Treatment Guideline Chart
Infective endocarditis is microbial infection of the endovascular structures of the heart.
It often presents in an occult fashion and early diagnosis depends on a high index of clinical suspicion especially in patients with congenital heart disease, prosthetic valves or previous infective endocarditis.
The established diagnosis of infective endocarditis is demonstrated by a positive blood culture and involvement of the endocardium detected during sepsis or systemic infection. It may also be established if there is involvement of the endocardium detected during sepsis or systemic infection but blood culture is negative.

Surgical Intervention

Principles of Surgical Treatment

  • Combined medical and surgical therapy for infective endocarditis (IE) can decrease mortality among patients who have congestive heart failure (CHF), perivalvular invasive disease, or uncontrolled infection despite maximal antimicrobial therapy
  • Objectives of surgical treatment: Removal of infected tissue, foreign material and hardware, debridement of paravalvular infection and cavities, restoration of cardiac integrity and valve function, and removal of threatening sources of embolism
  • The decision to perform surgery and its timing is dependent upon the cardiac and systemic complications caused by the infection, the microorganism’s virulence and the response to antimicrobial therapy
    • The optimal time to perform surgery is before severe hemodynamic disability or spread of the infection to perivalvular tissue occurs
      • Early surgery (while the patient is still on antibiotic treatment) is considered in patients with IE to avoid progression of heart failure (HF) and irreversible cardiac structural damage and to prevent embolism
      • Valve surgery is recommended without delay in patients with IE and an indication for surgery, who had a stroke but without evidence of intracranial hemorrhage or extensive neurological damage
      • Valve surgery should be delayed for ≥4 weeks in patients with IE and an indication for surgery, who had a major ischemic stroke when patient is hemodynamically stable
  • CHF is the strongest indication for surgery in IE

Surgery should be considered in the following:

  • Native valve endocarditis (NVE) patients with acute aortic or mitral regurgitation and CHF
  • Evidence of perivalvular extension
  • Persistent infection after 5-7 days of adequate antimicrobial therapy
  • Relapsing infection ie recurrence of bacteremia following a complete antibiotic course and subsequently negative blood cultures (BCs) with no known source of infection
  • Infection with microorganisms that have poor response to antibiotic therapy (eg fungi, Brucella sp, Coxiella sp, Staphylococcus lugdunensis, Enterococcus sp with high-level resistance to Gentamicin, Gram-negative organisms)
    • Left-sided IE caused by S aureus, fungal, or highly resistant organisms
  • NVE patients with mobile vegetation >10 mm before or during the first week of antibiotic therapy
  • Recurrent emboli despite appropriate antibiotic therapy
  • Obstructive or persistent vegetations
  • Early prosthetic valve endocarditis (PVE)
  • Hemodynamically significant prosthetic valve malfunction
  • IE complicated by annular or aortic abscess, destructive penetrating lesion, or heart block
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