will be needed in around 50% of patients.[20] Early surgical intervention (during initial hospitalization and before completion of the full course of antibiotics) is recommended for patients with any of the following: heart failure symptoms; left-sided IE caused by S aureus, fungal organism, or other highly-resistant pathogen; IE complicated by heart block, annular or aortic abscess or destructive penetrating lesions; persistent bacteremia or fever for >5 days despite appropriate antimicrobial therapy. Early surgery should also be considered for patients with: recurrent emboli and persistent vegetation; native left-sided valve IE with a mobile vegetation >10 mm in length.[20]

relatively penicillin-resistant streptococci

1st line – beta-lactam + gentamicin; or vancomycin ± gentamicin

Back

1st line –

beta-lactam + gentamicin; or vancomycin ± gentamicin

Some viridans strains are relatively resistant to penicillin or other antimicrobials, with minimum inhibitory concentration (MIC) values of 0.12 to 0.5 micrograms/mL.[6]

A beta-lactam (penicillin G, ampicillin, or ceftriaxone) for 4 weeks plus gentamicin for 2 weeks is the recommended regimen.[6] Amoxicillin may be considered as an alternative beta-lactam in some countries.[7]

Vancomycin only (for 4 weeks) is recommended in patients unable to tolerate penicillin (type I hypersensitivity reaction).[6] Gentamicin (for 2 weeks) may be added to vancomycin in some countries.[7]

It is reasonable to treat patients with penicillin-resistant streptococci (MIC ≥0.5 micrograms/mL) with ampicillin or penicillin G plus gentamicin in consultation with an infectious diseases specialist.[6]

The 2020 American Heart Association/American College of Cardiology guideline states that stable patients with left-sided IE caused by streptococcus, E faecalis, S aureus, or coagulase-negative staphylococci, and who have no evidence of paravalvular infection on transesophageal echocardiogram (TEE), can be considered for switching to oral antibiotic therapy after initial intravenous therapy.[20][104] Frequent follow-up from the multidisciplinary team is required, and a follow-up TEE is recommended 1 to 3 days prior to completion of the antibiotic course.[20]

Primary options

penicillin G sodium: 24 million units/day intravenously given in divided doses every 4-6 hours for 4 weeks

ampicillin: 2 g intravenously every 4 hours for 4 weeks

ceftriaxone: 2 g intravenously/intramuscularly once daily for 4 weeks

amoxicillin: 200 mg/kg/day intravenously given in divided doses every 4-6 hours for 4 weeks

-- AND --

gentamicin: 3 mg/kg intravenously/intramuscularly once daily for 2 weeks

Secondary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 4 weeks

and

gentamicin: 3 mg/kg intravenously/intramuscularly once daily for 2 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

methicillin-sensitive staphylococci

1st line – beta-lactam; or vancomycin; or daptomycin; or trimethoprim/sulfamethoxazole + clindamycin

Back

1st line –

beta-lactam; or vancomycin; or daptomycin; or trimethoprim/sulfamethoxazole + clindamycin

Staphylococcal endocarditis is becoming an increasingly recognized entity, due to high rates of hospital exposure and the development of resistant organisms.

A beta-lactam (oxacillin or nafcillin) is the treatment of choice in oxacillin-susceptible strains. Cefazolin may be used as an alternative in penicillin-allergic (nonanaphylactoid type) patients. Vancomycin or daptomycin are recommended in patients with oxacillin-resistant strains or patients who are unable to tolerate penicillin (type I hypersensitivity reaction). Recommended treatment course is 6 weeks.[6]

Other regimens for Staphylococcus aureus (e.g., trimethoprim/sulfamethoxazole plus clindamycin) may be used and treatment duration may differ (e.g., 4-6 weeks) in some countries.[7]

S aureus is the most common cause of endocarditis in the intravenous drug-abusing population.[3]

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. However, aminoglycosides are no longer recommended in this situation due to the increased risk of nephrotoxicity.[96][97] The American Heart Association recommends that intravenous drug users with IE should be offered 6 weeks of intravenous antibiotics. If this is not deemed achievable (e.g., patient decision or unplanned discharge) initial intravenous therapy should be followed up by appropriate oral treatment, with outpatient follow-up by addiction medicine and infectious disease specialists.[3]

Primary options

oxacillin: 12 g/day intravenously given in divided doses every 4-6 hours for 6 weeks

nafcillin: 12 g/day intravenously given in divided doses every 4-6 hours for 6 weeks

Secondary options

cefazolin: 6 g/day intravenously given in divided doses every 8 hours for 6 weeks

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

daptomycin: 8-10 mg/kg intravenously once daily for 6 weeks

sulfamethoxazole/trimethoprim: 960 mg/day intravenously given in divided doses every 4-6 hours for 1 week, then switch to oral therapy for 5 weeks

and

clindamycin: 1800 mg/day intravenously given in divided doses every 8 hours for 1 week

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

methicillin-resistant staphylococci

1st line – vancomycin; or daptomycin; or trimethoprim/sulfamethoxazole + clindamycin

Back

1st line –

vancomycin; or daptomycin; or trimethoprim/sulfamethoxazole + clindamycin

Vancomycin is the treatment of choice. Daptomycin may be used in cases of vancomycin resistance.[6]

Other regimens for Staphylococcus aureus (e.g., trimethoprim/sulfamethoxazole plus clindamycin) may be used, and treatment duration may differ (e.g., 4-6 weeks) in some countries.[7]

Primary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

Secondary options

daptomycin: 8-10 mg/kg intravenously once daily for 6 weeks

sulfamethoxazole/trimethoprim: 960 mg/day intravenously given in divided doses every 4-6 hours for 1 week, then switch to oral therapy for 5 weeks

and

clindamycin: 1800 mg/day intravenously given in divided doses every 8 hours for 1 week

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

penicillin-sensitive enterococci

1st line – beta-lactam or vancomycin + aminoglycoside; or double beta-lactam

Back

1st line –

beta-lactam or vancomycin + aminoglycoside; or double beta-lactam

Enterococci species are inherently impermeable to aminoglycoside medications, but when aminoglycosides are used in combination with penicillin, bactericidal concentrations can be reached.

Penicillin-sensitive strains of enterococci should be treated with 4-6 weeks of a penicillin (ampicillin or penicillin G) plus an aminoglycoside (gentamicin; or streptomycin if gentamicin-resistant/streptomycin susceptible) for native valve involvement. Amoxicillin may be considered as an alternative beta-lactam in some countries. Gentamicin may be recommended for only 2 weeks when used with amoxicillin.[7]

Patients who are symptomatic for <3 months should receive 4 weeks of therapy, while those who are symptomatic for >3 months should receive 6 weeks of therapy.[6]

A double beta-lactam regimen (ampicillin plus ceftriaxone) for 6 weeks may be used in patients with renal impairment (i.e., creatinine clearance <50 mL/min), abnormal cranial nerve VIII function, or aminoglycoside-resistant strains.[6] This combination is the regimen of choice in patients with Enterococcus faecalis strains with high-level aminoglycoside resistance, although it is not active against Enterococcus faecium.[7]

Vancomycin plus gentamicin (for 6 weeks) is recommended in patients unable to tolerate penicillin (type I hypersensitivity reaction).[6]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

Primary options

ampicillin: 2 g intravenously every 4 hours for 4-6 weeks

penicillin G sodium: 18-30 million units/day intravenously given in divided doses every 4 hours for 4-6 weeks

amoxicillin: 200 mg/kg/day intravenously given in divided doses every 4-6 hours for 4-6 weeks

-- AND --

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8-12 hours for 4-6 weeks

streptomycin: 15 mg/kg/day intravenously/intramuscularly given in 2 divided doses for 4-6 weeks

ampicillin: 2 g intravenously every 4 hours for 6 weeks

and

ceftriaxone: 2 g intravenously every 12 hours for 6 weeks

Secondary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8 hours for 6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

penicillin-resistant enterococci (beta-lactamase producing)

1st line – ampicillin/sulbactam or vancomycin + gentamicin

Back

1st line –

ampicillin/sulbactam or vancomycin + gentamicin

The treatment of enterococcal endocarditis, similar to that of viridans group streptococci, is based on the sensitivities to penicillin. Enterococci, unlike the viridans group streptococci, are not usually killed by antimicrobials, but merely inhibited. Enterococci species are inherently impermeable to aminoglycoside medications, but when aminoglycosides are used in combination with penicillin, bactericidal concentrations can be reached.

Rarely, strains of Enterococcus faecalis can produce an inducible beta-lactamase. These patients should be treated with ampicillin/sulbactam plus gentamicin.[6]

Vancomycin plus gentamicin (for 6 weeks) is recommended in patients unable to tolerate penicillin (type I hypersensitivity reaction).[6]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

Primary options

ampicillin/sulbactam: 3 g intravenously every 6 hours for 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8 hours for 6 weeks

Secondary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8 hours for 6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

penicillin-resistant enterococci (intrinsic)

1st line – vancomycin + gentamicin

Back

1st line –

vancomycin + gentamicin

Intrinsic penicillin resistance is uncommon in Enterococcus faecalis but is common in Enterococcus faecium. These patients should be treated with vancomycin plus gentamicin.[6]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

Primary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8 hours for 6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

vancomycin-resistant Enterococcus faecium (VREF)

1st line – linezolid or daptomycin

Back

1st line –

linezolid or daptomycin

Vancomycin-resistant enterococcal endocarditis is very difficult to manage and patients should be treated by a specialist.

Linezolid or daptomycin are recommended as first-line agents.[6]

Alternative regimens (e.g., quinupristin/dalfopristin, ceftaroline) should only be used under the guidance of an infectious diseases specialist.[6]

Primary options

linezolid: 600 mg intravenously/orally every 12 hours for at least 6 weeks

daptomycin: 10-12 mg/kg intravenously once daily for at least 6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

HACEK microorganisms

1st line – ceftriaxone; or ampicillin/sulbactam ± gentamicin; or ciprofloxacin; or ampicillin

Back

1st line –

ceftriaxone; or ampicillin/sulbactam ± gentamicin; or ciprofloxacin; or ampicillin

Increasingly, the Haemophilus species, Aggregatibacter, Cardiobacterium hominis, Eikenella corrodens, and Kingella species (HACEK) organisms have become ampicillin-resistant, and ampicillin should never be used as first-line therapy for HACEK-organism endocarditis.

These strains are susceptible to third- and fourth-generation cephalosporins (e.g., ceftriaxone) and possibly ampicillin/sulbactam. Treatment course is 4 weeks.[6]

These strains are also susceptible to fluoroquinolones. Fluoroquinolones have not been extensively studied in the treatment of IE, and therefore should be used only as an alternative for patients who cannot tolerate cephalosporins or ampicillin/sulbactam.[6]

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[100] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Ampicillin is an option if the growth of the isolate is sufficient to permit in vitro susceptibility results.[6]

Ampicillin/sulbactam plus gentamicin for 4-6 weeks may be recommended in some countries.[7]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

Primary options

ceftriaxone: 2 g intravenously/intramuscularly once daily for 4 weeks

ampicillin/sulbactam: 3 g intravenously every 6 hours for 4 weeks

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours for 4 weeks; 1000 mg orally (extended-release) once daily for 4 weeks

ampicillin: 2 g intravenously every 4 hours for 4 weeks

ampicillin/sulbactam: 3 g intravenously every 6 hours for 4-6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8 hours for 4-6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

culture-negative microorganisms (not HACEK)

1st line – consultation with infectious diseases specialist

Back

1st line –

consultation with infectious diseases specialist

A variety of organisms are implicated: Chlamydia spp; Coxiella spp; Bartonella spp; Brucella spp; and Legionella spp.

Consultation with an infectious diseases specialist should be sought due to the various mechanisms of antibiotic resistance found in non-HACEK organisms. Combination antibiotic therapy with a beta-lactam plus either an aminoglycoside or a fluoroquinolone for 6 weeks may be a reasonable option.[6] European recommendations are more specific and recommend specific regimens for each causative organism.[7]

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

fungal endocarditis

1st line – surgery + antifungal therapy

Back

1st line –

surgery + antifungal therapy

Fungal infections most frequently affect patients with prosthetic valves, or those who are immunocompromised.[101] Intravenous drug users are also at increased risk of fungal IE.[101] The most common causative agents are Candida and Aspergillus, with mortality >40% to 50%.[101] Treatment includes valve replacement and antifungal therapy.[101][102]

Early surgical intervention (during initial hospitalization) is recommended.[20][124] Valve replacement surgery is recommended for patients with native valve Candida endocarditis.[125] Choice of antifungal therapy is based largely limited, low-quality evidence from randomized trials.[124][125][126] Specialist advice should be sought.

prosthetic valve: confirmed endocarditis

penicillin-sensitive viridans group streptococci or Streptococcus gallolyticus

1st line – beta-lactam ± gentamicin; or vancomycin

Back

1st line –

beta-lactam ± gentamicin; or vancomycin

If the strain is highly sensitive, based on the minimum inhibitory concentration value (i.e., ≤0.12 micrograms/mL), the patient can be given penicillin G, ampicillin, or ceftriaxone for 6 weeks with or without gentamicin for 2 weeks.[6] Amoxicillin may be considered as an alternative beta-lactam in some countries.[7]

Vancomycin only (for 6 weeks) is recommended in patients unable to tolerate penicillin (type I hypersensitivity reaction).[6]

The 2020 American Heart Association/American College of Cardiology guideline states that stable patients with left-sided IE caused by streptococcus, E faecalis, S aureus, or coagulase-negative staphylococci, and who have no evidence of paravalvular infection on transesophageal echocardiogram (TEE), can be considered for switching to oral antibiotic therapy after initial intravenous therapy.[20][104] Frequent follow-up from the multidisciplinary team is required, and a follow-up TEE is recommended 1 to 3 days prior to completion of the antibiotic course.[20]

Primary options

penicillin G sodium: 24 million units/day intravenously given in divided doses every 4-6 hours for 6 weeks

ampicillin: 2 g intravenously every 4 hours for 6 weeks

ceftriaxone: 2 g intravenously/intramuscularly once daily for 6 weeks

amoxicillin: 100-200 mg/kg/day intravenously given in divided doses every 4-6 hours for 6 weeks

penicillin G sodium: 24 million units/day intravenously given in divided doses every 4-6 hours for 6 weeks

ampicillin: 2 g intravenously every 4 hours for 6 weeks

ceftriaxone: 2 g intravenously/intramuscularly once daily for 6 weeks

amoxicillin: 100-200 mg/kg/day intravenously given in divided doses every 4-6 hours for 6 weeks

-- AND --

gentamicin: 3 mg/kg/day intravenously/intramuscularly once daily for 2 weeks

Secondary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

relatively penicillin-resistant streptococci

1st line – beta-lactam + gentamicin; or vancomycin ± gentamicin

Back

1st line –

beta-lactam + gentamicin; or vancomycin ± gentamicin

A beta-lactam (penicillin G, ampicillin, or ceftriaxone) plus gentamicin is the recommended regimen if the strain is relatively resistant to penicillin, based on the minimum inhibitory concentration value (i.e., >0.12 micrograms/mL).[6] Amoxicillin may be considered as an alternative beta-lactam in some countries.[7]

Vancomycin only (for 6 weeks) is recommended in patients unable to tolerate penicillin (type I hypersensitivity reaction).[6] Gentamicin (for 2 weeks) may be added to vancomycin in some countries.[7]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

The 2020 American Heart Association/American College of Cardiology guideline states that stable patients with left-sided IE caused by streptococcus, E faecalis, S aureus, or coagulase-negative staphylococci, and who have no evidence of paravalvular infection on transesophageal echocardiogram (TEE), can be considered for switching to oral antibiotic therapy after initial intravenous therapy.[20][104] Frequent follow-up from the multidisciplinary team is required, and a follow-up TEE is recommended 1 to 3 days prior to completion of the antibiotic course.[20]

Primary options

penicillin G sodium: 24 million units/day intravenously given in divided doses every 4-6 hours for 6 weeks

ampicillin: 2 g intravenously every 4 hours for 6 weeks

ceftriaxone: 2 g intravenously/intramuscularly once daily for 6 weeks

amoxicillin: 200 mg/kg/day intravenously given in divided doses every 4-6 hours for 6 weeks

-- AND --

gentamicin: 3 mg/kg/day intravenously/intramuscularly once daily for 6 weeks

Secondary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

and

gentamicin: 3 mg/kg intravenously/intramuscularly once daily for 2 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

methicillin-sensitive staphylococci

1st line – nafcillin or oxacillin or cefazolin or vancomycin + rifampin + gentamicin

Back

1st line –

nafcillin or oxacillin or cefazolin or vancomycin + rifampin + gentamicin

Infections caused by Staphylococcus aureus are often rapidly progressive and carry a high mortality rate; therefore, combination therapy is recommended.[98][99]

The treatment of methicillin-sensitive strains should include nafcillin or oxacillin or cefazolin plus rifampin for at least 6 weeks. Gentamicin should be used for synergy during the first 2 weeks of therapy.[6]

Vancomycin plus rifampin (for at least 6 weeks) plus gentamicin (for 2 weeks) is recommended in patients unable to tolerate penicillin (type I hypersensitivity reaction).[6]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

The 2020 American Heart Association/American College of Cardiology guideline states that stable patients with left-sided IE caused by streptococcus, E faecalis, S aureus, or coagulase-negative staphylococci, and who have no evidence of paravalvular infection on transesophageal echocardiogram (TEE), can be considered for switching to oral antibiotic therapy after initial intravenous therapy.[20][104] Frequent follow-up from the multidisciplinary team is required, and a follow-up TEE is recommended 1 to 3 days prior to completion of the antibiotic course.[20]

Primary options

nafcillin: 12 g/day intravenously given in divided doses every 4 hours for at least 6 weeks

oxacillin: 12 g/day intravenously given in divided doses every 4 hours for at least 6 weeks

cefazolin: 6 g/day intravenously given in divided doses every 8 hours for 6 weeks

-- AND --

rifampin: 900 mg/day orally/intravenously given in divided doses every 8 hours for at least 6 weeks

-- AND --

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8-12 hours for 2 weeks

Secondary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for at least 6 weeks

and

rifampin: 900 mg/day orally/intravenously given in divided doses every 8 hours for at least 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8-12 hours for 2 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

methicillin-resistant staphylococci

1st line – vancomycin + rifampin + gentamicin

Back

1st line –

vancomycin + rifampin + gentamicin

Methicillin-resistant species are becoming more prevalent especially in hospitalized patients.

Vancomycin plus rifampin for 6 weeks is recommended. Gentamicin should be used for synergy during the first 2 weeks of therapy.[6]

The 2020 American Heart Association/American College of Cardiology guideline states that stable patients with left-sided IE caused by streptococcus, E faecalis, S aureus, or coagulase-negative staphylococci, and who have no evidence of paravalvular infection on transesophageal echocardiogram (TEE), can be considered for switching to oral antibiotic therapy after initial intravenous therapy.[20][104] Frequent follow-up from the multidisciplinary team is required, and a follow-up TEE is recommended 1 to 3 days prior to completion of the antibiotic course.[20]

Primary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for at least 6 weeks

and

rifampin: 900 mg/day orally/intravenously given in divided doses every 8 hours for at least 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8-12 hours for 2 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

penicillin-sensitive enterococci

1st line – beta-lactam or vancomycin + aminoglycoside; or double beta-lactam

Back

1st line –

beta-lactam or vancomycin + aminoglycoside; or double beta-lactam

Enterococci species are inherently impermeable to aminoglycoside medications, but when aminoglycosides are used in combination with penicillin, bactericidal concentrations can be reached.

Penicillin-sensitive strains of enterococci should be treated with 6 weeks of a penicillin (ampicillin or penicillin G) plus an aminoglycoside (gentamicin; or streptomycin if gentamicin-resistant/streptomycin susceptible) for prosthetic valve involvement.[6] Amoxicillin may be considered as an alternative beta-lactam in some countries. Gentamicin may be recommended for only 2 weeks when used with amoxicillin.[7]

Vancomycin plus gentamicin (for 6 weeks) is recommended in patients unable to tolerate penicillin (type I hypersensitivity reaction).[6]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

The 2020 American Heart Association/American College of Cardiology guideline states that stable patients with left-sided IE caused by streptococcus, E faecalis, S aureus, or coagulase-negative staphylococci, and who have no evidence of paravalvular infection on transesophageal echocardiogram (TEE), can be considered for switching to oral antibiotic therapy after initial intravenous therapy.[20][104] Frequent follow-up from the multidisciplinary team is required, and a follow-up TEE is recommended 1 to 3 days prior to completion of the antibiotic course.[20]

Primary options

ampicillin: 2 g intravenously every 4 hours for 6 weeks

penicillin G sodium: 18-30 million units/day intravenously given in divided doses every 4 hours for 6 weeks

amoxicillin: 200 mg/kg/day intravenously given in divided doses every 4-6 hours for 6 weeks

-- AND --

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8-12 hours for 6 weeks

streptomycin: 15 mg/kg/day intravenously/intramuscularly given in 2 divided doses for 6 weeks

ampicillin: 2 g intravenously every 4 hours for 6 weeks

and

ceftriaxone: 2 g intravenously every 12 hours for 6 weeks

Secondary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8-12 hours for 6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

penicillin-resistant enterococci (beta-lactamase producing)

1st line – ampicillin/sulbactam or vancomycin + gentamicin

Back

1st line –

ampicillin/sulbactam or vancomycin + gentamicin

Rarely, strains of Enterococcus faecalis can produce an inducible beta-lactamase. These patients should be treated with ampicillin/sulbactam plus gentamicin.[6]

Vancomycin plus gentamicin (for 6 weeks) is recommended in patients unable to tolerate penicillin (type I hypersensitivity reaction).[6]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

The 2020 American Heart Association/American College of Cardiology guideline states that stable patients with left-sided IE caused by streptococcus, E faecalis, S aureus, or coagulase-negative staphylococci, and who have no evidence of paravalvular infection on transesophageal echocardiogram (TEE), can be considered for switching to oral antibiotic therapy after initial intravenous therapy.[20][104] Frequent follow-up from the multidisciplinary team is required, and a follow-up TEE is recommended 1 to 3 days prior to completion of the antibiotic course.[20]

Primary options

ampicillin/sulbactam: 3 g intravenously every 6 hours for 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8 hours for 6 weeks

Secondary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8 hours for 6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

penicillin-resistant enterococci (intrinsic)

1st line – vancomycin + gentamicin

Back

1st line –

vancomycin + gentamicin

Intrinsic penicillin resistance is uncommon in Enterococcus faecalis but is common in Enterococcus faecium. These patients should be treated with vancomycin plus gentamicin.[6]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

Primary options

vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours for 6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8 hours for 6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

vancomycin-resistant Enterococcus faecium (VREF)

1st line – linezolid or daptomycin

Back

1st line –

linezolid or daptomycin

Vancomycin-resistant enterococci is very difficult to manage and patients should be treated by a specialist.

Linezolid or daptomycin are recommended as first-line agents.[6]

Alternative regimens (e.g., quinupristin/dalfopristin, ceftaroline) should only be used under the guidance of an infectious diseases specialist.[6]

Primary options

linezolid: 600 mg intravenously/orally every 12 hours for at least 6 weeks

daptomycin: 10-12 mg/kg intravenously once daily for at least 6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

HACEK microorganisms

1st line – ceftriaxone; or ampicillin/sulbactam ± gentamicin; or ciprofloxacin; or ampicillin

Back

1st line –

ceftriaxone; or ampicillin/sulbactam ± gentamicin; or ciprofloxacin; or ampicillin

Increasingly, theHaemophilus species, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella species (HACEK) organisms have become ampicillin-resistant, and ampicillin should never be used as first-line therapy for HACEK-organism endocarditis. These strains are susceptible to third- and fourth-generation cephalosporins (e.g., ceftriaxone) and possibly ampicillin/sulbactam. Treatment course is 6 weeks.[6]

Ampicillin is an option if the growth of the isolate is sufficient to permit in vitro susceptibility results.[6]

Ampicillin/sulbactam plus gentamicin for 4-6 weeks is recommended in some countries.[7]

Close monitoring of renal function and possible ototoxicity is important in patients receiving extended treatment with aminoglycosides.[6]

Primary options

ceftriaxone: 2 g intravenously/intramuscularly once daily for 6 weeks

ampicillin/sulbactam: 3 g intravenously every 6 hours for 6 weeks

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours for 6 weeks; 1000 mg orally (extended-release) once daily for 6 weeks

ampicillin: 2 g intravenously every 4 hours for 6 weeks

ampicillin/sulbactam: 3 g intravenously every 6 hours for 4-6 weeks

and

gentamicin: 3 mg/kg/day intravenously/intramuscularly given in divided doses every 8 hours for 4-6 weeks

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

culture-negative microorganisms (not HACEK)

1st line – consultation with infectious diseases specialist

Back

1st line –

consultation with infectious diseases specialist

A variety of organisms are implicated: Chlamydia spp; Coxiella spp; Bartonella spp; Brucella spp; and Legionella spp.

Consultation with an infectious diseases specialist should be sought due to the various mechanisms of antibiotic resistance found in non-HACEK organisms.

If the onset of symptoms is within one year of prosthetic valve surgery, antibiotic cover for staphylococci, enterococci, and aerobic gram-negative bacilli is suggested. If symptom onset is at more than one year after valve placement, cover for staphylococci, viridans group streptococci, and enterococci is recommended.[6] European recommendations are more specific and recommend specific regimens for each causative organism.[7]

Consider – surgery

Back

Consider –

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgery include the following:[6][7][91][106][107][108]

1) Heart failure, especially cardiogenic shock or pulmonary edema (requires emergency surgery), or poor hemodynamic tolerance (requires urgent surgery).

Surgical intervention is frequently required to cure the disease in patients with prosthetic valves.

Temporary cardiac pacing is recommended in patients with atrioventricular block secondary to mycotic abscess of the aortic root.

fungal endocarditis

1st line – surgery + antifungal therapy

Back

1st line –

surgery + antifungal therapy

Valve replacement surgery needs to be performed as soon as possible in prosthetic valve Candida endocarditis.[125] Choice of antifungal therapy is based largely limited, low-quality evidence from randomized trials.[124][125][126] Specialist advice should be sought.

ONGOING

at high risk of infective endocarditis

1st line – antibiotic prophylaxis

Back

1st line –

antibiotic prophylaxis

Antibiotic prophylaxis is recommended only for patients with underlying cardiac conditions associated with the highest risk of developing IE and at high risk of experiencing adverse outcomes from it: patients with prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts, or valve repairs using prosthetic material; patients who have suffered from a previous episode of IE; patients with unrepaired cyanotic congenital heart disease or repaired congenital heart disease with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device; or patients with cardiac transplant with valve regurgitation due to a structurally abnormal valve.[20]

Prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissues or the periapical region of the tooth, or perforation of the oral mucosa.[20][40]

Prophylaxis is not recommended for the following dental procedures: anesthetic injections through noninfected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa.[40]

Prophylaxis is not recommended in patients undergoing nondental procedures (e.g., transthoracic echocardiogram, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection.[20]

Amoxicillin is the preferred agent in patients that can take oral medication.[7][40]

Parenteral ampicillin, cefazolin, or ceftriaxone are options in patients who cannot take oral medication.[40]

In patients who are allergic to penicillins and can take oral medication, cephalexin (or another first- or second-generation oral cephalosporin), azithromycin, clarithromycin, or doxycycline are options.[40]

Cephalosporins should be avoided in patients with a history of anaphylaxis, angioedema, or urticaria with penicillins.[40]

Clindamycin is no longer recommended for antibiotic prophylaxis for a dental procedure.[40]

Antibiotics are administered as a single dose 30 to 60 minutes before the procedure.[40]

Primary options

amoxicillin: 2 g orally as a single dose 30-60 minutes before procedure

Secondary options

ampicillin: 2 g intravenously/intramuscularly as a single dose 30-60 minutes before procedure

cefazolin: 1 g intravenously/intramuscularly as a single dose 30-60 minutes before procedure

ceftriaxone: 1 g intravenously/intramuscularly as a single dose 30-60 minutes before procedure

cephalexin: 2 g orally as a single dose 30-60 minutes before procedure

azithromycin: 500 mg orally as a single dose 30-60 minutes before procedure

clarithromycin: 500 mg orally as a single dose 30-60 minutes before procedure

doxycycline: 100 mg orally as a single dose 30-60 minutes before procedure

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Infective endocarditis

Treatment algorithm

suspected infective endocarditis

supportive care

empiric broad-spectrum antibiotic therapy

surgery

native valve: confirmed endocarditis

beta-lactam ± gentamicin; or vancomycin

Primary options

Secondary options

surgery

beta-lactam + gentamicin; or vancomycin ± gentamicin

Primary options

Secondary options

surgery

beta-lactam; or vancomycin; or daptomycin; or trimethoprim/sulfamethoxazole + clindamycin

Primary options

Secondary options

surgery

vancomycin; or daptomycin; or trimethoprim/sulfamethoxazole + clindamycin

Primary options

Secondary options

surgery

beta-lactam or vancomycin + aminoglycoside; or double beta-lactam

Primary options

Secondary options

surgery

ampicillin/sulbactam or vancomycin + gentamicin

Primary options

Secondary options

surgery

vancomycin + gentamicin

Primary options

surgery

linezolid or daptomycin

Primary options

surgery

ceftriaxone; or ampicillin/sulbactam ± gentamicin; or ciprofloxacin; or ampicillin

Primary options

Secondary options

surgery

consultation with infectious diseases specialist

surgery

surgery + antifungal therapy

prosthetic valve: confirmed endocarditis

beta-lactam ± gentamicin; or vancomycin

Primary options

Secondary options

surgery

beta-lactam + gentamicin; or vancomycin ± gentamicin

Primary options

Secondary options

surgery

nafcillin or oxacillin or cefazolin or vancomycin + rifampin + gentamicin

Primary options

Secondary options

surgery

vancomycin + rifampin + gentamicin

Primary options

surgery

beta-lactam or vancomycin + aminoglycoside; or double beta-lactam

Primary options

Secondary options

surgery

ampicillin/sulbactam or vancomycin + gentamicin

Primary options

Secondary options

surgery

vancomycin + gentamicin

Primary options

surgery

linezolid or daptomycin

Primary options

surgery

ceftriaxone; or ampicillin/sulbactam ± gentamicin; or ciprofloxacin; or ampicillin

Primary options

Secondary options

surgery

consultation with infectious diseases specialist

surgery