Materiały źródłowe

• #1 Infectious Endocarditis: Diagnosis and Treatment | AAFP

  https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html

  Endocarditis should be suspected in any patient with unexplained fevers, night sweats, or signs of systemic illness, particularly if any of the following risk factors are present: a prosthetic heart valve, structural or congenital heart disease, intravenous drug use, and a recent history of invasive procedures (e.g., wound care, hemodialysis). […] The diagnosis of infectious endocarditis requires multiple clinical, laboratory, and imaging findings. Overdiagnosis and underdiagnosis of infectious endocarditis can be problematic; a missed diagnosis could prove fatal, whereas overdiagnosis can result in weeks of unnecessary antibiotic treatment. […] The widely accepted Duke criteria use a set of major and minor clinical and pathologic criteria to classify infectious endocarditis as definite, possible, or rejected.

• #1 Infective Endocarditis Diagnosis and Management

  https://www.uspharmacist.com/article/infective-endocarditis-diagnosis-and-management

  Many patients with endocarditis present with nonspecific symptoms that prompt a broad medical workup. […] The diagnosis of IE has been based upon microbiologic and echocardiographic evidence recommendations from the Modified Duke Criteria, last updated in 2000. […] In 2023, the International Society for Cardiovascular Infectious Diseases suggested significant updates to the Duke Criteria due to changes in microbiology, diagnostics, epidemiology, and treatment. […] Pathologic criteria are used to diagnose definitive IE. […] The 2023 update provided clarity and broadened these criteria to include microorganisms identified in the context of clinical signs of active endocarditis. […] These criteria have been updated to include three subsections: Microbiologic Major Criteria, Imaging Major Criteria, and Surgical Major Criteria, which is a 2023 suggested addition. […] The minor clinical criteria for diagnosis span seven categories. […] The 2023 updates to the modified Duke Criteria consider changes in microbiology, diagnostics, epidemiology, and treatment of IE, allowing for improved diagnosis of IE.

• #1 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  Myocardial abscess […] Development of partial dehiscence of a prosthetic valve […] New-onset valvular regurgitation […] Minor criteria for IE include the following: […] Predisposing heart condition or intravenous drug use (IVDA) […] Fever of 38C (100.4F) or higher […] Vascular phenomena, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions […] Immunologic phenomena such as glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor […] Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE […] Echocardiogram results consistent with IE but not meeting major echocardiographic criteria […] A definitive clinical diagnosis can be made based on the following:

• #1 Diagnosing and Treating Acute Infective Endocarditis | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/diagnosing-and-treating-acute-infective-endocarditis/2010-10

  Fever is by far the most common sign or symptom of acute infective endocarditis. Other constitutional symptoms include chills, sweats, loss of appetite, and malaise. […] Echocardiography is central to the diagnosis of endocarditis. Transthoracic echocardiogram (TTE) should be the initial study of choice in most cases, though transesophageal echocardiogram (TEE) has a higher sensitivity for detecting vegetations. This makes TEE useful for patients with suboptimal images on TTE, a high likelihood of IE, or prosthetic valves. […] The Modified Duke Criteria is a well-validated set of clinical, microbiological, and echocardiographic criteria for diagnosing infective endocarditis. The major criteria are two positive blood cultures with a typical microorganism for infective endocarditis and evidence of endocardial involvement on echocardiogram. The minor criteria include fever, a predisposing condition for IE (such as intravenous drug use), vascular phenomena, immunologic phenomena, and microbiological evidence not included in the major criteria. A classification of definite IE requires the presence of 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria. The presence of 1 major criterion and 1 minor criterion, or 3 minor criteria, indicates a possible case of IE.

• #1 Infectious Endocarditis: Diagnosis and Treatment | AAFP

  https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html

  Direct evidence of endocarditis can be obtained from histologic specimens collected during surgery or autopsy, or from a combination of two major clinical criteria, one major and three minor criteria, or five minor criteria. Possible endocarditis is defined as the presence of one major and one or two minor criteria, or three minor criteria. […] The American College of Cardiology and the American Heart Association recommend that echocardiography be performed to identify valvular abnormalities in all patients in whom there is moderate or high suspicion of endocarditis.

• #1 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  The Duke diagnostic criteria were developed by Durack and colleagues as a guide for reaching a valid definitive diagnosis of IE. The criteria combine the clinical, microbiologic, pathologic, and echocardiographic characteristics of a specific case. […] Major blood culture criteria for IE include the following: […] Two blood cultures positive for organisms typically found in patients with IE […] Blood cultures persistently positive for 1 of these organisms, from cultures drawn more than 12 hours apart […] Three or more separate blood cultures drawn at least 1 hour apart […] Major echocardiographic criteria include the following: […] Echocardiogram positive for IE, documented by an oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomic explanation

• #1 Novel Diagnostic Methods for Infective Endocarditis

  https://www.mdpi.com/1422-0067/25/2/1245

  In the case of non-identified bacteria, while fulfilling the other clinical criteria of infective endocarditis, we can diagnose blood culture-negative endocarditis (BCNIE). It refers to IE in which no causative micro-organism can be grown using the usual blood culture methods, thus remaining a diagnostic and therapeutic challenge. In the case of BCNIE, further diagnosis using special methods (which will be further listed in this article) is needed. […] Serological tests should be performed when blood cultures are negative after 48 h. One of the micro-organisms that serological tests are used to diagnose is Coxiella burnetii. The microbiological criteria for the diagnosis of IE in the ESC criteria in 2023 are immunoglobulin G (IgG) antibody titers against Coxiella burnetii IgG ≥ 1:800 and indirect immunofluorescence assays (IFA) to detect IgM and IgG antibodies against Bartonella henselael or Bartonella quintana, with IgG titers of ≥1:800.

• #1 Novel Diagnostic Methods for Infective Endocarditis

  https://www.mdpi.com/1422-0067/25/2/1245

  IE can include electrodes or native or prosthetic valves. The gold diagnostic standard—TTE and TEE—focuses on visualizing any complications of the valves in IE. However, it is also possible to image IE-induced inflammation using newer techniques. The pathophysiology of IE involves inflammation and bacterial proliferation, which leads to the formation of vegetation made of fibrin, micro-organisms, platelets, and inflammatory cells. […] Future research on infective endocarditis should focus on a better diagnosis of BCNIE. The identification of the pathogen responsible for IE leads to the implementation of effective treatment. This can be achieved through the standard use of 16S/18S PCR diagnostics and increasing its availability, as well as the further development of nuclear medicine imaging in IE.

• #1 Endocarditis: Causes, Symptoms and Treatment

  https://my.clevelandclinic.org/health/diseases/16957-endocarditis

  Infective endocarditis (IE) is a potentially fatal inflammation of your heart valves lining and sometimes heart chambers lining. […] Your healthcare provider will diagnose bacterial endocarditis after: […] Diagnostic tests for endocarditis include: […] Blood cultures that show bacteria or microorganisms that healthcare providers often see with endocarditis. […] Endocarditis can be life-limiting. Once you get it, you’ll need quick treatment to prevent damage to your heart valves and more serious complications. […] After taking your blood cultures, your healthcare provider will start you on intravenous (IV) antibiotic therapy. […] Endocarditis is fatal without treatment.

• #1 Novel Diagnostic Methods for Infective Endocarditis

  https://www.mdpi.com/1422-0067/25/2/1245

  The diagnosis is based on clinical suspicion, which is supported by microbiological data and imaging, as included in the latest ESC guidelines. Suspicion of IE is usually due to fever, new heart murmurs, and positive blood cultures if an alternative focus of infection is not known. This is especially true in patients with one or more risk factors. In the latest ESC guidelines, it is recommended that the endocarditis team be involved as soon as possible to help further manage patients with suspected IE. […] If IE is suspected, at least three sets of blood cultures should be obtained at 30 min intervals prior to antibiotic therapy. It is necessary to deliver the diagnosis and provide live bacteria for both identification and susceptibility testing. Blood cultures should be incubated in both aerobic and anaerobic atmospheres. Blood for the test is drawn from the patient’s veins from different insertion sites, with at least 1 h between the first and last collection.

• #1 Infective endocarditis – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/3000215

  Infective endocarditis (IE) often presents non-specifically, most commonly with fever and symptoms/signs of embolism. […] If you suspect IE, evaluate the patient urgently and seek early input from a cardiologist and an infectious disease or microbiology specialist. A multidisciplinary approach (e.g., with an endocarditis team’) is crucial for diagnosis and management. […] Prioritise obtaining three sets of blood cultures taken at 30-minute intervals prior to initiation of antibiotic therapy and echocardiography. […] Diagnostic investigations include blood cultures, echocardiography, full blood count, CRP, serum urea, electrolytes, and glucose, liver function tests, urinalysis, and ECG. […] Emerging tests include troponin I.

• #1 Feature | Infective Endocarditis: Words of Caution For Management

  https://www.acc.org/Latest-in-Cardiology/Articles/2022/03/12/01/42/Feature-Infective-Endocarditis-Words-of-Caution-For-Management

  Laboratory features of IE are nonspecific and should be considered in relation to the overall clinical picture. […] Recommendations for laboratory testing include collecting three sets of peripheral blood cultures using aseptic technique, at least 30 minutes apart but ideally six hours, before the initiation of antibiotic therapy. […] Despite many imaging advances in the diagnosis of IE, transthoracic echocardiography (TTE) remains the first-line approach given its availability and cost. […] TEE has a lower sensitivity for the diagnosis of IE in prosthetic valves and intracardiac devices compared with native valves, giving way to computed tomography (CT) and nuclear imaging techniques. […] The current guidance for empirical treatment from the ESC is summarized in the guideline document in the European Heart Journal. Once a pathogen is isolated, ideally within 48 hours, antibiotic therapy should be tailored.

• #1 Diagnostic criteria and problems in infective endocarditis

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1768277/

  Histological findings are included in the Duke and von Reyn diagnostic criteria and pathological examination of resected valvar tissue or embolic fragments remains the gold standard for the diagnosis of infective endocarditis. […] Several molecular approaches have been assessed for the detection and identification of pathogens in a wide variety of infectious diseases. […] Optimal antiseptic skin preparation is important and at least 10 ml of blood (less in children) should be obtained for each culture. […] To date, definitive studies of infective endocarditis have been difficult to perform because of its heterogenous nature. […] Modification of the original Duke criteria is now proposed to enhance diagnostic sensitivity, especially in culture negative cases.

• #1 Special Topic: Infective Endocarditis | Pioneering Diagnostics

  https://www.biomerieux.com/corp/en/education/medical-education/educational-booklets/blood-culture-a-key-investigation-for-diagnosis-of-blood-stream-infections/special-topic-infective-endocarditis.html

  Blood culture is essential in the diagnosis of infective endocarditis (infection of the heart valves). In this elusive disease, blood cultures may need to be taken repeatedly during febrile episodes, when bacteria are shed from the heart valves into the bloodstream. For patients with infective endocarditis, positive blood cultures will be obtained in over 90% of cases, if optimal culture conditions are respected. […] When suspected, the severity of this disease requires blood cultures to be drawn immediately to avoid unnecessary delays in appropriate treatment. […] If subacute infection is suspected, although it is important to attempt to establish the microbiological diagnosis, antimicrobial therapy should nevertheless be initiated as soon as possible. […] Diagnosis of fungal endocarditis can be very challenging, as blood cultures may take a long time to yield growth, with a yield for positive blood cultures of around 50%.

• #1 Diagnostic criteria and problems in infective endocarditis

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1768277/

  Few diseases present greater difficulties in the way of diagnosis than malignant endocarditis, difficulties which in many cases are practically insurmountable. […] The original von Reyn diagnostic criteria for infective endocarditis, based upon clinical and microbiological features, have now been surpassed by the Duke criteria which emphasise the role of echocardiography, the key imaging tool for both diagnosis and assessment of prognosis. […] Negative blood cultures occur in 2.531% of all cases of infective endocarditis, often delaying diagnosis and the onset of treatment with profound impact on clinical outcome. […] In 1997, Lamas and Eykyn proposed a number of clinical modifications to the Duke criteria to include newly diagnosed splenomegaly or clubbing, elevated inflammatory markers, haematuria, and the presence of central and peripheral venous lines.

• #1 Special Topic: Infective Endocarditis | Pioneering Diagnostics

  https://www.biomerieux.com/corp/en/education/medical-education/educational-booklets/blood-culture-a-key-investigation-for-diagnosis-of-blood-stream-infections/special-topic-infective-endocarditis.html

  In order to distinguish between contamination and true bacteremia, a total of three to five blood culture sets should be sufficient. […] Often patients with suspected infective endocarditis have been put on antibiotics prior to blood collection. This is the most common reason for culture-negative infective endocarditis. […] However, culture-negative endocarditis may also be due to fastidious microorganisms, such as Aspergillus spp., Brucella spp., Coxiella burnetii, Chlamydia spp. and HACEK microorganisms. […] However, if all blood culture bottles are negative after 5 days, and infectious endocarditis is still suspected, all bottles should be subcultured to chocolate agar.

• #1 Endocarditis – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

  To diagnose endocarditis, a health care provider does a physical exam and asks questions about your medical history and symptoms. Tests are done to help confirm or rule out endocarditis. […] Tests used to help diagnose endocarditis include: […] Blood culture test. This test helps identify germs in the bloodstream. Results from this test help determine the antibiotic or combination of antibiotics to use for treatment. […] Complete blood count. This test can determine if there’s a lot of white blood cells, which can be a sign of infection. A complete blood count can also help diagnose low levels of healthy red blood cells (anemia), which can be a sign of endocarditis. Other blood tests also may be done. […] Echocardiogram. Sound waves are used to create images of the beating heart. This test shows how well the heart’s chambers and valves pump blood. It can also show the heart’s structure. Your provider may use two different types of echocardiograms to help diagnose endocarditis.

• #1 Infective endocarditis – Symptoms, diagnosis and treatment | BMJ Best Practice US

  https://bestpractice.bmj.com/topics/en-us/139

  In cases of suspected IE, the patient should be evaluated urgently and early input from cardiology and an infectious disease or microbiology specialist should be sought. A multidisciplinary approach (e.g., with an endocarditis team) is crucial for diagnosis and management. […] At least three sets of blood cultures taken at different sites and at different times (ideally 6 hours between the first and last samples if clinical status allows) should be obtained prior to initiation of antibiotic therapy and echocardiography. […] Diagnostic tests include blood cultures, echocardiogram, CBC, CRP, serum chemistry panel with glucose, LFTs, urinalysis, and ECG. […] Tests to consider include rheumatoid factor, erythrocyte sedimentation rate, complement levels, cardiac CT, MRI, and Nuclear imaging and PET. […] Emerging tests include mean platelet volume (MPV), antibeta-2glycoprotein I antibodies, D-dimer, and troponin I.

• #1 Endocarditis: Diagnosis & Treatment | NewYork-Presbyterian

  https://www.nyp.org/heart/heart-inflammation/endocarditis/treatment

  How is Endocarditis Diagnosed? Diagnosis Before your doctor can diagnose endocarditis, a physical examination and discussion of the symptoms you are experiencing must be done. After this, diagnostic tests for endocarditis will be scheduled. These tests used for endocarditis diagnosis will include: Blood tests. Some reasons blood tests will be ordered are: To determine the type of bacteria causing the infection, a different pathogen causes each inflammatory heart condition. A complete blood count will establish whether an unusually high number of white blood cells are present, indicating an infection somewhere in the body. Blood tests revealing C-reactive proteins are an indication of heart inflammation. Echocardiograms. These ultrasound tests can reveal growths (called vegetations) on your heart valves, holes (abscesses), leaking valves (regurgitation), or narrowing valves (stenosis). An echocardiogram can also detect problems with existing artificial heart valves. Heart valve tissue. A small piece of heart valve tissue is examined for specific microbes. Positron emission tomography (PET) scans. These scans use nuclear medicine containing radioactive material to create a clear image of the infections location. Chest X-ray. A chest X-ray can show whether endocarditis has caused the heart to swell or if the infection has spread to the lungs. Electrocardiogram (ECG or EKG). This painless test records the hearts electrical activity through sensors attached to the chest, arms, and legs. This test is not explicitly designed to detect endocarditis. However, it can show if there is a disruption in the hearts electrical activity, which could indicate heart inflammation.

• #1 Endocarditis: Risk Factors, Symptoms, and Diagnosis

  https://www.healthline.com/health/endocarditis

  How is endocarditis diagnosed? Your doctor will go over your symptoms and medical history before conducting any tests. After this review, theyll use a stethoscope to listen to your heart. The following tests may also be done: […] If your doctor suspects you have endocarditis, a blood culture test will be ordered to confirm whether bacteria, fungi, or other microorganisms are causing it. Other blood tests can also reveal if your symptoms are caused by another condition, such as anemia. […] A transthoracic echocardiogram is a non-radiating imaging test used to view your heart and its valves. This test uses ultrasound waves to create an image of your heart, with the imaging probe placed on the front of your chest. Your doctor can use this imaging test to look for signs of damage or abnormal movements of your heart.

• #1 Infective endocarditis – Wikipedia

  https://en.wikipedia.org/wiki/Infective_endocarditis

  Infective endocarditis is an infection of the inner surface of the heart (endocardium), usually the valves. Diagnosis is suspected based on symptoms and supported by blood cultures or ultrasound of the heart. Echocardiography is the main type of diagnostic imaging used to establish the diagnosis of infective endocarditis. The transthoracic echocardiogram has a sensitivity and specificity of approximately 65% and 95% if the echocardiographer believes there is 'probable’ or 'almost certain’ evidence of endocarditis. However, in endocarditis involving a prosthetic valve, TTE has a sensitivity of approximately 50%, whereas TEE has a sensitivity exceeding 90%. Guidelines support the initial use of TTE over TEE in people with abnormal blood cultures, a new heart murmur, and suspected infective endocarditis. TEE is the preferred initial form of imaging in people with suspected infective endocarditis who have a moderate to high pretest probability of infective endocarditis, including people with prosthetic heart valves, blood cultures growing Staphylococcus, or have an intracardiac device (such as a pacemaker).

• #1 Infective Endocarditis Workup: Approach Considerations, Blood and Urine Studies, Blood Culture

  https://emedicine.medscape.com/article/216650-workup

  Echocardiography has become the indirect diagnostic method of choice, especially in patients who present with a clinical picture of IE but who have nondiagnostic blood culture results (eg, some patients with fungal endocarditis). The diagnosis of IE can never be excluded on the basis of negative echocardiogram findings, either from transthoracic echocardiography (TTE) or from TEE. […] The sensitivity of TEE in detecting the vegetations of NVE is 90-100%. In patients with PVE, the sensitivity of TEE under optimal circumstances is greater than 90%. […] Echocardiography is useful for predicting the potential complications of IE, especially those that are embolic in nature. […] In summary, the indications for performing echocardiography with Doppler in patients with IE are to provide a baseline in proven or highly suggestive cases of IE and to provide a means of documenting complications during therapy.

• #1 Endocarditis – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

  In a standard (transthoracic) echocardiogram, a wandlike device (transducer) is moved over the chest area. The device directs sound waves at the heart and records them as they bounce back. […] In a transesophageal echocardiogram, a flexible tube containing a transducer is guided down the throat and into the tube connecting the mouth to the stomach (esophagus). A transesophageal echocardiogram provides much more detailed pictures of the heart than is possible with a standard echocardiogram. […] Electrocardiogram (ECG or EKG). This quick and painless test measures the electrical activity of the heart. During an electrocardiogram (ECG), sensors (electrodes) are attached to the chest and sometimes to the arms or legs. It isn’t specifically used to diagnose endocarditis, but it can show if something is affecting the heart’s electrical activity.

• #1 Endocarditis: Risk Factors, Symptoms, and Diagnosis

  https://www.healthline.com/health/endocarditis

  When a transthoracic echocardiogram doesnt provide enough information to assess your heart accurately, your doctor might order an additional imaging test called a transesophageal echocardiogram. This is used to view your heart by way of your esophagus. […] An electrocardiogram (ECG or EKG) may be requested to get a better view of your hearts electrical activity. This test can detect an abnormal heart rhythm or rate. A technician will attach 12 to 15 soft electrodes to your skin. These electrodes are attached to electrical leads (wires), which are then attached to the EKG machine. […] A chest X-ray may be used to view your lungs and see if theyve collapsed or if fluid has built up in them. A buildup of fluid is called pulmonary edema. The X-ray can help your doctor tell the difference between endocarditis and other conditions involving with your lungs.

• #1 Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound | The Ultrasound Journal | Full Text

  https://theultrasoundjournal.springeropen.com/articles/10.1186/2036-7902-5-1

  However, bedside EUS, performed as part of the initial patient assessment, immediately suggested the correct diagnosis and allowed for earlier initiation of appropriate therapy and consultation with the appropriate specialists. […] Given that TTE is non-invasive, has no major safety issues, and can be obtained easily, it is the current standard initial imaging test for the evaluation of IE. […] In comparison, TEE is an invasive test with a low, but defined, risk of complications. […] For these reasons, most clinicians will begin the evaluation of IE with a TTE, even with the knowledge that this test is less sensitive than TEE for the diagnosis of IE. […] This case report demonstrates the potential utility of bedside cardiac TTE using modern ultrasound systems as an initial imaging test in the ED for patients in whom the clinical suspicion for IE is high.

• #1 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  Echocardiography remains the first-line test, but it can be normal or inconclusive in up to one-third of cases, especially in PVE or cardiac implantable electronic device infective endocarditis (CIED-IE). Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are essential techniques and can depict major imagistic criteria for diagnosis such as vegetations, abscesses, pseudoaneurysms, intracardiac fistulas, valvular perforations or aneurysms and new dehiscence of a prosthetic valve. The modified Duke criteria have a sensitivity and specificity of approximately 80% for native-valve IE (NVE) and significantly less for prosthetic material IE. New imaging techniques are required to improve diagnosis and consequently treatment and outcome. Imaging tools like cardiac computed tomography angiography (CTA), 18-fluorodeoxyglucose positron emission tomography/computed tomography (18 F-FDG PET-CT) and radiolabelled white-blood-cell single-photon emission tomography combined with computed tomography (WBC SPECT/CT) can reveal major criteria for diagnosis.

• #1 Infective endocarditis: Beyond the usual tests | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/86/8/559

  Infective endocarditis remains a diagnostic challenge. Although echocardiography is still the mainstay imaging test, it misses up to 30% of cases. Newer imaging tests 4-dimensional computed tomography (4D CT), fluorodeoxy glucose positron emission tomography (FDG-PET), and leukocyte scintigraphy are increasingly used as alternative or adjunct tests for select patients. They improve the sensitivity of clinical diagnosis of infective endocarditis when appropriately used, especially in the setting of a prosthetic valve. […] Echocardiography can produce false-negative results in native-valve infective endocarditis and is even less sensitive in patients with a prosthetic valve or cardiac implanted electronic device. […] 4D CT is a reasonable alternative to transesophageal echocardiography. It can also be used as a second test if echocardiography is inconclusive.

• #1 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  Early and accurate diagnosis is critical in IE and will have an important impact on the outcome. A delayed or missed diagnosis can have catastrophic consequences: heart failure, abscess formation, atrioventricular conduction abnormalities, prosthetic valve dysfunction and embolic events. The modified Duke criteria are in use and can classify patients into one of three categories: definite, possible or rejected. Imaging plays an important role in patients with IE, and elements described with different imagistic techniques are part of the diagnostic criteria. Current data support the role of the multidisciplinary approach in IE by a specialised endocarditis team that should include cardiologists, cardiac surgeons, infectious disease specialists, microbiologists and imaging specialists for improved management and outcome in IE. Cardiovascular imaging has become very complex with an increasing role in the diagnosis of IE. Cardiologists trained in multimodality imaging, but also radiology and nuclear medicine specialists, are currently key members in the Endocarditis Team.

• #1 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  These new tests will give complementary information to echocardiography and can improve diagnostic accuracy but are also able to evaluate the severity and the extent of the infection and perform a preoperative evaluation. In the absence of a definite diagnosis after TTE and TEE, multidetector CTA and nuclear imaging techniques such as 18 F FDG PET/CT or WBC SPECT/CT can reduce the rate of misdiagnosed IE. These new imagistic tools are particularly required in the setting of PVE, the paravalvular extension of infection and cardiac implantable electronic device infective endocarditis (CIED-IE). ECG gated CTA can visualise in 3D or 4D heart valves and perivalvular tissue and can accurately identify the perivalvular extension of infection, respectively, abscesses and pseudoaneurysms. The evaluation of the aortic valve and root and detection of coronary artery embolic complications can be achieved with cardiac CTA, providing important information for surgical planning. In cases with prosthetic valves with or without aortic duct prosthesis, adding CTA is advised.

• #1 Infective endocarditis: Beyond the usual tests | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/86/8/559

  Nuclear imaging tests FDG-PET and leukocyte scintigraphy increase the sensitivity of the Duke criteria for diagnosing infective endocarditis. They should be considered for evaluating suspected infective endocarditis in all patients who have a prosthetic valve or cardiac implanted electronic device, and whenever echocardiography is inconclusive and clinical suspicion remains high. […] Prompt diagnosis of infective endocarditis is critical. […] Echocardiography is the test used most frequently to evaluate for infective endocarditis, but it misses the diagnosis in almost one-third of cases, and even more often if the patient has a prosthetic valve. […] Several sophisticated imaging tests are available that complement echocardiography in diagnosing and assessing infective endocarditis; these include 4-dimensional computed tomography (4D CT), fluorodeoxy-glucose positron emission tomography (FDG-PET), and leukocyte scintigraphy.

• #1 Enhancing the Diagnosis of Infective Endocarditis: The Role of 18F-FDG PET/CT | Journal of Nuclear Medicine

  https://jnm.snmjournals.org/content/65/supplement_2/241357

  Infective endocarditis (IE) poses diagnostic challenges due to its diverse clinical presentations. Traditionally, diagnosis relies on echocardiography, microbial analysis, and clinical assessments as per the Modified Duke Criteria (MDC), but their accuracy is notably inconsistent, especially in cases involving prosthetic valves (PV) and cardiac-implantable electronic devices (CIEDs). […] 18F-FDG PET/CT has become a pivotal tool in the diagnosis of prosthetic valve endocarditis (PVE), particularly valuable in cases where echocardiographic results are inconclusive. This imaging modality enhances diagnostic accuracy by reducing the number of cases categorized as 'possible IE’ under Modified Duke Criteria (MDC) and correctly reclassifying them as definitive IE. […] While PET/CT is less sensitive than echocardiography for native valve endocarditis (NVE), its diagnostic sensitivity improves significantly when integrated with MDC. […] 18F-FDG PET/CT enhances the diagnostic precision of Modified Duke Criteria (MDC) for Infective Endocarditis (IE), especially in prosthetic valve endocarditis (PVE) and cardiac-implantable electronic device-related IE (CIED-IE).

• #1 Infective endocarditis: Beyond the usual tests | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/86/8/559

  Regardless of whether TTE or TEE is used, they are estimated to miss up to 30% of cases of infective endocarditis and its sequelae. […] For patients who have inconclusive results on echocardiography, contraindications to TEE, or poor sonic windows, cardiac CT can be an excellent alternative. […] 4D CT is increasingly being used in infective endocarditis, and growing evidence indicates that its accuracy is similar to that of TEE in the preoperative evaluation of patients with aortic prosthetic valve endocarditis. […] FDG-PET and leukocyte scintigraphy are other options for diagnosing infective endocarditis and determining the presence and extent of intra-and extracardiac infection. […] The most significant contribution of FDG-PET may be the ability to detect infective endocarditis early, when echocardiography is initially negative.

• #1 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  In patients with prosthetic valves, pacemakers, internal cardioverter defibrillators (ICDs) and left ventricular assist devices (LVADs), 18 F-FDG-PET/CT has demonstrated an additional diagnostic value for cardiac infection detection but also for the detection of extracardiac infectious foci in NVE and PVE. WBC SPECT/CT is an investigation with increased specificity but with low sensitivity and many disadvantages correlated with patient preparation and comfort. The investigation is a potential approach in patients with suspected PVE with inconclusive echocardiography. In these patients, 18 F-FDG-PET/CT is recommended as first-line investigation due to its high sensitivity in detecting active infection. In situations with inconclusive results for 18 F-FDG-PET/CT, WBC SPECT/CT is recommended due to its high specificity. In CIED-IE, 18 F-FDG-PET/CT and WBC SPECT/CT can add to the diagnosis. Pocket infections can be detected with high sensitivity by FDG-PET/CT, but for lead infections, the sensitivity is reduced. Multimodality imaging has an increasing role in the diagnosis of IE. A correct imaging evaluation is dependent on the informed use of the imaging tools.

• #1 Infective endocarditis: Beyond the usual tests | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/86/8/559

  Both FDG-PET and leukocyte scintigraphy have a high sensitivity, specificity, and negative predictive value for cardiac implanted electronic device infection, and should be strongly considered in patients in whom it is suspected but who have negative or inconclusive findings on echocardiography. […] Cerebral magnetic resonance imaging (MRI) is more sensitive than cerebral CT for detecting emboli in the brain. […] Cardiac MRI, typically obtained with gadolinium contrast, allows for better 3D assessment of cardiac structures and morphology than echocardiography or CT, and can detect infiltrative cardiac disease, myopericarditis, and much more.

• #1 Blood culture-negative endocarditis: Epidemiology, microbiology, and diagnosis – UpToDate

  https://www.uptodate.com/contents/blood-culture-negative-endocarditis-epidemiology-microbiology-and-diagnosis

  Blood culture-negative endocarditis: Epidemiology, microbiology, and diagnosis […] The primary means of IE diagnosis involves microbiologic testing in the form of blood cultures and imaging with echocardiography; other diagnostic tools can be used to provide supplemental information. […] Blood culture results are fundamental to defining an appropriate treatment course; however, they are not always diagnostic. […] Issues related to the causes and clinical approach to diagnostic evaluation of patients with blood culture-negative endocarditis (BCNE) due to infectious etiologies will be reviewed here. […] Blood culture negative endocarditis (BCNE) refers to endocarditis with no definitive microbiologic etiology following inoculation of at least three independently obtained blood samples in a standard blood-culture system, with negative cultures after five days of incubation.

• #1 Blood culture negative endocarditis | IJGM

  https://www.dovepress.com/blood-culture-negative-endocarditis-a-review-of-laboratory-diagnostic–peer-reviewed-fulltext-article-IJGM

  Infective endocarditis is a potentially fatal condition, and identifying the pathogen is crucial to optimizing antibiotic treatment. […] While a blood culture takes time and may yield negative results, it remains the gold standard for diagnosis, blood culture-negative endocarditis, which accounts for up to 20% of infective endocarditis cases, poses a clinical challenge with increasing mortality. […] To better understand the etiology of blood culture-negative infective endocarditis, we reviewed non-culture-based strategies and compared the results. […] The diagnosis of blood culture-negative endocarditis is frequently delayed, increasing the risk of morbidity and mortality. […] It has been noted that in culture-negative endocarditis patients, long-term mortality is higher than in culture-positive endocarditis patients.

• #1 Blood culture negative endocarditis | IJGM

  https://www.dovepress.com/blood-culture-negative-endocarditis-a-review-of-laboratory-diagnostic–peer-reviewed-fulltext-article-IJGM

  The presence of bacterial DNA is greater in valve tissue than in blood, which makes the PCR assays used for testing cardiac excised valve tissues more sensitive than those used for testing blood or serum. […] Serology and PCR may help to identify fastidious pathogens in blood samples or valves with Coxiella burnetii and Bartonella spp. being the most common identified pathogens. […] Next-generation sequencing has been applied in the diagnosis of culture-negative endocarditis and has great value in distinguishing streptococcal species and polymicrobial infection. […] For blood culture negative endocarditis patients, serology of Coxiella burnetii and Bartonella spp. are to be surveyed first, Coxiella burnetii and Bartonella spp anti-phase I IgG antibody titer of 1:800 is considered positive. […] If the patient has undergone surgery, the excised valve should be sent for culture, specific PCR, and broad-range PCR including 16SrRNA and 18SrRNA for bacteria and fungus, respectively.

• #1 Novel Diagnostic Methods for Infective Endocarditis

  https://www.mdpi.com/1422-0067/25/2/1245

  Cardiac surgery is performed in approximately 22.5–51.2% of patients. Material collected during cardiac surgery should be subjected to histo-pathological and microbiological examination. It is even more important in cases of BCNIE, as it can deliver the causative micro-organism and improve the antibiotic therapy. However, it should be noted that cultures from cardiac valve tissues have a low sensitivity of 6–26%. […] Specific molecular methods that can help diagnose IE include organism-specific PCR assays that detect a specific micro-organism, broad-range PCR with amplification primers targeting the bacterial 16S rRNA gene, targeted metagenomic sequencing (tMGS), and shotgun metagenomic sequencing (sMGS), in which all genomic DNA sequences are extracted from a blood or emission sample. The sensitivity and specificity of these techniques are higher for explanted tissue than for blood or plasma. They may provide a micro-organism diagnosis in BCNIE.

• #1 Introductory Chapter: Endocarditis – Diagnosis and Treatment | IntechOpen

  https://www.intechopen.com/chapters/88345

  Infective endocarditis (IE) is a major health challenge. The incidence is approximately 14 cases (1 death) per 100,000 individuals. The rising numbers of IE are due to the increased population at risk, but increased awareness and availability of diagnostic tools also accounts for higher rates of diagnosed IE. Echocardiography is the cornerstone among diagnostic tools, while computerized tomography and nuclear imaging techniques have sharpened diagnostic accuracy. […] Imaging is an essential part of the diagnostic workup. Transthoracic echocardiography and transesophageal echocardiography are initial steps and often conclusive. Even though these tools are widely accessible, the quality may differ. […] The definitions of IE have been revised. The major criteria are blood cultures positive for IE (typical microbes from two cultures) and confirmatory imaging (echocardiography, computerized tomography, and positron emission tomography). Minor criteria are predisposing conditions, fever higher than 38 C, embolic events with vascular disseminations, immunological phenomena, and microbiological evidence. A definite diagnosis of IE requires two major criteria, or one major and three minor, or five minor criteria. A possible diagnosis is defined as one major and at least one minor or three minor without a major criteria.

• #1 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis

  Infective endocarditis is infection of the endocardium, usually with bacteria (commonly, streptococci or staphylococci) or fungi. […] Diagnosis requires demonstration of microorganisms in blood and usually echocardiography. […] The diagnosis of infective endocarditis is usually based on a constellation of clinical findings rather than a single definitive test result. […] Because symptoms and signs are nonspecific, vary greatly, and may develop insidiously, diagnosis requires a high index of suspicion. Endocarditis should be suspected in patients with fever and no obvious source of infection, particularly if a heart murmur is present. […] Other than positive blood cultures, there are no specific laboratory findings. […] If endocarditis is suspected, 3 blood samples (20-mL each) should be obtained for culture.

• #1 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  Imaging is an important tool in the diagnosis and management of infective endocarditis (IE). Echocardiography is an essential examination, especially in native valve endocarditis (NVE), but its diagnostic accuracy is reduced in prosthetic valve endocarditis (PVE). The diagnostic ability is superior for transoesophageal echocardiography (TEE), but a negative test cannot exclude PVE. Both transthoracic echocardiography (TTE) and TEE can provide normal or inconclusive findings in up to 30% of cases, especially in patients with prosthetic devices. New advanced non-invasive imaging tests are increasingly used in the diagnosis of IE. Nuclear medicine imaging techniques have demonstrated their superiority over TEE for the diagnosis of PVE and cardiac implantable electronic device infective endocarditis (CIED-IE). Cardiac computed tomography angiography imaging is useful in PVE cases with inconclusive TTE and TEE investigations and for the evaluation of paravalvular complications. In the present review, imaging tools are described with their values and limitations for improving diagnosis in NVE, PVE and CIED-IE. Current knowledge about multimodality imaging approaches in IE and imaging methods to assess the local and distant complications of IE is also reviewed. Furthermore, a potential diagnostic work-up for different clinical scenarios is described. However, further studies are essential for refining diagnostic and management approaches in infective endocarditis, addressing limitations and optimizing advanced imaging techniques across different clinical scenarios.

• #1 Infectious Endocarditis – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK557641/

  A thorough physical exam may identify stigmata that reinforce the diagnosis and highlight complications of peripheral embolization. […] The diagnosis and management of infectious endocarditis can represent a prolonged and complex process. Efficient, safe, and effective patient care is best accomplished by the early involvement of an interprofessional team that includes cardiology, cardiothoracic surgery, infectious diseases, and a primary care provider.

• #1

  https://journals.lww.com/md-journal/fulltext/2020/07240/factors_associated_with_delayed_diagnosis_of.106.aspx

  Patients with infective endocarditis (IE), have high mortality and morbidity, however, its early diagnosis is difficult. Few studies have examined the delayed diagnosis of IE. We aimed to investigate the factors associated with the diagnostic delay of IE. […] The time to consider IE diagnosis was significantly delayed in patients who had inappropriate prior antibiotic use (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.01 to 2.57; P = .045), in patients without fever 38C (HR, 1.80; 95% CI, 1.11 to 2.90; P = .016), in patients with serum CRP level 10 mg/dL (HR, 1.53; 95% CI, 1.01 to 2.33; P = .046), and in patients who did not use an ambulance for hospital arrival (HR, 3.18; 95% CI, 1.72 to 5.85; P .001). […] Delay in considering IE diagnosis is associated with inappropriate prior antibiotics use, absence of high fever, absence of high CRP level, and use of a hospital arrival vehicle other than an ambulance. For earlier IE diagnosis, inappropriate use of antibiotics should be avoided and IE should not be excluded by relatively low level of temperature or serum CRP.

• #1

  https://journals.lww.com/md-journal/fulltext/2020/07240/factors_associated_with_delayed_diagnosis_of.106.aspx

  Early diagnosis of IE is essential through investigations including blood culture and echocardiography. […] Therefore, delayed diagnosis of IE is a critical issue that needs to be resolved, to save lives and avoid disability. […] The results show that the duration between the patient’s clinic/hospital visit and the day of obtaining blood cultures or the day recalling diagnosis of IE needs a lot to improve, during the period to a definite diagnosis. […] Diagnosis of IE was delayed in patients with inappropriate antibiotics use, patients transferred by non-ambulance vehicular services, patients without high fever, and patients with lower CRP level. Therefore, physicians need to take care of appropriate antibiotic use and consider obtaining blood cultures in patients who are transferred by other means of transportation than in ambulances, patients without fever 38C, and patients with lower CRP levels for earlier IE diagnosis.

• #1 General approach to the clinical diagnosis of endocarditis | Thoracic Key

  https://thoracickey.com/general-approach-to-the-clinical-diagnosis-of-endocarditis/

  The diagnosis of infectious endocarditis is quite often complex and may be among the most challenging diagnoses facing todays medical providers. […] Although early diagnosis and intervention are clearly associated with improved outcomes, in nearly 25% of endocarditis cases the diagnosis is made 1 month after onset of symptoms. […] Despite the widespread use of tools such as the Modified Duke Criteria, transesophageal echocardiography (TEE), and the newer modality of positron emission tomography (PET), endocarditis remains primarily a clinical diagnosis that is best made when considering a number of variables, including the patients risk factors, signs and symptoms, microbiologic data, echocardiographic and radiographic results, and clinical course. […] In this chapter we will highlight the clinical features of infectious endocarditis, review existing diagnostic algorithms and testing modalities, and outline a general approach to the diagnosis of this endovascular infection.

• #1 General approach to the clinical diagnosis of endocarditis | Thoracic Key

  https://thoracickey.com/general-approach-to-the-clinical-diagnosis-of-endocarditis/

  Perhaps the most important concept we will emphasize in this section is that no one sign, symptom, or test is perfectly sensitive or specific for endocarditis. […] With respect to the etiologic causes of endocarditis, gram-positive organisms predominate in several large series of cases, representing 80% of all identified endocarditis pathogens with S. aureus encountered the most frequently. […] Echocardiography, both transthoracic (TTE) and transesophageal, plays a critical role in the diagnosis of endocarditis. […] The utility of 18-FDG PET/CT is considerably lower in patients with native valve endocarditis with a 2020 study of 115 patients reporting a sensitivity of only 22%. […] Currently the ESC includes cardiac 18-FDG PET/CT in its prosthetic valve endocarditis diagnostic criteria, provided that it is obtained 3 or more months after surgical valve replacement.

• #2 Diagnostic criteria and problems in infective endocarditis

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1768277/

  Few diseases present greater difficulties in the way of diagnosis than malignant endocarditis, difficulties which in many cases are practically insurmountable. […] The original von Reyn diagnostic criteria for infective endocarditis, based upon clinical and microbiological features, have now been surpassed by the Duke criteria which emphasise the role of echocardiography, the key imaging tool for both diagnosis and assessment of prognosis. […] Negative blood cultures occur in 2.531% of all cases of infective endocarditis, often delaying diagnosis and the onset of treatment with profound impact on clinical outcome. […] In 1997, Lamas and Eykyn proposed a number of clinical modifications to the Duke criteria to include newly diagnosed splenomegaly or clubbing, elevated inflammatory markers, haematuria, and the presence of central and peripheral venous lines.

• #2 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  The Duke diagnostic criteria were developed by Durack and colleagues as a guide for reaching a valid definitive diagnosis of IE. The criteria combine the clinical, microbiologic, pathologic, and echocardiographic characteristics of a specific case. […] Major blood culture criteria for IE include the following: […] Two blood cultures positive for organisms typically found in patients with IE […] Blood cultures persistently positive for 1 of these organisms, from cultures drawn more than 12 hours apart […] Three or more separate blood cultures drawn at least 1 hour apart […] Major echocardiographic criteria include the following: […] Echocardiogram positive for IE, documented by an oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomic explanation

• #2 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  Two major criteria […] One major criterion and 3 minor criteria […] Five minor criteria […] The development of syndromic analysis (SA) better meets the diagnostic and therapeutic challenges of the current profile of IE. Syndromic analysis considers the patient’s current and past history, the tempo of the disease’s progression, recognition of pertinent findings on physical exam, and nonspecific laboratory testing. The resulting case profile leads to the selection studies that will most quickly produce a definitive diagnosis. […] There is an ever-growing urgency to diagnose IE and its complications, and to institute the most appropriate antibiotic treatment. The increasing resistance to the „tried and true” empiric regimens is becoming untenable because of the wide development of resistance to multiple classes of agents. This is especially true among those with opioid use disorder (OUD ) and other marginalized groups due to a decreased ability to access healthcare brought about by the multiple effects of COVID-19 on the healthcare system.

• #2 Diagnosing and Treating Acute Infective Endocarditis | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/diagnosing-and-treating-acute-infective-endocarditis/2010-10

  Fever is by far the most common sign or symptom of acute infective endocarditis. Other constitutional symptoms include chills, sweats, loss of appetite, and malaise. […] Echocardiography is central to the diagnosis of endocarditis. Transthoracic echocardiogram (TTE) should be the initial study of choice in most cases, though transesophageal echocardiogram (TEE) has a higher sensitivity for detecting vegetations. This makes TEE useful for patients with suboptimal images on TTE, a high likelihood of IE, or prosthetic valves. […] The Modified Duke Criteria is a well-validated set of clinical, microbiological, and echocardiographic criteria for diagnosing infective endocarditis. The major criteria are two positive blood cultures with a typical microorganism for infective endocarditis and evidence of endocardial involvement on echocardiogram. The minor criteria include fever, a predisposing condition for IE (such as intravenous drug use), vascular phenomena, immunologic phenomena, and microbiological evidence not included in the major criteria. A classification of definite IE requires the presence of 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria. The presence of 1 major criterion and 1 minor criterion, or 3 minor criteria, indicates a possible case of IE.

• #2 Infective Endocarditis Diagnosis and Management

  https://www.uspharmacist.com/article/infective-endocarditis-diagnosis-and-management

  Many patients with endocarditis present with nonspecific symptoms that prompt a broad medical workup. […] The diagnosis of IE has been based upon microbiologic and echocardiographic evidence recommendations from the Modified Duke Criteria, last updated in 2000. […] In 2023, the International Society for Cardiovascular Infectious Diseases suggested significant updates to the Duke Criteria due to changes in microbiology, diagnostics, epidemiology, and treatment. […] Pathologic criteria are used to diagnose definitive IE. […] The 2023 update provided clarity and broadened these criteria to include microorganisms identified in the context of clinical signs of active endocarditis. […] These criteria have been updated to include three subsections: Microbiologic Major Criteria, Imaging Major Criteria, and Surgical Major Criteria, which is a 2023 suggested addition. […] The minor clinical criteria for diagnosis span seven categories. […] The 2023 updates to the modified Duke Criteria consider changes in microbiology, diagnostics, epidemiology, and treatment of IE, allowing for improved diagnosis of IE.

• #2 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  Myocardial abscess […] Development of partial dehiscence of a prosthetic valve […] New-onset valvular regurgitation […] Minor criteria for IE include the following: […] Predisposing heart condition or intravenous drug use (IVDA) […] Fever of 38C (100.4F) or higher […] Vascular phenomena, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions […] Immunologic phenomena such as glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor […] Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE […] Echocardiogram results consistent with IE but not meeting major echocardiographic criteria […] A definitive clinical diagnosis can be made based on the following:

• #2 Infective endocarditis – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/3000215

  Infective endocarditis (IE) often presents non-specifically, most commonly with fever and symptoms/signs of embolism. […] If you suspect IE, evaluate the patient urgently and seek early input from a cardiologist and an infectious disease or microbiology specialist. A multidisciplinary approach (e.g., with an endocarditis team’) is crucial for diagnosis and management. […] Prioritise obtaining three sets of blood cultures taken at 30-minute intervals prior to initiation of antibiotic therapy and echocardiography. […] Diagnostic investigations include blood cultures, echocardiography, full blood count, CRP, serum urea, electrolytes, and glucose, liver function tests, urinalysis, and ECG. […] Emerging tests include troponin I.

• #2 Endocarditis Diagnosis and Treatment : Emergency Care BC

  https://emergencycarebc.ca/clinical_resource/clinical-summary/endocarditis-diagnosis-and-treatment/

  Endocarditis is an inflammation of the endocardium, with an in-hospital mortality rate of 14-22% […] Patients with suspected IE should be admitted to the hospital, with specialist consultation and initiation of antibiotic therapy. […] Critical diagnostic tests are blood cultures and echocardiography. […] Prior to antibiotic treatment, three sets of blood cultures must be drawn from different venipuncture sites, with the first and final cultures being drawn at least one hour apart. […] Urgent echocardiography should be completed (within 12 hours of presentation). Transthoracic echocardiography (TTE) is often the initial imaging modality, though it is less sensitive than transesophageal echocardiography (TEE). […] Diagnosis is aided using the Modified Duke Criteria (published by Li et al. in 2000), which describe the criteria for diagnosis of Definitive IE, Possible IE, or Rejection of IE.

• #2 Novel Diagnostic Methods for Infective Endocarditis

  https://www.mdpi.com/1422-0067/25/2/1245

  The diagnosis is based on clinical suspicion, which is supported by microbiological data and imaging, as included in the latest ESC guidelines. Suspicion of IE is usually due to fever, new heart murmurs, and positive blood cultures if an alternative focus of infection is not known. This is especially true in patients with one or more risk factors. In the latest ESC guidelines, it is recommended that the endocarditis team be involved as soon as possible to help further manage patients with suspected IE. […] If IE is suspected, at least three sets of blood cultures should be obtained at 30 min intervals prior to antibiotic therapy. It is necessary to deliver the diagnosis and provide live bacteria for both identification and susceptibility testing. Blood cultures should be incubated in both aerobic and anaerobic atmospheres. Blood for the test is drawn from the patient’s veins from different insertion sites, with at least 1 h between the first and last collection.

• #2 Blood culture-negative endocarditis: Epidemiology, microbiology, and diagnosis – UpToDate

  https://www.uptodate.com/contents/blood-culture-negative-endocarditis-epidemiology-microbiology-and-diagnosis

  Blood culture-negative endocarditis: Epidemiology, microbiology, and diagnosis […] The primary means of IE diagnosis involves microbiologic testing in the form of blood cultures and imaging with echocardiography; other diagnostic tools can be used to provide supplemental information. […] Blood culture results are fundamental to defining an appropriate treatment course; however, they are not always diagnostic. […] Issues related to the causes and clinical approach to diagnostic evaluation of patients with blood culture-negative endocarditis (BCNE) due to infectious etiologies will be reviewed here. […] Blood culture negative endocarditis (BCNE) refers to endocarditis with no definitive microbiologic etiology following inoculation of at least three independently obtained blood samples in a standard blood-culture system, with negative cultures after five days of incubation.

• #2 Endocarditis – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

  To diagnose endocarditis, a health care provider does a physical exam and asks questions about your medical history and symptoms. Tests are done to help confirm or rule out endocarditis. […] Tests used to help diagnose endocarditis include: […] Blood culture test. This test helps identify germs in the bloodstream. Results from this test help determine the antibiotic or combination of antibiotics to use for treatment. […] Complete blood count. This test can determine if there’s a lot of white blood cells, which can be a sign of infection. A complete blood count can also help diagnose low levels of healthy red blood cells (anemia), which can be a sign of endocarditis. Other blood tests also may be done. […] Echocardiogram. Sound waves are used to create images of the beating heart. This test shows how well the heart’s chambers and valves pump blood. It can also show the heart’s structure. Your provider may use two different types of echocardiograms to help diagnose endocarditis.

• #2 Infective endocarditis – Symptoms, diagnosis and treatment | BMJ Best Practice US

  https://bestpractice.bmj.com/topics/en-us/139

  In cases of suspected IE, the patient should be evaluated urgently and early input from cardiology and an infectious disease or microbiology specialist should be sought. A multidisciplinary approach (e.g., with an endocarditis team) is crucial for diagnosis and management. […] At least three sets of blood cultures taken at different sites and at different times (ideally 6 hours between the first and last samples if clinical status allows) should be obtained prior to initiation of antibiotic therapy and echocardiography. […] Diagnostic tests include blood cultures, echocardiogram, CBC, CRP, serum chemistry panel with glucose, LFTs, urinalysis, and ECG. […] Tests to consider include rheumatoid factor, erythrocyte sedimentation rate, complement levels, cardiac CT, MRI, and Nuclear imaging and PET. […] Emerging tests include mean platelet volume (MPV), antibeta-2glycoprotein I antibodies, D-dimer, and troponin I.

• #2 Blood Culture-Negative Endocarditis: Individualized Diagnosis, Management

  https://www.clinicaladvisor.com/features/blood-culture-negative-endocarditis/

  If the Duke criteria have been met to establish a diagnosis of endocarditis but the cultures remain negative for 7 days, more extensive investigation into the pathologic cause is needed. […] Histopathology remains the gold standard for pathologic analysis but it is not often feasible. […] In recent years, 16S ribosomal ribonucleic acid polymerase chain reaction (16S rRNA PCR) of excised tissue has played an important role in the diagnostic approach for BCNE. […] If the workup fails to reveal the underlying pathogen or cause, serology workup on Mycoplasma pneumonia, Legionella spp, and Chlamydia spp should be obtained. […] If all diagnostic testing for endocarditis has been exhausted and no pathogen or comorbidity has been identified as the cause of the patients illness, it is time to investigate other conditions in the differential diagnosis including atrial myxoma, antiphospholipid syndrome, and acute rheumatic fever.

• #2 Introductory Chapter: Endocarditis – Diagnosis and Treatment | IntechOpen

  https://www.intechopen.com/chapters/88345

  Infective endocarditis (IE) is a major health challenge. The incidence is approximately 14 cases (1 death) per 100,000 individuals. The rising numbers of IE are due to the increased population at risk, but increased awareness and availability of diagnostic tools also accounts for higher rates of diagnosed IE. Echocardiography is the cornerstone among diagnostic tools, while computerized tomography and nuclear imaging techniques have sharpened diagnostic accuracy. […] Imaging is an essential part of the diagnostic workup. Transthoracic echocardiography and transesophageal echocardiography are initial steps and often conclusive. Even though these tools are widely accessible, the quality may differ. […] The definitions of IE have been revised. The major criteria are blood cultures positive for IE (typical microbes from two cultures) and confirmatory imaging (echocardiography, computerized tomography, and positron emission tomography). Minor criteria are predisposing conditions, fever higher than 38 C, embolic events with vascular disseminations, immunological phenomena, and microbiological evidence. A definite diagnosis of IE requires two major criteria, or one major and three minor, or five minor criteria. A possible diagnosis is defined as one major and at least one minor or three minor without a major criteria.

• #2 Endocarditis – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

  In a standard (transthoracic) echocardiogram, a wandlike device (transducer) is moved over the chest area. The device directs sound waves at the heart and records them as they bounce back. […] In a transesophageal echocardiogram, a flexible tube containing a transducer is guided down the throat and into the tube connecting the mouth to the stomach (esophagus). A transesophageal echocardiogram provides much more detailed pictures of the heart than is possible with a standard echocardiogram. […] Electrocardiogram (ECG or EKG). This quick and painless test measures the electrical activity of the heart. During an electrocardiogram (ECG), sensors (electrodes) are attached to the chest and sometimes to the arms or legs. It isn’t specifically used to diagnose endocarditis, but it can show if something is affecting the heart’s electrical activity.

• #2 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  Echocardiography remains the first-line test, but it can be normal or inconclusive in up to one-third of cases, especially in PVE or cardiac implantable electronic device infective endocarditis (CIED-IE). Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are essential techniques and can depict major imagistic criteria for diagnosis such as vegetations, abscesses, pseudoaneurysms, intracardiac fistulas, valvular perforations or aneurysms and new dehiscence of a prosthetic valve. The modified Duke criteria have a sensitivity and specificity of approximately 80% for native-valve IE (NVE) and significantly less for prosthetic material IE. New imaging techniques are required to improve diagnosis and consequently treatment and outcome. Imaging tools like cardiac computed tomography angiography (CTA), 18-fluorodeoxyglucose positron emission tomography/computed tomography (18 F-FDG PET-CT) and radiolabelled white-blood-cell single-photon emission tomography combined with computed tomography (WBC SPECT/CT) can reveal major criteria for diagnosis.

• #2 Endocarditis: Diagnosis & Treatment | NewYork-Presbyterian

  https://www.nyp.org/heart/heart-inflammation/endocarditis/treatment

  How is Endocarditis Diagnosed? Diagnosis Before your doctor can diagnose endocarditis, a physical examination and discussion of the symptoms you are experiencing must be done. After this, diagnostic tests for endocarditis will be scheduled. These tests used for endocarditis diagnosis will include: Blood tests. Some reasons blood tests will be ordered are: To determine the type of bacteria causing the infection, a different pathogen causes each inflammatory heart condition. A complete blood count will establish whether an unusually high number of white blood cells are present, indicating an infection somewhere in the body. Blood tests revealing C-reactive proteins are an indication of heart inflammation. Echocardiograms. These ultrasound tests can reveal growths (called vegetations) on your heart valves, holes (abscesses), leaking valves (regurgitation), or narrowing valves (stenosis). An echocardiogram can also detect problems with existing artificial heart valves. Heart valve tissue. A small piece of heart valve tissue is examined for specific microbes. Positron emission tomography (PET) scans. These scans use nuclear medicine containing radioactive material to create a clear image of the infections location. Chest X-ray. A chest X-ray can show whether endocarditis has caused the heart to swell or if the infection has spread to the lungs. Electrocardiogram (ECG or EKG). This painless test records the hearts electrical activity through sensors attached to the chest, arms, and legs. This test is not explicitly designed to detect endocarditis. However, it can show if there is a disruption in the hearts electrical activity, which could indicate heart inflammation.

• #2 Infective endocarditis: Beyond the usual tests | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/86/8/559

  Nuclear imaging tests FDG-PET and leukocyte scintigraphy increase the sensitivity of the Duke criteria for diagnosing infective endocarditis. They should be considered for evaluating suspected infective endocarditis in all patients who have a prosthetic valve or cardiac implanted electronic device, and whenever echocardiography is inconclusive and clinical suspicion remains high. […] Prompt diagnosis of infective endocarditis is critical. […] Echocardiography is the test used most frequently to evaluate for infective endocarditis, but it misses the diagnosis in almost one-third of cases, and even more often if the patient has a prosthetic valve. […] Several sophisticated imaging tests are available that complement echocardiography in diagnosing and assessing infective endocarditis; these include 4-dimensional computed tomography (4D CT), fluorodeoxy-glucose positron emission tomography (FDG-PET), and leukocyte scintigraphy.

• #2 Infective endocarditis: Beyond the usual tests | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/86/8/559

  Infective endocarditis remains a diagnostic challenge. Although echocardiography is still the mainstay imaging test, it misses up to 30% of cases. Newer imaging tests 4-dimensional computed tomography (4D CT), fluorodeoxy glucose positron emission tomography (FDG-PET), and leukocyte scintigraphy are increasingly used as alternative or adjunct tests for select patients. They improve the sensitivity of clinical diagnosis of infective endocarditis when appropriately used, especially in the setting of a prosthetic valve. […] Echocardiography can produce false-negative results in native-valve infective endocarditis and is even less sensitive in patients with a prosthetic valve or cardiac implanted electronic device. […] 4D CT is a reasonable alternative to transesophageal echocardiography. It can also be used as a second test if echocardiography is inconclusive.

• #2 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  These new tests will give complementary information to echocardiography and can improve diagnostic accuracy but are also able to evaluate the severity and the extent of the infection and perform a preoperative evaluation. In the absence of a definite diagnosis after TTE and TEE, multidetector CTA and nuclear imaging techniques such as 18 F FDG PET/CT or WBC SPECT/CT can reduce the rate of misdiagnosed IE. These new imagistic tools are particularly required in the setting of PVE, the paravalvular extension of infection and cardiac implantable electronic device infective endocarditis (CIED-IE). ECG gated CTA can visualise in 3D or 4D heart valves and perivalvular tissue and can accurately identify the perivalvular extension of infection, respectively, abscesses and pseudoaneurysms. The evaluation of the aortic valve and root and detection of coronary artery embolic complications can be achieved with cardiac CTA, providing important information for surgical planning. In cases with prosthetic valves with or without aortic duct prosthesis, adding CTA is advised.

• #2 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  In patients with prosthetic valves, pacemakers, internal cardioverter defibrillators (ICDs) and left ventricular assist devices (LVADs), 18 F-FDG-PET/CT has demonstrated an additional diagnostic value for cardiac infection detection but also for the detection of extracardiac infectious foci in NVE and PVE. WBC SPECT/CT is an investigation with increased specificity but with low sensitivity and many disadvantages correlated with patient preparation and comfort. The investigation is a potential approach in patients with suspected PVE with inconclusive echocardiography. In these patients, 18 F-FDG-PET/CT is recommended as first-line investigation due to its high sensitivity in detecting active infection. In situations with inconclusive results for 18 F-FDG-PET/CT, WBC SPECT/CT is recommended due to its high specificity. In CIED-IE, 18 F-FDG-PET/CT and WBC SPECT/CT can add to the diagnosis. Pocket infections can be detected with high sensitivity by FDG-PET/CT, but for lead infections, the sensitivity is reduced. Multimodality imaging has an increasing role in the diagnosis of IE. A correct imaging evaluation is dependent on the informed use of the imaging tools.

• #2 Infective endocarditis: Beyond the usual tests | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/86/8/559

  Both FDG-PET and leukocyte scintigraphy have a high sensitivity, specificity, and negative predictive value for cardiac implanted electronic device infection, and should be strongly considered in patients in whom it is suspected but who have negative or inconclusive findings on echocardiography. […] Cerebral magnetic resonance imaging (MRI) is more sensitive than cerebral CT for detecting emboli in the brain. […] Cardiac MRI, typically obtained with gadolinium contrast, allows for better 3D assessment of cardiac structures and morphology than echocardiography or CT, and can detect infiltrative cardiac disease, myopericarditis, and much more.

• #2 Novel Diagnostic Methods for Infective Endocarditis

  https://www.mdpi.com/1422-0067/25/2/1245

  In the case of non-identified bacteria, while fulfilling the other clinical criteria of infective endocarditis, we can diagnose blood culture-negative endocarditis (BCNIE). It refers to IE in which no causative micro-organism can be grown using the usual blood culture methods, thus remaining a diagnostic and therapeutic challenge. In the case of BCNIE, further diagnosis using special methods (which will be further listed in this article) is needed. […] Serological tests should be performed when blood cultures are negative after 48 h. One of the micro-organisms that serological tests are used to diagnose is Coxiella burnetii. The microbiological criteria for the diagnosis of IE in the ESC criteria in 2023 are immunoglobulin G (IgG) antibody titers against Coxiella burnetii IgG ≥ 1:800 and indirect immunofluorescence assays (IFA) to detect IgM and IgG antibodies against Bartonella henselael or Bartonella quintana, with IgG titers of ≥1:800.

• #2 Novel Diagnostic Methods for Infective Endocarditis

  https://www.mdpi.com/1422-0067/25/2/1245

  Cardiac surgery is performed in approximately 22.5–51.2% of patients. Material collected during cardiac surgery should be subjected to histo-pathological and microbiological examination. It is even more important in cases of BCNIE, as it can deliver the causative micro-organism and improve the antibiotic therapy. However, it should be noted that cultures from cardiac valve tissues have a low sensitivity of 6–26%. […] Specific molecular methods that can help diagnose IE include organism-specific PCR assays that detect a specific micro-organism, broad-range PCR with amplification primers targeting the bacterial 16S rRNA gene, targeted metagenomic sequencing (tMGS), and shotgun metagenomic sequencing (sMGS), in which all genomic DNA sequences are extracted from a blood or emission sample. The sensitivity and specificity of these techniques are higher for explanted tissue than for blood or plasma. They may provide a micro-organism diagnosis in BCNIE.

• #2 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  Early and accurate diagnosis is critical in IE and will have an important impact on the outcome. A delayed or missed diagnosis can have catastrophic consequences: heart failure, abscess formation, atrioventricular conduction abnormalities, prosthetic valve dysfunction and embolic events. The modified Duke criteria are in use and can classify patients into one of three categories: definite, possible or rejected. Imaging plays an important role in patients with IE, and elements described with different imagistic techniques are part of the diagnostic criteria. Current data support the role of the multidisciplinary approach in IE by a specialised endocarditis team that should include cardiologists, cardiac surgeons, infectious disease specialists, microbiologists and imaging specialists for improved management and outcome in IE. Cardiovascular imaging has become very complex with an increasing role in the diagnosis of IE. Cardiologists trained in multimodality imaging, but also radiology and nuclear medicine specialists, are currently key members in the Endocarditis Team.

• #2

  https://journals.lww.com/md-journal/fulltext/2020/07240/factors_associated_with_delayed_diagnosis_of.106.aspx

  Patients with infective endocarditis (IE), have high mortality and morbidity, however, its early diagnosis is difficult. Few studies have examined the delayed diagnosis of IE. We aimed to investigate the factors associated with the diagnostic delay of IE. […] The time to consider IE diagnosis was significantly delayed in patients who had inappropriate prior antibiotic use (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.01 to 2.57; P = .045), in patients without fever 38C (HR, 1.80; 95% CI, 1.11 to 2.90; P = .016), in patients with serum CRP level 10 mg/dL (HR, 1.53; 95% CI, 1.01 to 2.33; P = .046), and in patients who did not use an ambulance for hospital arrival (HR, 3.18; 95% CI, 1.72 to 5.85; P .001). […] Delay in considering IE diagnosis is associated with inappropriate prior antibiotics use, absence of high fever, absence of high CRP level, and use of a hospital arrival vehicle other than an ambulance. For earlier IE diagnosis, inappropriate use of antibiotics should be avoided and IE should not be excluded by relatively low level of temperature or serum CRP.

• #3 Diagnosing and Treating Acute Infective Endocarditis | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/diagnosing-and-treating-acute-infective-endocarditis/2010-10

  Fever is by far the most common sign or symptom of acute infective endocarditis. Other constitutional symptoms include chills, sweats, loss of appetite, and malaise. […] Echocardiography is central to the diagnosis of endocarditis. Transthoracic echocardiogram (TTE) should be the initial study of choice in most cases, though transesophageal echocardiogram (TEE) has a higher sensitivity for detecting vegetations. This makes TEE useful for patients with suboptimal images on TTE, a high likelihood of IE, or prosthetic valves. […] The Modified Duke Criteria is a well-validated set of clinical, microbiological, and echocardiographic criteria for diagnosing infective endocarditis. The major criteria are two positive blood cultures with a typical microorganism for infective endocarditis and evidence of endocardial involvement on echocardiogram. The minor criteria include fever, a predisposing condition for IE (such as intravenous drug use), vascular phenomena, immunologic phenomena, and microbiological evidence not included in the major criteria. A classification of definite IE requires the presence of 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria. The presence of 1 major criterion and 1 minor criterion, or 3 minor criteria, indicates a possible case of IE.

• #3 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  Myocardial abscess […] Development of partial dehiscence of a prosthetic valve […] New-onset valvular regurgitation […] Minor criteria for IE include the following: […] Predisposing heart condition or intravenous drug use (IVDA) […] Fever of 38C (100.4F) or higher […] Vascular phenomena, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions […] Immunologic phenomena such as glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor […] Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE […] Echocardiogram results consistent with IE but not meeting major echocardiographic criteria […] A definitive clinical diagnosis can be made based on the following:

• #3 Endocarditis: Diagnosis & Treatment | NewYork-Presbyterian

  https://www.nyp.org/heart/heart-inflammation/endocarditis/treatment

  How is Endocarditis Diagnosed? Diagnosis Before your doctor can diagnose endocarditis, a physical examination and discussion of the symptoms you are experiencing must be done. After this, diagnostic tests for endocarditis will be scheduled. These tests used for endocarditis diagnosis will include: Blood tests. Some reasons blood tests will be ordered are: To determine the type of bacteria causing the infection, a different pathogen causes each inflammatory heart condition. A complete blood count will establish whether an unusually high number of white blood cells are present, indicating an infection somewhere in the body. Blood tests revealing C-reactive proteins are an indication of heart inflammation. Echocardiograms. These ultrasound tests can reveal growths (called vegetations) on your heart valves, holes (abscesses), leaking valves (regurgitation), or narrowing valves (stenosis). An echocardiogram can also detect problems with existing artificial heart valves. Heart valve tissue. A small piece of heart valve tissue is examined for specific microbes. Positron emission tomography (PET) scans. These scans use nuclear medicine containing radioactive material to create a clear image of the infections location. Chest X-ray. A chest X-ray can show whether endocarditis has caused the heart to swell or if the infection has spread to the lungs. Electrocardiogram (ECG or EKG). This painless test records the hearts electrical activity through sensors attached to the chest, arms, and legs. This test is not explicitly designed to detect endocarditis. However, it can show if there is a disruption in the hearts electrical activity, which could indicate heart inflammation.

• #3 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  These new tests will give complementary information to echocardiography and can improve diagnostic accuracy but are also able to evaluate the severity and the extent of the infection and perform a preoperative evaluation. In the absence of a definite diagnosis after TTE and TEE, multidetector CTA and nuclear imaging techniques such as 18 F FDG PET/CT or WBC SPECT/CT can reduce the rate of misdiagnosed IE. These new imagistic tools are particularly required in the setting of PVE, the paravalvular extension of infection and cardiac implantable electronic device infective endocarditis (CIED-IE). ECG gated CTA can visualise in 3D or 4D heart valves and perivalvular tissue and can accurately identify the perivalvular extension of infection, respectively, abscesses and pseudoaneurysms. The evaluation of the aortic valve and root and detection of coronary artery embolic complications can be achieved with cardiac CTA, providing important information for surgical planning. In cases with prosthetic valves with or without aortic duct prosthesis, adding CTA is advised.

• #3 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  In patients with prosthetic valves, pacemakers, internal cardioverter defibrillators (ICDs) and left ventricular assist devices (LVADs), 18 F-FDG-PET/CT has demonstrated an additional diagnostic value for cardiac infection detection but also for the detection of extracardiac infectious foci in NVE and PVE. WBC SPECT/CT is an investigation with increased specificity but with low sensitivity and many disadvantages correlated with patient preparation and comfort. The investigation is a potential approach in patients with suspected PVE with inconclusive echocardiography. In these patients, 18 F-FDG-PET/CT is recommended as first-line investigation due to its high sensitivity in detecting active infection. In situations with inconclusive results for 18 F-FDG-PET/CT, WBC SPECT/CT is recommended due to its high specificity. In CIED-IE, 18 F-FDG-PET/CT and WBC SPECT/CT can add to the diagnosis. Pocket infections can be detected with high sensitivity by FDG-PET/CT, but for lead infections, the sensitivity is reduced. Multimodality imaging has an increasing role in the diagnosis of IE. A correct imaging evaluation is dependent on the informed use of the imaging tools.

• #3 Infective endocarditis: Beyond the usual tests | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/86/8/559

  Both FDG-PET and leukocyte scintigraphy have a high sensitivity, specificity, and negative predictive value for cardiac implanted electronic device infection, and should be strongly considered in patients in whom it is suspected but who have negative or inconclusive findings on echocardiography. […] Cerebral magnetic resonance imaging (MRI) is more sensitive than cerebral CT for detecting emboli in the brain. […] Cardiac MRI, typically obtained with gadolinium contrast, allows for better 3D assessment of cardiac structures and morphology than echocardiography or CT, and can detect infiltrative cardiac disease, myopericarditis, and much more.

• #3 Novel Diagnostic Methods for Infective Endocarditis

  https://www.mdpi.com/1422-0067/25/2/1245

  Cardiac surgery is performed in approximately 22.5–51.2% of patients. Material collected during cardiac surgery should be subjected to histo-pathological and microbiological examination. It is even more important in cases of BCNIE, as it can deliver the causative micro-organism and improve the antibiotic therapy. However, it should be noted that cultures from cardiac valve tissues have a low sensitivity of 6–26%. […] Specific molecular methods that can help diagnose IE include organism-specific PCR assays that detect a specific micro-organism, broad-range PCR with amplification primers targeting the bacterial 16S rRNA gene, targeted metagenomic sequencing (tMGS), and shotgun metagenomic sequencing (sMGS), in which all genomic DNA sequences are extracted from a blood or emission sample. The sensitivity and specificity of these techniques are higher for explanted tissue than for blood or plasma. They may provide a micro-organism diagnosis in BCNIE.

• #3 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  Early and accurate diagnosis is critical in IE and will have an important impact on the outcome. A delayed or missed diagnosis can have catastrophic consequences: heart failure, abscess formation, atrioventricular conduction abnormalities, prosthetic valve dysfunction and embolic events. The modified Duke criteria are in use and can classify patients into one of three categories: definite, possible or rejected. Imaging plays an important role in patients with IE, and elements described with different imagistic techniques are part of the diagnostic criteria. Current data support the role of the multidisciplinary approach in IE by a specialised endocarditis team that should include cardiologists, cardiac surgeons, infectious disease specialists, microbiologists and imaging specialists for improved management and outcome in IE. Cardiovascular imaging has become very complex with an increasing role in the diagnosis of IE. Cardiologists trained in multimodality imaging, but also radiology and nuclear medicine specialists, are currently key members in the Endocarditis Team.

• #3

  https://journals.lww.com/md-journal/fulltext/2020/07240/factors_associated_with_delayed_diagnosis_of.106.aspx

  Patients with infective endocarditis (IE), have high mortality and morbidity, however, its early diagnosis is difficult. Few studies have examined the delayed diagnosis of IE. We aimed to investigate the factors associated with the diagnostic delay of IE. […] The time to consider IE diagnosis was significantly delayed in patients who had inappropriate prior antibiotic use (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.01 to 2.57; P = .045), in patients without fever 38C (HR, 1.80; 95% CI, 1.11 to 2.90; P = .016), in patients with serum CRP level 10 mg/dL (HR, 1.53; 95% CI, 1.01 to 2.33; P = .046), and in patients who did not use an ambulance for hospital arrival (HR, 3.18; 95% CI, 1.72 to 5.85; P .001). […] Delay in considering IE diagnosis is associated with inappropriate prior antibiotics use, absence of high fever, absence of high CRP level, and use of a hospital arrival vehicle other than an ambulance. For earlier IE diagnosis, inappropriate use of antibiotics should be avoided and IE should not be excluded by relatively low level of temperature or serum CRP.

• #4 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  Myocardial abscess […] Development of partial dehiscence of a prosthetic valve […] New-onset valvular regurgitation […] Minor criteria for IE include the following: […] Predisposing heart condition or intravenous drug use (IVDA) […] Fever of 38C (100.4F) or higher […] Vascular phenomena, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions […] Immunologic phenomena such as glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor […] Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE […] Echocardiogram results consistent with IE but not meeting major echocardiographic criteria […] A definitive clinical diagnosis can be made based on the following:

• #4 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  Early and accurate diagnosis is critical in IE and will have an important impact on the outcome. A delayed or missed diagnosis can have catastrophic consequences: heart failure, abscess formation, atrioventricular conduction abnormalities, prosthetic valve dysfunction and embolic events. The modified Duke criteria are in use and can classify patients into one of three categories: definite, possible or rejected. Imaging plays an important role in patients with IE, and elements described with different imagistic techniques are part of the diagnostic criteria. Current data support the role of the multidisciplinary approach in IE by a specialised endocarditis team that should include cardiologists, cardiac surgeons, infectious disease specialists, microbiologists and imaging specialists for improved management and outcome in IE. Cardiovascular imaging has become very complex with an increasing role in the diagnosis of IE. Cardiologists trained in multimodality imaging, but also radiology and nuclear medicine specialists, are currently key members in the Endocarditis Team.

• #4

  https://journals.lww.com/md-journal/fulltext/2020/07240/factors_associated_with_delayed_diagnosis_of.106.aspx

  Patients with infective endocarditis (IE), have high mortality and morbidity, however, its early diagnosis is difficult. Few studies have examined the delayed diagnosis of IE. We aimed to investigate the factors associated with the diagnostic delay of IE. […] The time to consider IE diagnosis was significantly delayed in patients who had inappropriate prior antibiotic use (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.01 to 2.57; P = .045), in patients without fever 38C (HR, 1.80; 95% CI, 1.11 to 2.90; P = .016), in patients with serum CRP level 10 mg/dL (HR, 1.53; 95% CI, 1.01 to 2.33; P = .046), and in patients who did not use an ambulance for hospital arrival (HR, 3.18; 95% CI, 1.72 to 5.85; P .001). […] Delay in considering IE diagnosis is associated with inappropriate prior antibiotics use, absence of high fever, absence of high CRP level, and use of a hospital arrival vehicle other than an ambulance. For earlier IE diagnosis, inappropriate use of antibiotics should be avoided and IE should not be excluded by relatively low level of temperature or serum CRP.

• #5 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  Myocardial abscess […] Development of partial dehiscence of a prosthetic valve […] New-onset valvular regurgitation […] Minor criteria for IE include the following: […] Predisposing heart condition or intravenous drug use (IVDA) […] Fever of 38C (100.4F) or higher […] Vascular phenomena, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions […] Immunologic phenomena such as glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor […] Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE […] Echocardiogram results consistent with IE but not meeting major echocardiographic criteria […] A definitive clinical diagnosis can be made based on the following:

• #5 Multimodality Imaging Diagnosis in Infective Endocarditis

  https://www.mdpi.com/2075-1729/14/1/54

  Early and accurate diagnosis is critical in IE and will have an important impact on the outcome. A delayed or missed diagnosis can have catastrophic consequences: heart failure, abscess formation, atrioventricular conduction abnormalities, prosthetic valve dysfunction and embolic events. The modified Duke criteria are in use and can classify patients into one of three categories: definite, possible or rejected. Imaging plays an important role in patients with IE, and elements described with different imagistic techniques are part of the diagnostic criteria. Current data support the role of the multidisciplinary approach in IE by a specialised endocarditis team that should include cardiologists, cardiac surgeons, infectious disease specialists, microbiologists and imaging specialists for improved management and outcome in IE. Cardiovascular imaging has become very complex with an increasing role in the diagnosis of IE. Cardiologists trained in multimodality imaging, but also radiology and nuclear medicine specialists, are currently key members in the Endocarditis Team.

• #6 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  Myocardial abscess […] Development of partial dehiscence of a prosthetic valve […] New-onset valvular regurgitation […] Minor criteria for IE include the following: […] Predisposing heart condition or intravenous drug use (IVDA) […] Fever of 38C (100.4F) or higher […] Vascular phenomena, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions […] Immunologic phenomena such as glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor […] Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE […] Echocardiogram results consistent with IE but not meeting major echocardiographic criteria […] A definitive clinical diagnosis can be made based on the following:

• #7 Infective Endocarditis: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/216650-overview

  Myocardial abscess […] Development of partial dehiscence of a prosthetic valve […] New-onset valvular regurgitation […] Minor criteria for IE include the following: […] Predisposing heart condition or intravenous drug use (IVDA) […] Fever of 38C (100.4F) or higher […] Vascular phenomena, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions […] Immunologic phenomena such as glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor […] Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE […] Echocardiogram results consistent with IE but not meeting major echocardiographic criteria […] A definitive clinical diagnosis can be made based on the following:

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