Zapalenie wsierdzia

Zapalenie wsierdzia
Leczenie

Zapalenie wsierdzia (endocarditis) to ciężka infekcja wsierdzia lub zastawek serca, najczęściej o etiologii bakteryjnej, wymagająca szybkiej diagnostyki i agresywnej antybiotykoterapii. Kluczowe jest pobranie co najmniej dwóch, najlepiej trzech zestawów posiewów krwi przed rozpoczęciem leczenia, co umożliwia ukierunkowanie terapii. Leczenie obejmuje dożylne podawanie wysokich dawek antybiotyków przez 2-8 tygodni, z hospitalizacją co najmniej przez pierwszy tydzień. Terapia empiryczna różni się w zależności od rodzaju zastawki (natywna vs sztuczna) i lokalnych wzorców oporności, np. wankomycyna 15 mg/kg i.v. co 8-12 h plus ceftriakson 2 g i.v./dobę dla zastawki natywnej. Po identyfikacji patogenu i antybiogramie terapia jest dostosowywana, np. penicylina G 12-18 mln j./dobę przez 4 tygodnie dla paciorkowców wrażliwych na penicylinę, czy nafcylina 2 g i.v. co 4 h przez 4-6 tygodni dla MSSA. Monitorowanie stężeń leków (wankomycyna: szczyt 30-45 µg/ml, minimalne 10-15 µg/ml; gentamycyna: 3-4 µg/ml i <1 µg/ml) jest niezbędne dla optymalizacji terapii i minimalizacji toksyczności.

Zapalenie wsierdzia – definicja i wprowadzenie

Zapalenie wsierdzia (endocarditis) to poważna infekcja wewnętrznej wyściółki serca (wsierdzia) lub zastawek serca. Najczęściej ma charakter bakteryjny, choć może być również spowodowane przez grzyby i inne patogeny. Jest to schorzenie o wysokiej śmiertelności, wymagające szybkiej identyfikacji czynnika etiologicznego oraz starannie dobranej antybiotykoterapii¹. Zapalenie wsierdzia może wystąpić zarówno na zastawkach natywnych, jak i sztucznych (protezach zastawkowych), a także może dotyczyć wszczepialnych urządzeń kardiologicznych¹². Bez szybkiego i agresywnego leczenia zapalenie wsierdzia może być śmiertelne³.

Ogólne zasady leczenia zapalenia wsierdzia

Leczenie zapalenia wsierdzia obejmuje kilka kluczowych elementów: szybką diagnostykę, odpowiednią antybiotykoterapię oraz, w niektórych przypadkach powikłanego zapalenia wsierdzia, leczenie chirurgiczne⁴. Właściwe leczenie wymaga podejścia interdyscyplinarnego z udziałem specjalistów chorób zakaźnych, kardiologii i kardiochirurgii, którzy wspólnie podejmują decyzje dotyczące terapii przeciwdrobnoustrojowej oraz oceniają potrzebę interwencji chirurgicznej⁵.

Kluczowe jest, aby przed rozpoczęciem antybiotykoterapii pobrać co najmniej dwa (najlepiej trzy) zestawy posiewów krwi z dwóch różnych miejsc żylnych. Umożliwi to ukierunkowanie leczenia antybiotykami na podstawie wyników posiewów i antybiogramów⁶. W przypadkach o przebiegu powolnym, niepowikłanym, antybiotykoterapię można odroczyć do czasu otrzymania wyników posiewów. Natomiast u pacjentów z ostrym początkiem choroby lub cechami powikłanego zapalenia wsierdzia, należy niezwłocznie wdrożyć leczenie empiryczne⁷.

Antybiotykoterapia w zapaleniu wsierdzia

Podstawowe zasady antybiotykoterapii

Leczenie zapalenia wsierdzia wymaga stosowania wysokich dawek antybiotyków podawanych dożylnie, zazwyczaj przez 2-8 tygodni⁸. Początkowo pacjent powinien być hospitalizowany przez co najmniej tydzień, aby monitorować skuteczność leczenia oraz obserwować potencjalne powikłania⁹. Gdy stan pacjenta się poprawi (ustąpienie gorączki i poważnych objawów), może być on wypisany ze szpitala i kontynuować leczenie antybiotykami w warunkach ambulatoryjnych lub domowych¹⁰.

Skuteczne leczenie przeciwdrobnoustrojowe w zapaleniu wsierdzia opiera się na sterylizacji wegetacji i całkowitej eradykacji drobnoustrojów. Ze względu na dużą koncentrację patogenów w wegetacjach (10-100 milionów bakterii na gram tkanki), ich głębokie położenie w skrzeplinie oraz obecność biofilmu utrudniającego działanie antybiotyków, konieczne jest stosowanie leków bakteriobójczych¹¹.

Antybiotykoterapia empiryczna

Przed uzyskaniem wyników posiewów krwi, w przypadkach wymagających niezwłocznego leczenia, stosuje się terapię empiryczną ukierunkowaną na najczęstsze patogeny¹². Wybór antybiotyków zależy od tego, czy zapalenie wsierdzia dotyczy zastawki natywnej czy sztucznej, oraz od lokalnych wzorców oporności drobnoustrojów¹³.

Dla pacjentów z zapaleniem wsierdzia zastawki natywnej, którzy nie używają dożylnie narkotyków, empiryczne leczenie obejmuje zazwyczaj wankomycynę (15 mg/kg i.v. co 8-12 godzin) w połączeniu z ceftriaksonem (2 g i.v. dziennie)¹⁴. U pacjentów z podejrzeniem zapalenia wsierdzia zastawki sztucznej, terapia empiryczna powinna być szersza i obejmować MRSA, enterokoki oraz patogeny Gram-ujemne¹⁵. Zalecane jest podawanie wankomycyny, gentamycyny i rifampicyny¹⁶.

Według zaleceń American Heart Association (AHA), początkowo empiryczna terapia w zapaleniu wsierdzia zastawki natywnej może obejmować wankomycynę lub ampicylinę z sulbaktamem (Unasyn) w połączeniu z aminoglikozydem (plus rifampicyna u pacjentów z zastawkami sztucznymi)¹⁷.

Antybiotykoterapia celowana

Po uzyskaniu wyników posiewów krwi i antybiogramu, terapia antybiotykowa powinna zostać dostosowana do zidentyfikowanego patogenu i jego wrażliwości na antybiotyki¹⁸. Wybór antybiotyku zależy również od tego, czy infekcja dotyczy zastawki natywnej czy sztucznej¹⁹.

Schematy leczenia dla najczęstszych patogenów według zaleceń AHA²⁰:

Zapalenie wsierdzia paciorkowcowe

Dla zapalenia wsierdzia zastawki natywnej wywołanego przez wrażliwe na penicylinę paciorkowce zieleniejące, S. bovis lub inne paciorkowce (MIC penicyliny ≤0,1 µg/ml):

Penicylina G 12-18 milionów jednostek/dobę i.v. w ciągłym wlewie lub w 6 równych dawkach przez 4 tygodnie²¹
Alternatywnie, ceftriakson 2 g i.v. lub i.m. raz dziennie przez 4 tygodnie²²

Dla paciorkowców względnie opornych na penicylinę (MIC 0,1-0,5 µg/ml):

Penicylina G 18 milionów jednostek/dobę i.v. przez 4 tygodnie w połączeniu z gentamycyną przez pierwsze 2 tygodnie²³

W przypadku zapalenia wsierdzia zastawki sztucznej wywołanego przez paciorkowce, leczenie powinno trwać dłużej (6 tygodni), a gentamycyna powinna być podawana przez co najmniej pierwsze 2 tygodnie²⁴.

Zapalenie wsierdzia gronkowcowe

Dla zapalenia wsierdzia zastawki natywnej wywołanego przez metycylinowrażliwe S. aureus (MSSA):

Nafcylina lub oksacylina 2 g i.v. co 4 godziny przez 4-6 tygodni²⁵
Możliwe dodanie gentamycyny przez pierwsze 3-5 dni w celu przyspieszenia eliminacji bakteriemii²⁶

Dla zapalenia wsierdzia zastawki natywnej wywołanego przez metycylinooporne S. aureus (MRSA):

Wankomycyna przez 6 tygodni²⁷
Alternatywnie, daptomycyna (6 mg/kg/24h) została zatwierdzona do leczenia bakteriemii S. aureus i prawostronnego zapalenia wsierdzia²⁸
Linezolid może dawać lepsze wyniki niż wankomycyna w leczeniu infekcji wywołanych przez MRSA i MSSA²⁹

W przypadku zapalenia wsierdzia zastawki sztucznej wywołanego przez gronkowce, zalecana jest terapia skojarzona obejmująca nafcylinę lub oksacylinę (dla MSSA) lub wankomycynę (dla MRSA) w połączeniu z rifampicyną przez co najmniej 6 tygodni oraz gentamycyną przez pierwsze 2 tygodnie³⁰.

Zapalenie wsierdzia enterokokowe

Dla zapalenia wsierdzia wywołanego przez enterokoki wrażliwe na penicylinę i gentamycynę:

Penicylina G 18-30 milionów jednostek/dobę i.v. w połączeniu z gentamycyną 1 mg/kg i.m. lub i.v. co 8 godzin przez 4-6 tygodni³¹
Alternatywnie, ampicylina 12 g/dobę i.v. w połączeniu z gentamycyną³²

Dla enterokoków opornych na penicylinę, ale wrażliwych na wankomycynę:

Wankomycyna w połączeniu z gentamycyną przez 6 tygodni³³

Połączenie inhibitora syntezy ściany komórkowej (penicylina, ampicylina) z aminoglikozydem (gentamycyna, streptomycyna) jest konieczne do osiągnięcia działania bakteriobójczego przeciwko enterokokom³⁴.

Zapalenie wsierdzia wywołane przez grupę HACEK

Dla zapalenia wsierdzia wywołanego przez drobnoustroje z grupy HACEK:

Ceftriakson 2 g dziennie i.v. lub i.m. przez 4 tygodnie³⁵
W przypadku zastawki sztucznej, leczenie powinno trwać 6 tygodni³⁶

Zapalenie wsierdzia grzybicze

Zapalenie wsierdzia wywołane przez grzyby jest rzadkie i występuje głównie po operacjach zastawek sztucznych oraz u osób używających dożylnie narkotyków³⁷. W takich przypadkach stosuje się leki przeciwgrzybicze, a często konieczna jest również interwencja chirurgiczna³⁸. Niektórzy pacjenci wymagają długotrwałego przyjmowania leków przeciwgrzybiczych, aby zapobiec nawrotom zapalenia wsierdzia³⁹.

Monitorowanie leczenia przeciwdrobnoustrojowego

W trakcie leczenia zapalenia wsierdzia konieczne jest regularne monitorowanie skuteczności terapii. Obejmuje to kontrolę parametrów klinicznych (ustąpienie gorączki i innych objawów), badania laboratoryjne oraz badania obrazowe⁴⁰.

W przypadku stosowania niektórych antybiotyków, takich jak wankomycyna czy aminoglikozydy, zaleca się monitorowanie stężenia leku w surowicy, aby zapewnić odpowiedni poziom terapeutyczny i zminimalizować ryzyko działań niepożądanych⁴¹. Dla wankomycyny docelowe stężenia szczytowe i minimalne wynoszą odpowiednio 30-45 µg/ml i 10-15 µg/ml, natomiast dla gentamycyny – 3-4 µg/ml i poniżej 1 µg/ml⁴².

U pacjentów z zapaleniem wsierdzia wywołanym przez paciorkowce wrażliwe na penicylinę poprawa następuje zwykle w ciągu 3-7 dni od rozpoczęcia leczenia. Natomiast pacjenci z zapaleniem wsierdzia gronkowcowym reagują wolniej⁴³.

Doustna antybiotykoterapia w zapaleniu wsierdzia

Tradycyjnie leczenie zapalenia wsierdzia opiera się na dożylnym podawaniu antybiotyków. Jednak w ostatnich latach pojawiły się dowody sugerujące, że u wybranych pacjentów można rozważyć przejście na doustną terapię antybiotykową w późniejszej fazie leczenia⁴⁴⁴⁵.

Kandydatami do takiej zmiany są pacjenci, którzy szybko uzyskali eliminację bakteriemii, szybko ustąpiła u nich gorączka i nie ma dowodów na zatory czy wzrost wegetacji. Dodatkowo nie powinno być potrzeby pilnej interwencji chirurgicznej, a co najmniej jeden z przepisanych antybiotyków musi osiągać udokumentowane stężenia bakteriobójcze przy podaniu doustnym⁴⁶.

Badania wykazały, że pacjenci z lewostronnym zapaleniem wsierdzia w stabilnym stanie, którzy otrzymali co najmniej 10 dni dożylnych antybiotyków, mogą przejść na leczenie doustne na pozostałą część terapii⁴⁷. Dowody przemawiające za stosowaniem leczenia doustnego są najlepiej udokumentowane dla patogenów Gram-dodatnich, takich jak enterokoki, MRSA i gronkowce koagulazo-ujemne⁴⁸.

Leczenie chirurgiczne zapalenia wsierdzia

Wskazania do leczenia chirurgicznego

Około 15-25% pacjentów z zapaleniem wsierdzia ostatecznie wymaga interwencji chirurgicznej⁴⁹. Wskazania do leczenia chirurgicznego w zapaleniu wsierdzia zastawki natywnej obejmują⁵⁰:

Niewydolność serca oporna na standardowe leczenie medyczne
Zapalenie wsierdzia grzybicze (z wyjątkiem wywołanego przez Histoplasma capsulatum)
Utrzymująca się posocznica po 72 godzinach odpowiedniej antybiotykoterapii
Nawracające zatory septyczne, szczególnie po 2 tygodniach antybiotykoterapii
Pęknięcie tętniaka zatoki Valsalvy
Zaburzenia przewodzenia spowodowane ropniem przegrody
Infekcja płatka przedniego zastawki mitralnej u pacjentów z zapaleniem wsierdzia zastawki aortalnej

Operacja wymiany zastawki powinna być przeprowadzona niezwłocznie, jeśli wystąpi którykolwiek z następujących stanów⁵¹:

Umiarkowana do ciężkiej niewydolność serca
Dysfunkcja zastawki
Tworzenie się ropnia okołozastawkowego lub mięśnia sercowego
Obecność niestabilnej zastawki, która odrywa się od pierścienia zastawkowego
Więcej niż jeden epizod zatorowy z utrzymującymi się wegetacjami widocznymi w przezprzełykowym badaniu echokardiograficznym
Obecność wegetacji większych niż 1 cm średnicy

W przypadku zapalenia wsierdzia zastawki sztucznej, jeśli nie reaguje ono na leczenie przeciwdrobnoustrojowe i wyniki posiewów krwi pozostają dodatnie lub dochodzi do nawrotu bakteriemii, zastawka sztuczna powinna zostać wymieniona⁵².

Czas wykonania operacji

Według wytycznych American Association for Thoracic Surgery (AATS), gdy wskazanie do operacji zostanie ustalone, zabieg powinien być wykonany jak najszybciej⁵³. Wytyczne AATS podkreślają, że powód i czas operacji nie mogą być rozpatrywane oddzielnie, ale muszą być analizowane łącznie⁵⁴.

Zalecenia dotyczące czasu wykonania operacji w zapaleniu wsierdzia⁵⁵:

W ciągu 24-48 godzin od rozpoznania w przypadku ciężkiej niedomykalności zastawki lub zmiany destrukcyjnej/penetrującej z niestabilnością hemodynamiczną lub objawami niewydolności serca klasy III lub IV według NYHA
W ciągu 1 tygodnia od rozpoznania w przypadku ciężkiej niedomykalności zastawki lub zmiany destrukcyjnej/penetrującej bez niestabilności hemodynamicznej lub objawów niewydolności serca klasy III lub IV; lub w przypadku opornej infekcji (definiowanej jako ropień, utrzymująca się bakteriemia, oporny drobnoustrój lub nawracające zapalenie wsierdzia zastawki sztucznej)
W ciągu 24-48 godzin od rozpoznania w celu zapobiegania zatorom (zdefiniowanym jako nawracające zatory z pozostałymi wegetacjami lub wegetacjami o wielkości ≥10 mm bez wcześniejszego epizodu zatorowego)

W przypadku pacjentów z udarem i deficytami neurologicznymi, czas operacji jest ustalany przez wyważenie potrzeby operacji serca z ryzykiem powiększenia udaru lub wywołania krwawienia śródczaszkowego podczas zabiegu⁵⁶.

Rodzaje zabiegów chirurgicznych

Operacja zapalenia wsierdzia może obejmować napranie lub wymianę uszkodzonej zastawki serca, usunięcie zakażonej tkanki oraz drenaż ropni⁵⁷. Główne zabiegi chirurgiczne stosowane w leczeniu zapalenia wsierdzia to⁵⁸:

Naprawa uszkodzonej zastawki serca – może być atrakcyjną alternatywą dla wymiany zastawki u niektórych pacjentów, szczególnie w przypadku zastawki mitralnej⁵⁹
Wymiana uszkodzonych zastawek serca na sztuczne – wykorzystuje się zastawkę mechaniczną lub biologiczną (tkankową) wykonaną z tkanki naturalnej (np. świńskiej, bydlęcej lub ludzkiej)⁶⁰
Drenaż ropni, które mogły się rozwinąć w mięśniu sercowym⁶¹

Zaletą zastawki biologicznej jest to, że nie zawiera metalu, więc długotrwałe stosowanie leków przeciwzakrzepowych nie jest konieczne. Zastawki mechaniczne zawierają materiały, które są bardziej podatne na tworzenie skrzepów krwi i wymagają stosowania leków przeciwzakrzepowych. Zaletą jest jednak to, że służą przez wiele lat⁶².

W przypadku prawostronnego zapalenia wsierdzia, leczenie jest zwykle zachowawcze. Jeśli konieczna jest operacja, preferuje się naprawę zastawki zamiast jej wymiany, aby uniknąć przyszłej infekcji zastawki sztucznej z powodu dalszego stosowania narkotyków dożylnych⁶³.

Leczenie zapalenia wsierdzia związanego z urządzeniami wszczepianymi

W przypadku zapalenia wsierdzia obejmującego wszczepione urządzenie kardiologiczne, konieczne jest całkowite usunięcie stymulatora serca lub defibrylatora, w tym wszystkich elektrod i generatora⁶⁴. Wytyczne AHA dotyczące infekcji wszczepialnych urządzeń kardiologicznych zalecają całkowite usunięcie zakażonego urządzenia i elektrod u wszystkich pacjentów z potwierdzoną infekcją, co wykazano przez zapalenie wsierdzia zastawkowe i/lub elektrodowe lub posocznicę⁶⁵.

Wytyczne AHA zalecają, że jeśli posiewy krwi były dodatnie przed usunięciem urządzenia, należy pobrać posiewy krwi po usunięciu urządzenia, a wszczepienie nowego urządzenia powinno być opóźnione do czasu, gdy posiewy krwi będą ujemne przez co najmniej 72 godziny⁶⁶.

Leczenie podtrzymujące i zapobiegawcze

Leczenie powikłań zapalenia wsierdzia

Poza antybiotykoterapią i ewentualnym leczeniem chirurgicznym, ważne jest również leczenie powikłań zapalenia wsierdzia. Obejmuje to⁶⁷:

Leczenie niewydolności serca
Suplementację tlenową w razie potrzeby
Hemodializę w przypadku ciężkiej niewydolności nerek

Interwencje wewnątrznaczyniowe mogą być stosowane w leczeniu ostrych, dużych zatorów septycznych⁶⁸.

Profilaktyka antybiotykowa

Osoby z wysokim ryzykiem zapalenia wsierdzia mogą wymagać profilaktyki antybiotykowej przed określonymi zabiegami stomatologicznymi i innymi procedurami medycznymi⁶⁹. Według American Heart Association, profilaktyka antybiotykowa jest zalecana przed zabiegami stomatologicznymi dla osób z określonymi schorzeniami serca⁷⁰.

Pacjenci, którzy zostali skutecznie leczeni z powodu zapalenia wsierdzia w przeszłości, wymagają profilaktyki antybiotykowej przed określonymi zabiegami stomatologicznymi i innymi procedurami⁷¹. Wytyczne AATS sugerują, że pacjenci, którzy przeszli operację z powodu zapalenia wsierdzia, stanowią grupę wysokiego ryzyka nawrotu zapalenia wsierdzia i powinni otrzymać profilaktykę⁷².

Opieka długoterminowa

Po zakończeniu leczenia zapalenia wsierdzia konieczna jest długoterminowa obserwacja pacjenta. Obejmuje to regularne wizyty kontrolne, badania krwi oraz w niektórych przypadkach badania obrazowe, takie jak echokardiografia⁷³.

Pacjenci powinni być edukowani w zakresie codziennej higieny jamy ustnej, regularnych wizyt u dentysty oraz potrzeby profilaktyki antybiotykowej przed określonymi zabiegami⁷⁴. Ważne jest również, aby pacjenci byli świadomi objawów nawrotu zapalenia wsierdzia i wiedzieli, kiedy należy szukać pomocy medycznej⁷⁵.

Rokowanie i efekty leczenia zapalenia wsierdzia

Wyniki leczenia zapalenia wsierdzia zależą od wielu czynników, w tym od wieku pacjenta, organizmu wywołującego infekcję, obecności powikłań, wyników badań echokardiograficznych oraz chorób współistniejących⁷⁶.

Nieleczone zapalenie wsierdzia jest śmiertelne⁷⁷. Jednak przy wczesnym, agresywnym leczeniu, większość pacjentów przeżywa⁷⁸. Wcześniejsze leczenie zapalenia wsierdzia prowadzi do lepszego długoterminowego rokowania⁷⁹.

U niektórych pacjentów poprawa następuje w ciągu kilku dni od rozpoczęcia leczenia. U innych może to trwać dłużej⁸⁰. Nawrót zwykle występuje w ciągu 4 tygodni od zakończenia leczenia. Ponowne leczenie antybiotykami może być skuteczne, ale może być również konieczna operacja⁸¹.

Czas trwania leczenia antybiotykami (od 2 do 8 tygodni) zależy od charakterystyki infekcji i drobnoustrojów wywołujących⁸². Po operacji zapalenia wsierdzia standardowy czas podawania antybiotyków dożylnych wynosi 6 tygodni, licząc od dnia operacji, ale schemat i czas trwania mogą być modyfikowane i dostosowywane w zależności od organizmu i jego wrażliwości na leki przeciwdrobnoustrojowe, odpowiedzi na leczenie i patologii⁸³.

Podsumowanie i przyszłe kierunki

Leczenie zapalenia wsierdzia wymaga multidyscyplinarnego podejścia, z udziałem kardiologów, specjalistów chorób zakaźnych, mikrobiologów, kardiochirurgów i farmaceutów⁸⁴. Wczesna diagnoza i odpowiednie leczenie są kluczowe dla poprawy rokowania⁸⁵.

Obecne wytyczne ESC z 2023 roku dotyczące postępowania w zapaleniu wsierdzia uwzględniają liczne osiągnięcia w opiece nad pacjentami, w tym udoskonalenie wskazań do profilaktyki antybiotykowej, poprawę możliwości diagnostycznych, utworzenie zespołów ds. zapalenia wsierdzia i ośrodków zastawek serca, identyfikację pacjentów kwalifikujących się do ambulatoryjnej antybiotykoterapii, diagnostykę i stratyfikację ryzyka u pacjentów z powikłaniami zapalenia wsierdzia oraz opiekę skoncentrowaną na pacjencie w ostrej fazie i podczas obserwacji⁸⁶.

Ciągły postęp w diagnostyce i leczeniu zapalenia wsierdzia, w tym techniki diagnostyki syndromowej i udoskonalone metody szybkiej oceny dodatnich posiewów krwi, pokazują obiecujące wyniki⁸⁷. Przyszłe badania powinny pomóc lepiej zdefiniować rolę antybiotyków doustnych w leczeniu zapalenia wsierdzia oraz optymalne strategie leczenia w przypadku opornych infekcji⁸⁸.

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Materiały źródłowe

#1 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/
Infective endocarditis is an uncommon infection with a high mortality rate. It requires prompt identification and carefully selected antibiotic therapy. This activity outlines the general antibiotic principles associated with treating infective endocarditis and highlights the importance of the interprofessional team in caring for patients with this condition. […] The management of endocarditis requires an interprofessional approach by infectious disease, cardiology, and cardiac surgery to manage antimicrobial therapy and assess for possible surgical intervention. Early consultation with cardiothoracic surgery has been shown to improve mortality and is mandatory in patients presenting with complications. […] The treatment of endocarditis should be pathogen-directed and directed by blood cultures and antibiotic sensitivities. Therefore it is imperative to obtain at least two separate blood cultures (preferably three) from two different venous sites for targeted antibiotic therapy before administering antibiotics.
#1 Antimicrobial therapy of prosthetic valve endocarditis – UpToDate
https://www.uptodate.com/contents/antimicrobial-therapy-of-prosthetic-valve-endocarditis
Antimicrobial therapy of prosthetic valve endocarditis […] Issues related to the antimicrobial therapy of prosthetic valve infective endocarditis (PVE) will be reviewed here; the content reflects American and European guidelines. […] Suggested regimens for therapy of prosthetic valve endocarditis due to Staphylococcus species […] Suggested regimens for therapy of prosthetic valve endocarditis due to penicillin-susceptible viridans streptococci and Streptococcus gallolyticus (bovis) (MIC â¤0.12 mcg/mL) […] Suggested regimens for therapy of prosthetic valve endocarditis due to strains of viridans streptococci and Streptococcus gallolyticus (bovis) relatively or fully resistant to penicillin G […] Suggested regimens for therapy of prosthetic valve endocarditis due to enterococcal strains susceptible to penicillin and gentamicin
#2 2023 ESC Guidelines for the management of endocarditis
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Endocarditis-Guidelines
The current guidelines have been developed to support healthcare professionals with the diagnosis and management of patients with infective endocarditis, an infrequent but oftentimes fatal disease that can present with multiple different clinical scenarios. […] Since then there have been multiple developments in the care of patients with infective endocarditis including refinements of the indications for antibiotic prophylaxis, improvements in diagnostic capabilities, establishment of endocarditis teams and heart valve centres, identification of patients eligible for outpatient antibiotic therapy, diagnosis and risk-stratification of patients suffering complications of endocarditis (in particular stroke), management of patients with transcatheter heart valve- and cardiac implantable electronic device-associated infective endocarditis, and patient-centred care during the acute and follow-up phases of this challenging disease. […] The current document should serve as a guide for clinicians involved in the diagnosis and management of infective endocarditis patients and should lead to improved outcomes for this serious disease.
#3 Endocarditis: Causes, Symptoms and Treatment
https://my.clevelandclinic.org/health/diseases/16957-endocarditis
Endocarditis, most often from a bacterial infection, inflames the lining of your heart valves and chambers. Treatment includes several weeks of antibiotics or other medicine and sometimes surgery. With quick, aggressive treatment, many people survive. Without treatment, endocarditis can be fatal. […] 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. They’ll use a broad-spectrum antibiotic to cover as many suspected bacterial species as possible. As soon as they know which specific type of organism you have, they’ll adjust your antibiotics to target it. Usually, you’ll receive IV antibiotics for as long as six weeks to cure your infection.
#4 Overview of management of infective endocarditis in adults – UpToDate
https://www.uptodate.com/contents/overview-of-management-of-infective-endocarditis-in-adults
The management of infective endocarditis (IE) includes prompt diagnosis, treatment with antimicrobial therapy, and in some cases of complicated IE, surgical management. […] Preventive measures including antimicrobial prophylaxis may reduce the risk of initial and recurrent IE for patients with relevant risk factors. […] Details regarding antimicrobial therapy and surgery for IE are discussed separately, as are issues related to prevention of IE. […] The diagnosis of IE is relatively straightforward in some patients but can be quite challenging in patients who present early in the course of infection and/or patients with nonspecific symptoms. […] IE should be suspected in patients with fever (with or without bacteremia) and/or relevant cardiac risk factors (prior IE, presence of a prosthetic valve or cardiac device, history of valvular or congenital heart disease) or noncardiac risk factors (intravenous drug use, indwelling intravenous lines or cardiac devices, or a recent dental or surgical procedure).
#5 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/
Infective endocarditis is an uncommon infection with a high mortality rate. It requires prompt identification and carefully selected antibiotic therapy. This activity outlines the general antibiotic principles associated with treating infective endocarditis and highlights the importance of the interprofessional team in caring for patients with this condition. […] The management of endocarditis requires an interprofessional approach by infectious disease, cardiology, and cardiac surgery to manage antimicrobial therapy and assess for possible surgical intervention. Early consultation with cardiothoracic surgery has been shown to improve mortality and is mandatory in patients presenting with complications. […] The treatment of endocarditis should be pathogen-directed and directed by blood cultures and antibiotic sensitivities. Therefore it is imperative to obtain at least two separate blood cultures (preferably three) from two different venous sites for targeted antibiotic therapy before administering antibiotics.
#6 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/
Infective endocarditis is an uncommon infection with a high mortality rate. It requires prompt identification and carefully selected antibiotic therapy. This activity outlines the general antibiotic principles associated with treating infective endocarditis and highlights the importance of the interprofessional team in caring for patients with this condition. […] The management of endocarditis requires an interprofessional approach by infectious disease, cardiology, and cardiac surgery to manage antimicrobial therapy and assess for possible surgical intervention. Early consultation with cardiothoracic surgery has been shown to improve mortality and is mandatory in patients presenting with complications. […] The treatment of endocarditis should be pathogen-directed and directed by blood cultures and antibiotic sensitivities. Therefore it is imperative to obtain at least two separate blood cultures (preferably three) from two different venous sites for targeted antibiotic therapy before administering antibiotics.
#7 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/
In patients who present with an indolent, uncomplicated course, antibiotic therapy can be delayed until cultures and sensitivities are available. However, in patients with a more acute presentation or features of complicated endocarditis, prompt empiric treatment is often required to reduce the risk of complications. […] The presence of a bioprosthetic valve or implantable cardiac device plays a significant influence on antibiotic selection duration of treatment as it portends a more severe infection with higher rates of treatment failure than native valve endocarditis. […] Empiric antibiotic therapy for prosthetic valve and health-care-associated endocarditis should be broader and cover MRSA, enterococci, and gram-negative pathogens. […] The prognosis of endocarditis depends upon infecting organism, the presence of complications, echo findings, and patient characteristics such as age or comorbidities. […] Management of antibiotic regimens for infective endocarditis is best achieved with an interprofessional team involving physicians, infectious disease experts, specialty-trained nursing staff, and pharmacists all collaborating to manage the cases to an optimal patient outcome.
#8 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis
Treatment consists of a prolonged course of antimicrobial therapy. Surgery may be needed for mechanical complications or resistant organisms. Typically, antimicrobials are given IV. Because they must be given for 2 to 8 weeks, home IV therapy is often used. […] Any apparent source of bacteremia must be managed: necrotic tissue debrided, abscesses drained, and foreign material and infected devices removed. Patients with infective endocarditis should be evaluated by a dentist and treated for oral diseases that could cause bacteremia and subsequent endocarditis. […] Organisms within biofilms adherent to catheters and other devices may not respond to antimicrobial therapy, leading to treatment failure or relapse. […] Antibiotics should not be given until adequate blood cultures (minimally 2, but ideally 3, samples from different sites over 1 hour) have been obtained. An empiric regimen should cover typical pathogens (ie, Staphylococci and Streptococci species), take into account local resistance pattern, such as MRSA prevalence, and include an agent highly effective at killing (eg, a beta-lactam antibiotic).
#9 Endocarditis – Diagnosis & treatment – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582
Many people with endocarditis are successfully treated with antibiotics. Sometimes, surgery may be needed to fix or replace damaged heart valves and clean up any remaining signs of the infection. […] The type of medication you receive depends on what’s causing the endocarditis. […] High doses of antibiotics are used to treat endocarditis caused by bacteria. If you receive antibiotics, you’ll generally spend a week or more in the hospital so that care providers can determine if the treatment is working. […] Once your fever and any severe symptoms have gone away, you might be able to leave the hospital. Some people continue antibiotics with visits to a provider’s office or at home with home care. Antibiotics are usually taken for several weeks. […] If endocarditis is caused by a fungal infection, antifungal medication is given. Some people need lifelong antifungal pills to prevent endocarditis from returning.
#10
https://www.nhs.uk/conditions/endocarditis/treatment/
Most cases of endocarditis can be treated with a course of antibiotics. You’ll usually have to be admitted to hospital so the antibiotics can be given through a drip in your arm (intravenously). […] If your symptoms are severe, you may be prescribed a mixture of different antibiotics before getting the result of the blood sample. This is a precautionary measure to prevent your symptoms becoming worse. […] Once your fever and any severe symptoms subside, you may be able to leave hospital and continue receiving antibiotics at home by a drip (IV). […] If your blood sample shows that fungi are causing your infection, you’ll be prescribed an antifungal medicine. […] You may need surgery to repair damage to the heart. […] Surgery will usually be recommended if: your symptoms or test results suggest you have experienced heart failure, a serious condition where your heart’s not pumping blood around your body efficiently; you continue to have a high temperature (fever) despite treatment with antibiotics or antifungals; your endocarditis is caused by particularly aggressive fungi or drug-resistant bacteria; you experience 1 or more blood clots despite treatment with antibiotics or antifungals; you have an artificial (prosthetic) heart valve; the results of your echocardiogram suggest that a collection of pus (abscess) or an abnormal passageway (fistula) has developed inside your heart. […] The 3 main surgical procedures used to treat endocarditis are: repair of the damaged heart valve; replacement of the damaged heart valves with prosthetic ones during aortic valve replacement surgery; draining of any abscesses and repair of any fistulas that may have developed in the heart muscle.
#11 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
In the cases of SBE, treatment generally may be safely delayed until culture and sensitivity results are available. If the patient’s condition is stable, waiting does not increase the risk for complications in this form of the disease. […] Eradicating bacteria from the fibrin-platelet thrombus is extremely difficult because of (1) the high concentration of organisms present within the vegetation (ie, 10-100 million bacteria per gram of tissue), (2) their position deep within the thrombus, (3) their location in both a reduced metabolic and reproductive state, and (4) the interference of fibrin and white cells with antibiotic action. For all these reasons, bactericidal antibiotics are considered necessary for cure of valvular infection. […] Evidence has shown that patients with left-sided endocarditis in stable condition who received at least 10 days of intravenous antibiotics could be switched to oral administration for the remainder of their therapeutic course.
#12 Infective endocarditis: diagnosis, treatment and prevention – The Pharmaceutical Journal
https://pharmaceutical-journal.com/article/ld/infective-endocarditis-diagnosis-treatment-and-prevention
Empirical antibacterial therapy should provide coverage against commonly expected pathogens â this should be tailored based on the presence of prosthetic valves and/or recent risk factors for infection, such as active intravenous drug use. […] The updated ESC guidelines have resulted in a gradual change to the management of IE in the UK. […] Prolonged (two to six weeks) antibacterial therapy is advised for IE treatment. […] Initially, therapy is intravenously administered and the pharmacy team play an active role in the facilitation of continuous treatment. […] Surgical interventions to remove infected vegetations or repair cardiac structure may be indicated in IE with valvular dysfunction precipitating heart failure; in patients with persistent bacteraemia despite targeted antimicrobial therapy; and patients with risk of embolisation (mobile vegetation >10mm observed).
#13 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
All patients with proven or highly suspected IE initially should be assessed by and actively followed by at least an infectious diseases consultant, especially as regards initial antibiotic therapy and any changes in such during the entire therapeutic course. […] In general, avoid the use of vancomycin. It is extremely challenging to achieve and sustain therapeutic levels in situations of unstable renal function. Gentamicin may need to be added because a growing degree of tolerance of staphylococci and enterococci to vancomycin may induce partial resistance of bacteria to daptomycin and other antibiotics by inducing cellular wall thickening. […] In the setting of acute IE, institute antibiotic therapy as soon as possible to minimize valvular damage. Three to 5 sets of blood cultures are obtained within 60 to 90 minutes, followed by the infusion of the appropriate antibiotic regimen. If molecular blood testing is not available, the initial antibiotic choice is arrived at by SA and attention to local resistance patterns.
#14 Endocarditis Diagnosis and Treatment : Emergency Care BC
https://emergencycarebc.ca/clinical_resource/clinical-summary/endocarditis-diagnosis-and-treatment/
In intravenous drug users 76% of IE is right-sided, predominantly affecting the tricuspid valve: […] Patients with suspected IE should be admitted to the hospital, with specialist consultation and initiation of antibiotic therapy. […] For patients with native valve IE who do not use IV drugs, empiric antibiotic treatment is vancomycin (15mg/kg IV q8-12h) plus ceftriaxone (2g IV daily). […] Empiric antibiotic treatment is vancomycin (15mg/kg IV q8-12h) plus one of gentamicin (1.5-2mg/kg IV q8h), tobramycin (1.5-2mg/kg IV q8h), or ciprofloxacin (400mg IV q12h or 750mg PO bid). […] Empiric antibiotic treatment is vancomycin (15mg/kg IV q8-12h), gentamicin (1mg/kg IV q8h) and rifampin (300mg PO tid or 600mg PO bid), with or without fluconazole (800mg IV or PO daily). […] Early surgical consult should be obtained in patients with heart failure, conduction block, abscess, difficult to treat pathogens, persistent infection, and large vegetations. […] Treatment is often multidisciplinary with consultation from cardiology, infectious disease, and cardiac surgery specialists.
#15 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/
In patients who present with an indolent, uncomplicated course, antibiotic therapy can be delayed until cultures and sensitivities are available. However, in patients with a more acute presentation or features of complicated endocarditis, prompt empiric treatment is often required to reduce the risk of complications. […] The presence of a bioprosthetic valve or implantable cardiac device plays a significant influence on antibiotic selection duration of treatment as it portends a more severe infection with higher rates of treatment failure than native valve endocarditis. […] Empiric antibiotic therapy for prosthetic valve and health-care-associated endocarditis should be broader and cover MRSA, enterococci, and gram-negative pathogens. […] The prognosis of endocarditis depends upon infecting organism, the presence of complications, echo findings, and patient characteristics such as age or comorbidities. […] Management of antibiotic regimens for infective endocarditis is best achieved with an interprofessional team involving physicians, infectious disease experts, specialty-trained nursing staff, and pharmacists all collaborating to manage the cases to an optimal patient outcome.
#16 Endocarditis Diagnosis and Treatment : Emergency Care BC
https://emergencycarebc.ca/clinical_resource/clinical-summary/endocarditis-diagnosis-and-treatment/
In intravenous drug users 76% of IE is right-sided, predominantly affecting the tricuspid valve: […] Patients with suspected IE should be admitted to the hospital, with specialist consultation and initiation of antibiotic therapy. […] For patients with native valve IE who do not use IV drugs, empiric antibiotic treatment is vancomycin (15mg/kg IV q8-12h) plus ceftriaxone (2g IV daily). […] Empiric antibiotic treatment is vancomycin (15mg/kg IV q8-12h) plus one of gentamicin (1.5-2mg/kg IV q8h), tobramycin (1.5-2mg/kg IV q8h), or ciprofloxacin (400mg IV q12h or 750mg PO bid). […] Empiric antibiotic treatment is vancomycin (15mg/kg IV q8-12h), gentamicin (1mg/kg IV q8h) and rifampin (300mg PO tid or 600mg PO bid), with or without fluconazole (800mg IV or PO daily). […] Early surgical consult should be obtained in patients with heart failure, conduction block, abscess, difficult to treat pathogens, persistent infection, and large vegetations. […] Treatment is often multidisciplinary with consultation from cardiology, infectious disease, and cardiac surgery specialists.
#17 Infectious Endocarditis: Diagnosis and Treatment | AAFP
https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html
Infectious endocarditis should be suspected in patients who have unexplained fevers, particularly in the presence of risk factors or cardiac findings. […] Initial empiric therapy in patients with suspected endocarditis should include vancomycin or ampicillin/sulbactam (Unasyn) plus an aminoglycoside (plus rifampin in patients with prosthetic valves). […] Valve replacement should be considered in selected patients with infectious endocarditis. […] Patients who have been successfully treated for infectious endocarditis in the past require antimicrobial prophylaxis before certain dental and other procedures. […] Successful treatment requires appropriate antibiotic therapy. Initial empiric therapy may include vancomycin or ampicillin/sulbactam (Unasyn) plus an aminoglycoside (plus rifampin in patients with prosthetic valves).
#18 Infectious Endocarditis: Diagnosis and Treatment | AAFP
https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html
The choice of definitive antibiotic therapy is based on the causative microorganism and its antibiotic susceptibility, and whether the involved valve is native or prosthetic. […] Surgery may need to be considered in selected patients; the benefits are greatest in patients with the most indications. […] Surgical intervention should be considered in patients with fungal infection, infection with aggressive antibiotic-resistant bacteria or bacteria that respond poorly to antibiotics, left-sided infectious endocarditis caused by gram-negative bacteria, persistent infection with positive blood cultures after one week of antibiotic therapy, or one or more embolic events during the first two weeks of antibiotic therapy. […] Anticoagulation in patients with infectious endocarditis is controversial, particularly in those with mechanical valve endocarditis. […] Patients should receive information about daily dental hygiene, regular visits to the dentist, and the need for antibiotic prophylaxis for certain procedures.
#19 Infective Endocarditis Diagnosis and Management
https://www.uspharmacist.com/article/infective-endocarditis-diagnosis-and-management
Definitive antimicrobial therapy selection for IE depends on multiple factors such as the organism isolation, and presence of native valve endocarditis (NVE) or prosthetic valve. […] Streptococcal endocarditis is typically caused by VGS species or Streptococcus gallolyticus, and antibiotic treatment regimens are determined based on penicillin-susceptibility data. […] In patients with endocarditis of prosthetic valve caused by highly penicillin-susceptible VGS or S gallolyticus, longer treatment durations are recommended compared with native valve infection. […] Staphylococcal endocarditis is most commonly caused by coagulase-positive staphylococci, specifically S aureus. […] Antibiotic treatment regimens in patients with staphylococcal infection are determined based on presence of native or prosthetic valve.
#20 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Treat all patients in a hospital or skilled nursing facility to allow adequate monitoring of the development of complications and the response to antibiotic therapy. […] The American Heart Association (AHA) has developed guidelines for treating IE caused by the most frequently encountered microorganisms. […] Antibiotic doses are predicated on normal renal function. […] Adult NVE caused by penicillin-susceptible S viridans, S bovis, and other streptococci (MIC of penicillin of 0.1 mcg/mL) should be treated with 1 of the following regimens: Administer penicillin G at 12-18 million units/day (U/d) IV by continuous pump or in 6 equally divided doses for 4 weeks. […] For NVE caused by relatively resistant streptococci (MICs of penicillin of 0.1-0.5 mcg/mL), the following regimens are recommended: Administer penicillin G at 18 million U/d IV, either by continuous pump or in 6 equally divided doses, for 4 weeks.
#21 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Treat all patients in a hospital or skilled nursing facility to allow adequate monitoring of the development of complications and the response to antibiotic therapy. […] The American Heart Association (AHA) has developed guidelines for treating IE caused by the most frequently encountered microorganisms. […] Antibiotic doses are predicated on normal renal function. […] Adult NVE caused by penicillin-susceptible S viridans, S bovis, and other streptococci (MIC of penicillin of 0.1 mcg/mL) should be treated with 1 of the following regimens: Administer penicillin G at 12-18 million units/day (U/d) IV by continuous pump or in 6 equally divided doses for 4 weeks. […] For NVE caused by relatively resistant streptococci (MICs of penicillin of 0.1-0.5 mcg/mL), the following regimens are recommended: Administer penicillin G at 18 million U/d IV, either by continuous pump or in 6 equally divided doses, for 4 weeks.
#22 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html
Infection with viridans streptococci is a common cause of endocarditis involving native valves with preexisting congenital or acquired defects. S. bovis is another streptococcal species that causes bacterial endocarditis. Most of these organisms are highly sensitive to penicillin. Patients infected with one of these organisms should be treated for four weeks with intravenous penicillin in doses of 12 million to 18 million units every 24 hours or 2 g of ceftriaxone (Rocephin) in a single daily dose given intravenously or intramuscularly. The penicillin can be administered continuously or in six divided doses. The bacteriologic cure rate with such treatment is approximately 98 percent. […] Accumulating evidence has shown that an equivalent cure rate can be achieved with a two-week combination of penicillin or ceftriaxone and gentamicin (Garamycin) administered intramuscularly or intravenously. This alternative two-week regimen is appropriate for uncomplicated bacterial endocarditis in patients with a low risk of complications from gentamicin.
#23 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Treat all patients in a hospital or skilled nursing facility to allow adequate monitoring of the development of complications and the response to antibiotic therapy. […] The American Heart Association (AHA) has developed guidelines for treating IE caused by the most frequently encountered microorganisms. […] Antibiotic doses are predicated on normal renal function. […] Adult NVE caused by penicillin-susceptible S viridans, S bovis, and other streptococci (MIC of penicillin of 0.1 mcg/mL) should be treated with 1 of the following regimens: Administer penicillin G at 12-18 million units/day (U/d) IV by continuous pump or in 6 equally divided doses for 4 weeks. […] For NVE caused by relatively resistant streptococci (MICs of penicillin of 0.1-0.5 mcg/mL), the following regimens are recommended: Administer penicillin G at 18 million U/d IV, either by continuous pump or in 6 equally divided doses, for 4 weeks.
#24 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html
When infection with viridans streptococci involves a prosthetic valve, penicillin should be administered for six weeks with concomitant gentamicin during at least the first two weeks. Patients with viridans streptococci infection who have a documented allergy to penicillin should be treated with vancomycin (Vancocin), 30 mg per kg every 24 hours intravenously in two divided doses. If the dosage exceeds 2 g in 24 hours, serum levels should be monitored. Vancomycin and gentamicin dosages and intervals should be adjusted in patients with impaired renal function. Patients with an equivocal history of penicillin allergy should be challenged with a test dose. […] Medical treatment of enterococcal endocarditis is challenging and difficult because of the increasing resistance of enterococci to multiple antibiotics. Enterococcal organisms are uniformly resistant to a concentration of penicillin G of 0.1 g per mL. A combination of high-dose penicillin or ampicillin and an aminoglycoside (streptomycin or gentamicin) has a synergistic bactericidal effect on enterococci and usually produces cure. However, enterococcal resistance to aminoglycosides has become a problem. Testing the isolated organism is crucial to determine the pattern of antibiotic susceptibility/resistance; an organism resistant to gentamicin may be sensitive to streptomycin and vice versa.
#25 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Increasing numbers of enterococci have aminoglycoside-inactivating enzymes that make them relatively resistant to the usual synergistic combinations. […] Continuously infused ampicillin (serum level of 16 mcg/mL) is probably the best therapy for aminoglycoside-resistant enterococci. […] High peak levels of gentamicin are not necessary to establish synergistic bactericidal activity against enterococci. […] Vancomycin-resistant isolates of Enterococcus faecium and Enterococcus faecalis (ie, vancomycin-resistant enterococci [VRE]) produce some of the most challenging nosocomial infections. […] NVE caused by methicillin-sensitive S aureus (MSSA) should be treated as follows: Administer nafcillin or oxacillin at 2 g IV every 4 hours for 4-6 weeks. […] Vancomycin therapy is associated with a significant failure rate (up to 35%) in the treatment of MSSA and MRSA BSI/IE.
#26 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
It is of the utmost importance to have blood cultures drawn before initiating therapy. […] If treatment is started before then, it should be aimed at the common pathogens; a combination of nafcillin (or vancomycin, if the patient is allergic to penicillin or in an area with high prevalence of methicillin-resistant Staphylococcus aureus [MRSA]) and gentamicin is an acceptable combination. Further tailoring of the antibiotic regimen should occur once the organism is identified. Most patients with uncomplicated IE become afebrile in 3 to 5 days with appropriate antibiotic treatment. Surveillance cultures should be obtained 48 to 72 hours after treatment begins to ensure eradication of the organism. […] The most common treatment regimens for specific organisms are as follows: Methicillin-sensitive Staphylococcus aureus (MSSA): nafcillin or oxacillin for 6 weeks, plus optional gentamicin for 3-5 days; Methicillin-resistant Staphylococcus aureus (MRSA): vancomycin for 6 weeks; Staphylococcus with prosthetic valve: nafcillin or oxacillin plus rifampin for at least 6 weeks, with gentamicin given for 2 weeks; for methicillin-resistant strains, use vancomycin in place of nafcillin or oxacillin; Penicillin-susceptible Streptococcus: penicillin G or ceftriaxone for 4 weeks; vancomycin for 4 weeks if penicillin allergy is present; Penicillin-resistant Streptococcus: ceftriaxone for 4 weeks plus gentamicin for 2 weeks, or vancomycin for 4 weeks; Enterococci: penicillin G or ampicillin plus gentamicin for 4-6 weeks, or vancomycin plus gentamicin for 6 weeks; HACEK microorganisms: ceftriaxone for 4 weeks, ampicillin-sulbactam for 4 weeks, or ciprofloxacin for 4 weeks.
#27 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
It is of the utmost importance to have blood cultures drawn before initiating therapy. […] If treatment is started before then, it should be aimed at the common pathogens; a combination of nafcillin (or vancomycin, if the patient is allergic to penicillin or in an area with high prevalence of methicillin-resistant Staphylococcus aureus [MRSA]) and gentamicin is an acceptable combination. Further tailoring of the antibiotic regimen should occur once the organism is identified. Most patients with uncomplicated IE become afebrile in 3 to 5 days with appropriate antibiotic treatment. Surveillance cultures should be obtained 48 to 72 hours after treatment begins to ensure eradication of the organism. […] The most common treatment regimens for specific organisms are as follows: Methicillin-sensitive Staphylococcus aureus (MSSA): nafcillin or oxacillin for 6 weeks, plus optional gentamicin for 3-5 days; Methicillin-resistant Staphylococcus aureus (MRSA): vancomycin for 6 weeks; Staphylococcus with prosthetic valve: nafcillin or oxacillin plus rifampin for at least 6 weeks, with gentamicin given for 2 weeks; for methicillin-resistant strains, use vancomycin in place of nafcillin or oxacillin; Penicillin-susceptible Streptococcus: penicillin G or ceftriaxone for 4 weeks; vancomycin for 4 weeks if penicillin allergy is present; Penicillin-resistant Streptococcus: ceftriaxone for 4 weeks plus gentamicin for 2 weeks, or vancomycin for 4 weeks; Enterococci: penicillin G or ampicillin plus gentamicin for 4-6 weeks, or vancomycin plus gentamicin for 6 weeks; HACEK microorganisms: ceftriaxone for 4 weeks, ampicillin-sulbactam for 4 weeks, or ciprofloxacin for 4 weeks.
#28 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Outpatient treatment of nonenterococcal streptococci, MSSA, MRSA, VISA, CoNS, and VSE IE may be facilitated by use of dalbavancin, which requires IV administration every 7 days. […] Treat PVE caused by MSSA as follows: Administer nafcillin or oxacillin at 2 g IV every 4 hours for 6 weeks or longer. […] Treatment with linezolid appears to result in outcomes superior to those with vancomycin against many types of infections caused by MRSA and MSSA. […] Daptomycin (6 mg/kg/24 h) has been approved for the treatment of S aureus BSI and right-sided IE. […] Patients with culture-negative PVE should be given daptomycin or meropenem or linezolid targeting possible enterococcal or CoNS infections. […] Treatment of other microorganisms is as follows: For P aeruginosa, administer ceftazidime, cefepime, or imipenem, combined with high-dose tobramycin at 8 mg/kg/d in 3 divided doses, to attain peak blood levels of 15-20 mcg/mL, for 6 weeks.
#29 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Increasing numbers of enterococci have aminoglycoside-inactivating enzymes that make them relatively resistant to the usual synergistic combinations. […] Continuously infused ampicillin (serum level of 16 mcg/mL) is probably the best therapy for aminoglycoside-resistant enterococci. […] High peak levels of gentamicin are not necessary to establish synergistic bactericidal activity against enterococci. […] Vancomycin-resistant isolates of Enterococcus faecium and Enterococcus faecalis (ie, vancomycin-resistant enterococci [VRE]) produce some of the most challenging nosocomial infections. […] NVE caused by methicillin-sensitive S aureus (MSSA) should be treated as follows: Administer nafcillin or oxacillin at 2 g IV every 4 hours for 4-6 weeks. […] Vancomycin therapy is associated with a significant failure rate (up to 35%) in the treatment of MSSA and MRSA BSI/IE.
#30 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Outpatient treatment of nonenterococcal streptococci, MSSA, MRSA, VISA, CoNS, and VSE IE may be facilitated by use of dalbavancin, which requires IV administration every 7 days. […] Treat PVE caused by MSSA as follows: Administer nafcillin or oxacillin at 2 g IV every 4 hours for 6 weeks or longer. […] Treatment with linezolid appears to result in outcomes superior to those with vancomycin against many types of infections caused by MRSA and MSSA. […] Daptomycin (6 mg/kg/24 h) has been approved for the treatment of S aureus BSI and right-sided IE. […] Patients with culture-negative PVE should be given daptomycin or meropenem or linezolid targeting possible enterococcal or CoNS infections. […] Treatment of other microorganisms is as follows: For P aeruginosa, administer ceftazidime, cefepime, or imipenem, combined with high-dose tobramycin at 8 mg/kg/d in 3 divided doses, to attain peak blood levels of 15-20 mcg/mL, for 6 weeks.
#31 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Enterococcal Therapy: Infective endocarditis caused by nonresistant enterococci, resistant S viridans (MICs of penicillin G of 0.5 mcg/mL), or nutritionally variant S viridans and PVE caused by penicillin-Gsusceptible S viridans or S bovis should be treated as follows: Administer penicillin G at 18-30 million U/d IV, either by continuous pump or in 6 equally divided doses daily, combined with gentamicin at 1 mg/kg (based on ideal body weight) IM or IV every 8 hours for 4-6 weeks. […] Enterococcal PVE generally responds as well as disease involving native valves. Six weeks of treatment is recommended for patients with symptoms of enterococcal IE of more than 3 months duration, with relapsed infection, or with PVE. […] A combination of an inhibitor of cell wall synthesis (ie, penicillin) with an aminoglycoside (ie, gentamicin, streptomycin) is necessary to achieve bactericidal activity against the enterococci.
#32 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html
Patients with an infecting organism that is relatively sensitive to gentamicin should be treated with a combination of high-dose penicillin (18 million to 30 million units every 24 hours, intravenously) and gentamicin at standard dosage for four to six weeks. Streptomycin at a dosage of 7.5 mg per kg every 12 hours may be substituted for gentamicin if the susceptibility pattern favors streptomycin. Other amino-glycosides are not as effective as these agents. Ampicillin in a dosage of 12 g every 24 hours intravenously can be substituted for penicillin in these regimens. Cephalosporins are not effective in the treatment of enterococcal bacterial endocarditis. Vancomycin in a dosage of 30 mg per kg every 24 hours should be used in patients with penicillin allergy. […] Patients with prosthetic valve infection with MSSA should be treated with a combination of oxacillin or nafcillin and rifampin (300 mg orally every eight hours) for at least six weeks. In addition, gentamicin should be administered during the first two weeks of this course of therapy.
#33 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html
Patients with an infecting organism that is relatively sensitive to gentamicin should be treated with a combination of high-dose penicillin (18 million to 30 million units every 24 hours, intravenously) and gentamicin at standard dosage for four to six weeks. Streptomycin at a dosage of 7.5 mg per kg every 12 hours may be substituted for gentamicin if the susceptibility pattern favors streptomycin. Other amino-glycosides are not as effective as these agents. Ampicillin in a dosage of 12 g every 24 hours intravenously can be substituted for penicillin in these regimens. Cephalosporins are not effective in the treatment of enterococcal bacterial endocarditis. Vancomycin in a dosage of 30 mg per kg every 24 hours should be used in patients with penicillin allergy. […] Patients with prosthetic valve infection with MSSA should be treated with a combination of oxacillin or nafcillin and rifampin (300 mg orally every eight hours) for at least six weeks. In addition, gentamicin should be administered during the first two weeks of this course of therapy.
#34 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Enterococcal Therapy: Infective endocarditis caused by nonresistant enterococci, resistant S viridans (MICs of penicillin G of 0.5 mcg/mL), or nutritionally variant S viridans and PVE caused by penicillin-Gsusceptible S viridans or S bovis should be treated as follows: Administer penicillin G at 18-30 million U/d IV, either by continuous pump or in 6 equally divided doses daily, combined with gentamicin at 1 mg/kg (based on ideal body weight) IM or IV every 8 hours for 4-6 weeks. […] Enterococcal PVE generally responds as well as disease involving native valves. Six weeks of treatment is recommended for patients with symptoms of enterococcal IE of more than 3 months duration, with relapsed infection, or with PVE. […] A combination of an inhibitor of cell wall synthesis (ie, penicillin) with an aminoglycoside (ie, gentamicin, streptomycin) is necessary to achieve bactericidal activity against the enterococci.
#35 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html
For patients allergic to penicillin, a first-generation cephalosporin (cefazolin [Ancef] 2 g intravenously every eight hours) or vancomycin should be used instead of nafcillin or oxacillin for the treatment of MSSA endocarditis. […] Patients with endocarditis of a native valve caused by an organism in the HACEK group should be treated with ceftriaxone in a dosage of 2 g daily intravenously or intramuscularly for four weeks. Patients with infection of a prosthetic valve should be treated with ceftriaxone for six weeks.
#36 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html
For patients allergic to penicillin, a first-generation cephalosporin (cefazolin [Ancef] 2 g intravenously every eight hours) or vancomycin should be used instead of nafcillin or oxacillin for the treatment of MSSA endocarditis. […] Patients with endocarditis of a native valve caused by an organism in the HACEK group should be treated with ceftriaxone in a dosage of 2 g daily intravenously or intramuscularly for four weeks. Patients with infection of a prosthetic valve should be treated with ceftriaxone for six weeks.
#37 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Prosthetic valve endocarditis is especially difficult to treat, as the microorganisms adhere to the foreign body and may make them impervious to the bactericidal action of agents active in the cell wall. […] All patients with PVE require at least 6 weeks of antimicrobial therapy. […] If PVE does not respond to antimicrobial therapy and blood cultures results remain positive or if a relapse of bacteremia occurs after infection, the prosthetic valve should be replaced. […] Fungal endocarditis is rare, and it primarily occurs after prosthetic valve surgery and in individuals who abuse intravenous drugs. […] Empiric therapy of OUDIE should be aimed at S aureus. […] Monitoring During Therapy: Some clinicians obtain peak and trough blood samples during antimicrobial therapy of IE in order to run serum bactericidal tests.
#38 Endocarditis – Diagnosis & treatment – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582
Many people with endocarditis are successfully treated with antibiotics. Sometimes, surgery may be needed to fix or replace damaged heart valves and clean up any remaining signs of the infection. […] The type of medication you receive depends on what’s causing the endocarditis. […] High doses of antibiotics are used to treat endocarditis caused by bacteria. If you receive antibiotics, you’ll generally spend a week or more in the hospital so that care providers can determine if the treatment is working. […] Once your fever and any severe symptoms have gone away, you might be able to leave the hospital. Some people continue antibiotics with visits to a provider’s office or at home with home care. Antibiotics are usually taken for several weeks. […] If endocarditis is caused by a fungal infection, antifungal medication is given. Some people need lifelong antifungal pills to prevent endocarditis from returning.
#39 Endocarditis – Diagnosis & treatment – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582
Many people with endocarditis are successfully treated with antibiotics. Sometimes, surgery may be needed to fix or replace damaged heart valves and clean up any remaining signs of the infection. […] The type of medication you receive depends on what’s causing the endocarditis. […] High doses of antibiotics are used to treat endocarditis caused by bacteria. If you receive antibiotics, you’ll generally spend a week or more in the hospital so that care providers can determine if the treatment is working. […] Once your fever and any severe symptoms have gone away, you might be able to leave the hospital. Some people continue antibiotics with visits to a provider’s office or at home with home care. Antibiotics are usually taken for several weeks. […] If endocarditis is caused by a fungal infection, antifungal medication is given. Some people need lifelong antifungal pills to prevent endocarditis from returning.
#40 Endocarditis â a rare but serious heart condition | healthdirect
https://www.healthdirect.gov.au/endocarditis
Endocarditis is a serious and complex condition. If diagnosed, you will need to be treated in hospital, at least initially. You might need treatment in an intensive care unit. […] The main treatment for endocarditis is antibiotics. This will initially be through an intravenous (IV) drip into a vein. […] You may need surgery to remove infected tissue and to rebuild or replace your damaged heart valves. […] You will need to have repeated blood tests, x-rays and other imaging tests to monitor your progress. […] If you are at risk of endocarditis, you should talk with your doctor to learn more about prevention. […] If you are at risk of endocarditis, antibiotics may be recommended before certain dental procedures. Talk to your doctor and dentist about the risks and benefits of taking antibiotics before dental work.
#41 Treatment of Infectious Endocarditis
https://www.uspharmacist.com/article/treatment-of-infectious-endocarditis
The treatment of IE involves prompt and appropriate pharmacologic therapy, although surgery may be required. Pharmacists have a vital role in preventing certain adverse effects of medications, as well as in ensuring optimal therapeutic efficacy. When using penicillin, the time-dependent killing nature of the antibiotic can be maximized by continuous infusions or by ensuring that the doses are given every four to six hours. In addition, monitoring of vancomycin and aminoglycoside concentrations can help avoid the side effects of nephrotoxicity and ototoxicity and ensure the efficacy of these drugs.
#42 Treatment of Infectious Endocarditis
https://www.uspharmacist.com/article/treatment-of-infectious-endocarditis
Pharmacologic Treatment of Common Organisms Initiating the appropriate treatment in patients is critical because of the high mortality rate associated with IE. This article focuses on the treatment of IE according to the American Heart Association (AHA) guidelines for the most common organisms: viridans group streptococci, the Staphylococcus species, and the Enterococcus species. The treatment of IE is highly dependent on whether the patient has a native or prosthetic valve. Not only is the treatment slightly different, but the duration of treatment is often longer for patients with a prosthetic valve. The treatment of IE caused by these organisms involves classifying the bacteria as highly penicillin-susceptible (minimum inhibitory concentration [MIC] 0.12 mcg/mL) or relatively/fully penicillin-resistant (MIC 0.12 mcg/mL). In both native- and prosthetic-valve IE, penicillin and ceftriaxone are considered the drugs of choice, and gentamicin may be added for synergy. The duration of treatment depends on whether the valve is native or prosthetic. If gentamicin is used, it is important to achieve peak and trough serum concentrations of 3 to 4 mcg/mL and less than 1 mcg/mL, respectively. Vancomycin can be considered in patients unable to take a beta-lactam antibiotic. It should be noted that target peak and trough concentrations for vancomycin are 30 to 45 mcg/mL and 10 to 15 mcg/mL, respectively. For IE patients with a native valve, the duration of treatment is two to four weeks depending on the drug regimen and MIC of the organism. However, six weeks of treatment is required for prosthetic valve disease.
#43 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis
After starting therapy, patients with penicillin-susceptible streptococcal endocarditis usually feel better, and fever is reduced within 3 to 7 days. […] Patients with staphylococcal endocarditis tend to respond more slowly. […] Relapse usually occurs within 4 weeks. Antibiotic retreatment may be effective, but surgery may also be required.
#44 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Experience has been gained with completing the last 2 to 3 weeks of antibiotic treatment via the oral route. Candidates for this switch are those who had rapidly cleared their BSI; rapidly defervesced; and showed no evidence of embolization or growth of their vegetations. There is no apparent need for cardiac surgery in the near future. Antibiotics are given orally for long-term suppression of an infected device that cannot be removed. At least 1 of the prescribed agents must be documented to achieve bactericidal levels when taken by mouth. There must be no evidence of malabsorption. There should be no concerns about compliance with the treatment regimen (eg, cases of OUDIE). The evidence that supports the oral route is best established for gram-positive pathogens such as enterococci, MRSA, and CoNS.
#45 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
In the cases of SBE, treatment generally may be safely delayed until culture and sensitivity results are available. If the patient’s condition is stable, waiting does not increase the risk for complications in this form of the disease. […] Eradicating bacteria from the fibrin-platelet thrombus is extremely difficult because of (1) the high concentration of organisms present within the vegetation (ie, 10-100 million bacteria per gram of tissue), (2) their position deep within the thrombus, (3) their location in both a reduced metabolic and reproductive state, and (4) the interference of fibrin and white cells with antibiotic action. For all these reasons, bactericidal antibiotics are considered necessary for cure of valvular infection. […] Evidence has shown that patients with left-sided endocarditis in stable condition who received at least 10 days of intravenous antibiotics could be switched to oral administration for the remainder of their therapeutic course.
#46 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Experience has been gained with completing the last 2 to 3 weeks of antibiotic treatment via the oral route. Candidates for this switch are those who had rapidly cleared their BSI; rapidly defervesced; and showed no evidence of embolization or growth of their vegetations. There is no apparent need for cardiac surgery in the near future. Antibiotics are given orally for long-term suppression of an infected device that cannot be removed. At least 1 of the prescribed agents must be documented to achieve bactericidal levels when taken by mouth. There must be no evidence of malabsorption. There should be no concerns about compliance with the treatment regimen (eg, cases of OUDIE). The evidence that supports the oral route is best established for gram-positive pathogens such as enterococci, MRSA, and CoNS.
#47 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
In the cases of SBE, treatment generally may be safely delayed until culture and sensitivity results are available. If the patient’s condition is stable, waiting does not increase the risk for complications in this form of the disease. […] Eradicating bacteria from the fibrin-platelet thrombus is extremely difficult because of (1) the high concentration of organisms present within the vegetation (ie, 10-100 million bacteria per gram of tissue), (2) their position deep within the thrombus, (3) their location in both a reduced metabolic and reproductive state, and (4) the interference of fibrin and white cells with antibiotic action. For all these reasons, bactericidal antibiotics are considered necessary for cure of valvular infection. […] Evidence has shown that patients with left-sided endocarditis in stable condition who received at least 10 days of intravenous antibiotics could be switched to oral administration for the remainder of their therapeutic course.
#48 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
Experience has been gained with completing the last 2 to 3 weeks of antibiotic treatment via the oral route. Candidates for this switch are those who had rapidly cleared their BSI; rapidly defervesced; and showed no evidence of embolization or growth of their vegetations. There is no apparent need for cardiac surgery in the near future. Antibiotics are given orally for long-term suppression of an infected device that cannot be removed. At least 1 of the prescribed agents must be documented to achieve bactericidal levels when taken by mouth. There must be no evidence of malabsorption. There should be no concerns about compliance with the treatment regimen (eg, cases of OUDIE). The evidence that supports the oral route is best established for gram-positive pathogens such as enterococci, MRSA, and CoNS.
#49 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
The basic criticism of these tests is that they are conducted in an in vitro environment outside the area of infection. […] Approximately 15% to 25% of patients with IE eventually require surgery. […] Indications for surgical intervention in patients with NVE are as follows: Congestive heart failure refractory to standard medical therapy, Fungal IE (except that caused by Histoplasma capsulatum), Persistent sepsis after 72 hours of appropriate antibiotic treatment, Recurrent septic emboli, especially after 2 weeks of antibiotic treatment, Rupture of an aneurysm of the sinus of Valsalva, Conduction disturbances caused by a septal abscess, Kissing infection of the anterior mitral leaflet in patients with IE of the aortic valve. […] Valve replacement surgery should be performed promptly if any of the following occurs: moderate-to-severe congestive heart failure, valve dysfunction, perivalvular or myocardial abscess formation, the presence of an unstable valve that is becoming detached from the valve ring, more than 1 embolic episode with persistent vegetations observed on transesophageal echocardiogram, or the presence of vegetations larger than 1 cm in diameter.
#50 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
The basic criticism of these tests is that they are conducted in an in vitro environment outside the area of infection. […] Approximately 15% to 25% of patients with IE eventually require surgery. […] Indications for surgical intervention in patients with NVE are as follows: Congestive heart failure refractory to standard medical therapy, Fungal IE (except that caused by Histoplasma capsulatum), Persistent sepsis after 72 hours of appropriate antibiotic treatment, Recurrent septic emboli, especially after 2 weeks of antibiotic treatment, Rupture of an aneurysm of the sinus of Valsalva, Conduction disturbances caused by a septal abscess, Kissing infection of the anterior mitral leaflet in patients with IE of the aortic valve. […] Valve replacement surgery should be performed promptly if any of the following occurs: moderate-to-severe congestive heart failure, valve dysfunction, perivalvular or myocardial abscess formation, the presence of an unstable valve that is becoming detached from the valve ring, more than 1 embolic episode with persistent vegetations observed on transesophageal echocardiogram, or the presence of vegetations larger than 1 cm in diameter.
#51 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
The basic criticism of these tests is that they are conducted in an in vitro environment outside the area of infection. […] Approximately 15% to 25% of patients with IE eventually require surgery. […] Indications for surgical intervention in patients with NVE are as follows: Congestive heart failure refractory to standard medical therapy, Fungal IE (except that caused by Histoplasma capsulatum), Persistent sepsis after 72 hours of appropriate antibiotic treatment, Recurrent septic emboli, especially after 2 weeks of antibiotic treatment, Rupture of an aneurysm of the sinus of Valsalva, Conduction disturbances caused by a septal abscess, Kissing infection of the anterior mitral leaflet in patients with IE of the aortic valve. […] Valve replacement surgery should be performed promptly if any of the following occurs: moderate-to-severe congestive heart failure, valve dysfunction, perivalvular or myocardial abscess formation, the presence of an unstable valve that is becoming detached from the valve ring, more than 1 embolic episode with persistent vegetations observed on transesophageal echocardiogram, or the presence of vegetations larger than 1 cm in diameter.
#52 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
If PVE does not respond to antimicrobial therapy and blood cultures results remain positive or if a relapse of bacteremia occurs after infection, the prosthetic valve should be replaced. […] The AHA guidelines on CIED infections and their management recommend complete removal of infected CIED and leads for the following patients: All patients with definite CIED infection, as shown by valvular and/or lead endocarditis or sepsis. […] The AHA guideline recommends that if blood cultures were positive before the device extraction, blood cultures should be taken after the device removal and new device placement should be delayed until blood cultures have been negative for at least 72 hours. […] The AHA guideline states that long-term suppressive antimicrobial therapy should be considered for patients with CIED infection who are not candidates for CIED removal.
#53 Current AATS guidelines on surgical treatment of infective endocarditis – Pettersson- Annals of Cardiothoracic Surgery
https://www.annalscts.com/article/view/16669/17073
The 2016 American Association for Thoracic Surgery (AATS) guidelines for surgical treatment of infective endocarditis (IE) are question based and address questions of specific relevance to cardiac surgeons. […] Standard indications for surgery are severe heart failure, severe valve dysfunction, prosthetic valve infection, invasion beyond the valve leaflets, recurrent systemic embolization, large mobile vegetations, or persistent sepsis despite adequate antibiotic therapy for more than 57 days. […] The guidelines emphasize that once an indication for surgery is established, the operation should be performed as soon as possible. […] Surgery not only removes infected tissue and foreign material, but also mechanically disrupts the biofilm and exposes residual live microorganisms to antimicrobials, antibodies, and immune cells.
#54 Current AATS guidelines on surgical treatment of infective endocarditis – Pettersson- Annals of Cardiothoracic Surgery
https://www.annalscts.com/article/view/16669/17073
Surgery is, however, always followed by a full course of intravenous antimicrobial therapy for cure. […] The AATS guidelines emphasize that reason and timing of surgery cannot be separated but must be seen in relation to each other. […] The final decision to operate should be a consensus decision by the treating team. […] The AATS guidelines recommend urgent or even emergency surgery in patients with left-sided NVE or PVE who exhibit mobile vegetations greater than 10 mm in length with clinical evidence of embolic phenomenon despite appropriate antibiotic therapy. […] AATS guidelines recommend urgent or even emergency surgery in patients with left-sided NVE or PVE who exhibit mobile vegetations greater than 10 mm in length with clinical evidence of embolic phenomenon despite appropriate antibiotic therapy.
#55 Recommendations for Surgical Treatment of Infective Endocarditis
https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2022/05/09/19/39/Current-Recommendations-and-Uncertainties
Surgical timing: When surgery is indicated, the ESC and the ACC/AHA guidelines differ in their relative descriptions of timing. […] ACC/AHA guidelines describe early surgical intervention, defined as during the index hospitalization and before the cessation of antibiotic therapy. […] In contrast, ESC guidelines describe surgical timing as emergent (within 24 hours), urgent (within days), or elective (after at least 1-2 weeks of antibiotic therapy). […] The authors recommend surgical intervention of definite left-sided IE: […] Within 24-48 hours of diagnosis for severe valve regurgitation or a destructive/penetrating lesion with hemodynamic instability or NYHA class III or IV symptoms. […] Within 1 week of diagnosis for either severe valve regurgitation or a destructive/penetrating lesion without hemodynamic instability or NYHA class 3 or 4 symptoms; or for refractory infection (defined by abscess, persistent bacteremia, resistant organism, or relapsing PVE). […] Within 24-48 hours of diagnosis for embolic prevention (defined as recurrent emboli with residual vegetation or vegetation size 10 mm without prior embolic event).
#56 Current AATS guidelines on surgical treatment of infective endocarditis – Pettersson- Annals of Cardiothoracic Surgery
https://www.annalscts.com/article/view/16669/17073
As per the AATS guidelines, once an indication for surgery is established, the patient should be operated on within days, and earlier surgery (emergency or within 48 hours) is reasonable for patients with large mobile vegetations at imminent risk of embolism. […] In patients with stroke and neurologic deficits, timing is decided by weighing the need for cardiac surgery against the risk of expanding the stroke or provoking intracranial bleeding during the operation. […] The primary objective of surgery for right-sided IE is most often to eliminate the cause of persistent sepsis and the source of septic emboli to the lung, by radical debridement of infected vegetations and foreign material. […] Tricuspid valve repair should be attempted whenever possible. […] The AATS emphasize that specimens should be handled properly and divided between pathology and microbiology for microscopy and cultures. […] After surgery for active IE, standard duration of postoperative intravenous antimicrobial treatment is 6 weeks, counted from the day of surgery, but regimen and duration may be modified and adjusted depending on the organism and its sensitivity to antimicrobials, treatment response, and pathology.
#57
https://www.nhs.uk/conditions/endocarditis/treatment/
Most cases of endocarditis can be treated with a course of antibiotics. You’ll usually have to be admitted to hospital so the antibiotics can be given through a drip in your arm (intravenously). […] If your symptoms are severe, you may be prescribed a mixture of different antibiotics before getting the result of the blood sample. This is a precautionary measure to prevent your symptoms becoming worse. […] Once your fever and any severe symptoms subside, you may be able to leave hospital and continue receiving antibiotics at home by a drip (IV). […] If your blood sample shows that fungi are causing your infection, you’ll be prescribed an antifungal medicine. […] You may need surgery to repair damage to the heart. […] Surgery will usually be recommended if: your symptoms or test results suggest you have experienced heart failure, a serious condition where your heart’s not pumping blood around your body efficiently; you continue to have a high temperature (fever) despite treatment with antibiotics or antifungals; your endocarditis is caused by particularly aggressive fungi or drug-resistant bacteria; you experience 1 or more blood clots despite treatment with antibiotics or antifungals; you have an artificial (prosthetic) heart valve; the results of your echocardiogram suggest that a collection of pus (abscess) or an abnormal passageway (fistula) has developed inside your heart. […] The 3 main surgical procedures used to treat endocarditis are: repair of the damaged heart valve; replacement of the damaged heart valves with prosthetic ones during aortic valve replacement surgery; draining of any abscesses and repair of any fistulas that may have developed in the heart muscle.
#58
https://www.nhs.uk/conditions/endocarditis/treatment/
Most cases of endocarditis can be treated with a course of antibiotics. You’ll usually have to be admitted to hospital so the antibiotics can be given through a drip in your arm (intravenously). […] If your symptoms are severe, you may be prescribed a mixture of different antibiotics before getting the result of the blood sample. This is a precautionary measure to prevent your symptoms becoming worse. […] Once your fever and any severe symptoms subside, you may be able to leave hospital and continue receiving antibiotics at home by a drip (IV). […] If your blood sample shows that fungi are causing your infection, you’ll be prescribed an antifungal medicine. […] You may need surgery to repair damage to the heart. […] Surgery will usually be recommended if: your symptoms or test results suggest you have experienced heart failure, a serious condition where your heart’s not pumping blood around your body efficiently; you continue to have a high temperature (fever) despite treatment with antibiotics or antifungals; your endocarditis is caused by particularly aggressive fungi or drug-resistant bacteria; you experience 1 or more blood clots despite treatment with antibiotics or antifungals; you have an artificial (prosthetic) heart valve; the results of your echocardiogram suggest that a collection of pus (abscess) or an abnormal passageway (fistula) has developed inside your heart. […] The 3 main surgical procedures used to treat endocarditis are: repair of the damaged heart valve; replacement of the damaged heart valves with prosthetic ones during aortic valve replacement surgery; draining of any abscesses and repair of any fistulas that may have developed in the heart muscle.
#59 Endocarditis Treatment Options | Temple Health
https://www.templehealth.org/services/conditions/endocarditis/treatment-options
Lifestyle changes and medications can help reduce the chances of endocarditis if you are at risk. […] In cases where you have developed this condition, your doctor will take steps to quickly treat the infection and any damage it has caused your heart. […] If you have been diagnosed with endocarditis you will receive high doses of IV antibiotics for between 2 and 6 weeks. […] To reduce your chances of developing endocarditis, your doctor may prescribe antibiotics before dental or medical procedures that could allow bacteria to enter your bloodstream. […] When the infection has damaged your heart valves, surgery may be necessary. Examples of surgical therapies include: Heart Valve Repair may be an attractive alternative to heart valve replacement for some patients. This is more common with the mitral valve and can decrease complications while allowing for a quicker recovery.
#60 Endocarditis – Diagnosis & treatment – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582
Heart valve surgery may be needed to treat persistent endocarditis infections or to replace a damaged valve. Surgery is sometimes needed to treat endocarditis that’s caused by a fungal infection. […] Depending on your specific condition, your health care provider may recommend heart valve repair or replacement. Heart valve replacement uses a mechanical valve or a valve made from cow, pig or human heart tissue (biologic tissue valve).
#61
https://www.nhs.uk/conditions/endocarditis/treatment/
Most cases of endocarditis can be treated with a course of antibiotics. You’ll usually have to be admitted to hospital so the antibiotics can be given through a drip in your arm (intravenously). […] If your symptoms are severe, you may be prescribed a mixture of different antibiotics before getting the result of the blood sample. This is a precautionary measure to prevent your symptoms becoming worse. […] Once your fever and any severe symptoms subside, you may be able to leave hospital and continue receiving antibiotics at home by a drip (IV). […] If your blood sample shows that fungi are causing your infection, you’ll be prescribed an antifungal medicine. […] You may need surgery to repair damage to the heart. […] Surgery will usually be recommended if: your symptoms or test results suggest you have experienced heart failure, a serious condition where your heart’s not pumping blood around your body efficiently; you continue to have a high temperature (fever) despite treatment with antibiotics or antifungals; your endocarditis is caused by particularly aggressive fungi or drug-resistant bacteria; you experience 1 or more blood clots despite treatment with antibiotics or antifungals; you have an artificial (prosthetic) heart valve; the results of your echocardiogram suggest that a collection of pus (abscess) or an abnormal passageway (fistula) has developed inside your heart. […] The 3 main surgical procedures used to treat endocarditis are: repair of the damaged heart valve; replacement of the damaged heart valves with prosthetic ones during aortic valve replacement surgery; draining of any abscesses and repair of any fistulas that may have developed in the heart muscle.
#62 Endocarditis Treatment Options | Temple Health
https://www.templehealth.org/services/conditions/endocarditis/treatment-options
Heart Valve Replacement is performed using either a bioprosthetic (tissue) heart valve that is made from natural sources (eg, pig, cow or human) or a mechanical heart valve. The advantage to a bioprosthetic valve is that it does not contain metal and therefore blood thinners are not needed long term. Mechanical valves contain substances that are more likely to form blood clots and require the use of blood thinners. The advantage, however, is that they last for many years.
#63 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis
As soon as possible, the empiric antimicrobial regimen should be adjusted based on culture results. […] Surgery (debridement, valve repair, or valve replacement) is sometimes required for treatment of infectious endocarditis. Surgery is typically indicated in patients with heart failure, patients with uncontrolled infection, and patients at risk for embolism. […] Timing of surgery requires experienced clinical judgment. If heart failure caused by a correctable lesion is worsening, surgery may be required after only 24 to 72 hours of antimicrobial therapy. […] Endocarditis involving an implanted cardiac electronic device requires complete removal of the pacemaker or defibrillator, including all leads and the generator. […] Right-sided endocarditis is usually managed medically. If surgery is necessary, then valve repair is preferred over replacement to avoid future prosthetic valve infection due to any continued IV drug use.
#64 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis
As soon as possible, the empiric antimicrobial regimen should be adjusted based on culture results. […] Surgery (debridement, valve repair, or valve replacement) is sometimes required for treatment of infectious endocarditis. Surgery is typically indicated in patients with heart failure, patients with uncontrolled infection, and patients at risk for embolism. […] Timing of surgery requires experienced clinical judgment. If heart failure caused by a correctable lesion is worsening, surgery may be required after only 24 to 72 hours of antimicrobial therapy. […] Endocarditis involving an implanted cardiac electronic device requires complete removal of the pacemaker or defibrillator, including all leads and the generator. […] Right-sided endocarditis is usually managed medically. If surgery is necessary, then valve repair is preferred over replacement to avoid future prosthetic valve infection due to any continued IV drug use.
#65 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
If PVE does not respond to antimicrobial therapy and blood cultures results remain positive or if a relapse of bacteremia occurs after infection, the prosthetic valve should be replaced. […] The AHA guidelines on CIED infections and their management recommend complete removal of infected CIED and leads for the following patients: All patients with definite CIED infection, as shown by valvular and/or lead endocarditis or sepsis. […] The AHA guideline recommends that if blood cultures were positive before the device extraction, blood cultures should be taken after the device removal and new device placement should be delayed until blood cultures have been negative for at least 72 hours. […] The AHA guideline states that long-term suppressive antimicrobial therapy should be considered for patients with CIED infection who are not candidates for CIED removal.
#66 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
If PVE does not respond to antimicrobial therapy and blood cultures results remain positive or if a relapse of bacteremia occurs after infection, the prosthetic valve should be replaced. […] The AHA guidelines on CIED infections and their management recommend complete removal of infected CIED and leads for the following patients: All patients with definite CIED infection, as shown by valvular and/or lead endocarditis or sepsis. […] The AHA guideline recommends that if blood cultures were positive before the device extraction, blood cultures should be taken after the device removal and new device placement should be delayed until blood cultures have been negative for at least 72 hours. […] The AHA guideline states that long-term suppressive antimicrobial therapy should be considered for patients with CIED infection who are not candidates for CIED removal.
#67 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment
The major goals of therapy for IE are to eradicate the infectious agent from the thrombus and to address the intra and extracardiac complications of valvular infection. The latter includes both the intracardiac and extracardiac consequences of IE. Some of the effects of IE require surgical intervention. Emergent care should focus on making the correct diagnosis and stabilizing the patient. General measures include the following: Treatment of congestive heart failure, Supplemental oxygenation if required, Hemodialysis may be necessary in the setting of severe renal failure. […] All positive blood cultures should be evaluated by rapid diagnostic technology such as Malditof can identify pathogens(bacterial or fungal) within hours of documenting a positive gram stain. E-plex technology enhances traditional culture and sensitivity results by detecting specific resistance factors of a given pathogen. E-plex complements traditional methods of culture and sensitivity because it only surveys select pathogens and genes.
#68 Endocarditis – EMCrit Project
https://emcrit.org/ibcc/endo/
Antibiotic therapy: Empiric therapy: […] Definitive therapy: Methicillin-sensitive Staph. […] Methicillin-resistant Staph. […] Enterococcus. […] Streptococcus pneumoniae. […] Beta-hemolytic Streptococci. […] Oral Streptococci. […] Granulicatella Abiotrophia. […] HACEK. […] Indications for surgical consultation: Valve regurgitation or fistula causing heart failure. […] Myocardial abscess. […] Vegetation enlargement, despite antibiotics. […] Persistent fever with positive cultures. […] Large vegetation with multiple embolic phenomena. […] Management: Endovascular intervention can be used for the management of acute, large-vessel septic embolism. […] Antibiotic therapy is needed for the management of endocarditis. […] Consideration should be given to selecting a regimen with adequate penetration of the brain.
#69 Infective Endocarditis | American Heart Association
https://www.heart.org/en/health-topics/infective-endocarditis
Antibiotic prophylaxis is reasonable before the above-mentioned dental procedures for people with heart conditions who have any of the following: […] Antibiotic prophylaxis may be reasonable for certain medical procedures on the respiratory tract or infected skin, skin structures or musculoskeletal tissue for adults with underlying heart conditions associated with the highest risk of poor outcomes from IE. […] Antibiotic prophylaxis is not recommended solely to prevent IE for adults who have some non-dental procedures, including genitourinary or gastrointestinal tract procedures. […] Your health care team can provide you with more information and answer your questions about preventing IE.
#70 Endocarditis – Symptoms & causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/symptoms-causes/syc-20352576
Endocarditis is usually caused by an infection. […] Without quick treatment, endocarditis can damage or destroy the heart valves. Treatments for endocarditis include medications and surgery. […] Endocarditis is usually caused by an infection with bacteria, fungi or other germs. The germs enter the bloodstream and travel to the heart. In the heart, they attach to damaged heart valves or damaged heart tissue. […] If you’re at high risk of endocarditis, the American Heart Association recommends taking antibiotics an hour before having any dental work done. […] If you have endocarditis or any type of congenital heart disease, talk to your dentist and other care providers about your risks and whether you need preventive antibiotics.
#71 Infectious Endocarditis: Diagnosis and Treatment | AAFP
https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html
Infectious endocarditis should be suspected in patients who have unexplained fevers, particularly in the presence of risk factors or cardiac findings. […] Initial empiric therapy in patients with suspected endocarditis should include vancomycin or ampicillin/sulbactam (Unasyn) plus an aminoglycoside (plus rifampin in patients with prosthetic valves). […] Valve replacement should be considered in selected patients with infectious endocarditis. […] Patients who have been successfully treated for infectious endocarditis in the past require antimicrobial prophylaxis before certain dental and other procedures. […] Successful treatment requires appropriate antibiotic therapy. Initial empiric therapy may include vancomycin or ampicillin/sulbactam (Unasyn) plus an aminoglycoside (plus rifampin in patients with prosthetic valves).
#72 Current AATS guidelines on surgical treatment of infective endocarditis – Pettersson- Annals of Cardiothoracic Surgery
https://www.annalscts.com/article/view/16669/html
In patients with stroke and neurologic deficits, timing is decided by weighing the need for cardiac surgery against the risk of expanding the stroke or provoking intracranial bleeding during the operation. […] The AATS guidelines suggest that patients who have undergone surgery for IE constitute a high-risk group for recurrent IE and should be recommended for IE prophylaxis accordingly.
#73 Infective Endocarditis – Heart and Blood Vessel Disorders – Merck Manual Consumer Version
https://www.merckmanuals.com/home/heart-and-blood-vessel-disorders/endocarditis/infective-endocarditis
High doses of antibiotics are given intravenously, but sometimes surgery is needed to repair or replace damaged heart valves. […] Treatment usually consists of at least 2 weeks and often up to 8 weeks of antibiotics given by vein (intravenously) in high doses. Antibiotic therapy is almost always started in the hospital but may be finished at home with the help of a home nurse. Some people with certain types of infection may be able to switch to antibiotics taken by mouth after a period of intravenous treatment. […] Antibiotics alone do not always cure an infection, particularly if the valve is one that has been replaced. One reason is that the bacteria that cause endocarditis in a person with a replacement valve are often resistant to antibiotics. […] Heart surgery may be needed to repair or replace damaged valves, remove vegetations, or drain abscesses if antibiotics do not work, a valve leaks significantly, or a birth defect connects one chamber to another. […] Doctors may use a series of echocardiography examinations to ensure that the infected area is decreasing. They may also do echocardiography at the end of treatment to have a record of the appearance of heart valves because infective endocarditis may recur.
#74 Infectious Endocarditis: Diagnosis and Treatment | AAFP
https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html
The choice of definitive antibiotic therapy is based on the causative microorganism and its antibiotic susceptibility, and whether the involved valve is native or prosthetic. […] Surgery may need to be considered in selected patients; the benefits are greatest in patients with the most indications. […] Surgical intervention should be considered in patients with fungal infection, infection with aggressive antibiotic-resistant bacteria or bacteria that respond poorly to antibiotics, left-sided infectious endocarditis caused by gram-negative bacteria, persistent infection with positive blood cultures after one week of antibiotic therapy, or one or more embolic events during the first two weeks of antibiotic therapy. […] Anticoagulation in patients with infectious endocarditis is controversial, particularly in those with mechanical valve endocarditis. […] Patients should receive information about daily dental hygiene, regular visits to the dentist, and the need for antibiotic prophylaxis for certain procedures.
#75 Treatment for Infective Endocarditis
https://umcno.staywellsolutionsonline.com/Wellness/Fitness/Tools/3,90503
Infective endocarditis is very serious. It can lead to many problems and even death. Possible complications include: Heart valve damage. Inability of the heart to pump well (heart failure). Kidney failure. Spreading of the infection to other areas of the heart or to other parts of the body, such as the lungs or brain. Death. […] You may need to take antibiotic medicine before some medical and dental procedures. This is to help prevent endocarditis if you have: An artificial heart valve. A congenital heart defect. Had infectious endocarditis in the past. […] Contact your health care provider right away if you have: Fever of 100.4F (38C) or higher, or as advised by your provider. Night sweats or chills. Unexplained weight loss. Swelling of your feet, legs, or belly (abdomen). Skin changes. […] Call 911 if any of these occur: Trouble breathing. Fast, slow, or irregular heart rate. Chest pain or pressure, nausea or vomiting, profuse sweating, dizziness, or fainting. Sudden numbness or weakness in arms, legs, or face, or difficulty speaking.
#76 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/
In patients who present with an indolent, uncomplicated course, antibiotic therapy can be delayed until cultures and sensitivities are available. However, in patients with a more acute presentation or features of complicated endocarditis, prompt empiric treatment is often required to reduce the risk of complications. […] The presence of a bioprosthetic valve or implantable cardiac device plays a significant influence on antibiotic selection duration of treatment as it portends a more severe infection with higher rates of treatment failure than native valve endocarditis. […] Empiric antibiotic therapy for prosthetic valve and health-care-associated endocarditis should be broader and cover MRSA, enterococci, and gram-negative pathogens. […] The prognosis of endocarditis depends upon infecting organism, the presence of complications, echo findings, and patient characteristics such as age or comorbidities. […] Management of antibiotic regimens for infective endocarditis is best achieved with an interprofessional team involving physicians, infectious disease experts, specialty-trained nursing staff, and pharmacists all collaborating to manage the cases to an optimal patient outcome.
#77 Endocarditis: Causes, Symptoms and Treatment
https://my.clevelandclinic.org/health/diseases/16957-endocarditis
If endocarditis damages your heart valve and any other part of your heart, you may need surgery to fix your heart valve and improve your heart function. […] Antibiotics treat bacterial endocarditis. For other types of endocarditis, you may need blood thinners or antifungal medicines. Medicines can have side effects, but this treatment is necessary to protect your life. Some people feel better within a few days of starting treatment. For others, it can take longer. […] You can expect to take antibiotics for two to eight weeks to get rid of your infection. Most people survive endocarditis when they get aggressive treatment, but your risk of endocarditis being fatal depends on: […] Endocarditis is fatal without treatment. […] With aggressive treatment, most people recover from endocarditis.
#78 Endocarditis: Causes, Symptoms and Treatment
https://my.clevelandclinic.org/health/diseases/16957-endocarditis
If endocarditis damages your heart valve and any other part of your heart, you may need surgery to fix your heart valve and improve your heart function. […] Antibiotics treat bacterial endocarditis. For other types of endocarditis, you may need blood thinners or antifungal medicines. Medicines can have side effects, but this treatment is necessary to protect your life. Some people feel better within a few days of starting treatment. For others, it can take longer. […] You can expect to take antibiotics for two to eight weeks to get rid of your infection. Most people survive endocarditis when they get aggressive treatment, but your risk of endocarditis being fatal depends on: […] Endocarditis is fatal without treatment. […] With aggressive treatment, most people recover from endocarditis.
#79 Endocarditis: Symptoms & Treatment | Mass General Brigham
https://www.massgeneralbrigham.org/en/patient-care/services-and-specialties/heart/conditions/endocarditis
Once the treatment regimen for endocarditis is complete, it is critical to make regular dental checkups, continue taking medications as prescribed, and keep cuts in the skin clean. If dental work is needed, discuss the procedure both with the doctor and dentist, who will likely need to prescribe a round of antibiotics before the procedure. […] In general, earlier treatment for endocarditis leads to a better long-term outlook. Most patients who receive aggressive treatment early will recover without any lasting effects. For patients that experience complications from endocarditis, full recovery may take longer. […] Endocarditis can be successfully treated with antibiotics to target the cause of the bacterial infection. It is critical to seek treatment right away for endocarditis for the highest chance of recovery. Surgery may be needed to repair a damaged heart valve and any other damage caused by the infection.
#80 Endocarditis: Causes, Symptoms and Treatment
https://my.clevelandclinic.org/health/diseases/16957-endocarditis
If endocarditis damages your heart valve and any other part of your heart, you may need surgery to fix your heart valve and improve your heart function. […] Antibiotics treat bacterial endocarditis. For other types of endocarditis, you may need blood thinners or antifungal medicines. Medicines can have side effects, but this treatment is necessary to protect your life. Some people feel better within a few days of starting treatment. For others, it can take longer. […] You can expect to take antibiotics for two to eight weeks to get rid of your infection. Most people survive endocarditis when they get aggressive treatment, but your risk of endocarditis being fatal depends on: […] Endocarditis is fatal without treatment. […] With aggressive treatment, most people recover from endocarditis.
#81 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis
After starting therapy, patients with penicillin-susceptible streptococcal endocarditis usually feel better, and fever is reduced within 3 to 7 days. […] Patients with staphylococcal endocarditis tend to respond more slowly. […] Relapse usually occurs within 4 weeks. Antibiotic retreatment may be effective, but surgery may also be required.
#82 Endocarditis – Diagnosis & treatment – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582
Many people with endocarditis are successfully treated with antibiotics. Sometimes, surgery may be needed to fix or replace damaged heart valves and clean up any remaining signs of the infection. […] The type of medication you receive depends on what’s causing the endocarditis. […] High doses of antibiotics are used to treat endocarditis caused by bacteria. If you receive antibiotics, you’ll generally spend a week or more in the hospital so that care providers can determine if the treatment is working. […] Once your fever and any severe symptoms have gone away, you might be able to leave the hospital. Some people continue antibiotics with visits to a provider’s office or at home with home care. Antibiotics are usually taken for several weeks. […] If endocarditis is caused by a fungal infection, antifungal medication is given. Some people need lifelong antifungal pills to prevent endocarditis from returning.
#83 Current AATS guidelines on surgical treatment of infective endocarditis – Pettersson- Annals of Cardiothoracic Surgery
https://www.annalscts.com/article/view/16669/17073
As per the AATS guidelines, once an indication for surgery is established, the patient should be operated on within days, and earlier surgery (emergency or within 48 hours) is reasonable for patients with large mobile vegetations at imminent risk of embolism. […] In patients with stroke and neurologic deficits, timing is decided by weighing the need for cardiac surgery against the risk of expanding the stroke or provoking intracranial bleeding during the operation. […] The primary objective of surgery for right-sided IE is most often to eliminate the cause of persistent sepsis and the source of septic emboli to the lung, by radical debridement of infected vegetations and foreign material. […] Tricuspid valve repair should be attempted whenever possible. […] The AATS emphasize that specimens should be handled properly and divided between pathology and microbiology for microscopy and cultures. […] After surgery for active IE, standard duration of postoperative intravenous antimicrobial treatment is 6 weeks, counted from the day of surgery, but regimen and duration may be modified and adjusted depending on the organism and its sensitivity to antimicrobials, treatment response, and pathology.
#84 Infective Endocarditis Diagnosis and Management
https://www.uspharmacist.com/article/infective-endocarditis-diagnosis-and-management
Treatment of prosthetic valve IE caused by staphylococci requires combination antibiotic therapy. […] Enterococcal endocarditis is most commonly caused by E faecalis or Enterococcus faecium and accounts for 13% to 18% of all endocarditis cases. […] Gram-negative endocarditis accounts for 1% to 10% of all cases and is typically caused by organisms in the HACEK group. […] Additional information on management of IE including treatment of culture-negative endocarditis, fungal endocarditis, indications for surgery, and role of antimicrobial prophylaxis can be found in the guidelines. […] Pharmacists play a key role in the management of IE. The recent Wiki Guideline consensus statement on diagnosis and management of IE notes that management by multidisciplinary teams, including pharmacy, may be beneficial to the management of IE.
#85
https://www.nhs.uk/conditions/endocarditis/
Endocarditis is treated with a course of antibiotics given via a drip. You’ll need to be admitted to hospital for this. […] Some people also need surgery to repair or replace a damaged heart valve or drain any abscesses that develop. […] Endocarditis is a serious illness, especially if complications develop. Early diagnosis and treatment is vital to improve the outlook for the condition.
#86 2023 ESC Guidelines for the management of endocarditis
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Endocarditis-Guidelines
The current guidelines have been developed to support healthcare professionals with the diagnosis and management of patients with infective endocarditis, an infrequent but oftentimes fatal disease that can present with multiple different clinical scenarios. […] Since then there have been multiple developments in the care of patients with infective endocarditis including refinements of the indications for antibiotic prophylaxis, improvements in diagnostic capabilities, establishment of endocarditis teams and heart valve centres, identification of patients eligible for outpatient antibiotic therapy, diagnosis and risk-stratification of patients suffering complications of endocarditis (in particular stroke), management of patients with transcatheter heart valve- and cardiac implantable electronic device-associated infective endocarditis, and patient-centred care during the acute and follow-up phases of this challenging disease. […] The current document should serve as a guide for clinicians involved in the diagnosis and management of infective endocarditis patients and should lead to improved outcomes for this serious disease.
#87 Infective Endocarditis: Practice Essentials, Background, Pathophysiology
https://emedicine.medscape.com/article/1976353-overview
Approach Considerations […] 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. […] Syndromic diagnostic techniques along with updated techniques of rapidly evaluating positive blood cultures show great promise. […] The treatment of a given patient should reflect a collaboration of the microbiology laboratory, treating clinicians, and antimicrobial stewardship teams.
#88 Oral antibiotic therapy for the treatment of infective endocarditis: a systematic review | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-14-140
Both studies also defined eligibility criteria, provided details of the setting and location of the study, and gave a detailed description of the intervention used. […] The main findings of our review are: a) Reported cure rates for IE caused by susceptible organisms and treated with appropriate oral antibiotic regimens range between 77-100%; and b) Limited evidence from one small clinical trial suggests that the combination of oral ciprofloxacin and rifampin for the treatment of uncomplicated right-sided IE caused by susceptible strains of S. aureus in IVDUs could be as effective as, and produce less adverse events than conventional IV antibiotic regimens. […] In conclusion, oral antibiotics with favourable pharmacokinetic profiles appear effective in treating selected cases of IE caused by susceptible organisms. Because of its favourable pharmacokinetic profile, high-dose oral amoxicillin for the treatment of IE caused by susceptible streptococci is particularly appealing but studies of better quality are needed before further recommendations can be made about this approach in clinical settings. The same considerations apply to the use of oral linezolid in cases of S. aureus IE. Oral combination therapy with ciprofloxacin and rifampin appears to be an acceptable alternative for the treatment of uncomplicated right-side endocarditis caused by susceptible strains of S. aureus in IVDUs but until adequate clinical trials are available, this approach should be reserved for special situations in which conventional IV antibiotic therapy is not possible or it is undesirable. Ongoing and future investigations should help to better define the role of oral antibiotics in the treatment of IE.

Zapalenie wsierdzia Leczenie

Zapalenie wsierdzia – definicja i wprowadzenie

Ogólne zasady leczenia zapalenia wsierdzia

Antybiotykoterapia w zapaleniu wsierdzia

Podstawowe zasady antybiotykoterapii

Antybiotykoterapia empiryczna

Antybiotykoterapia celowana

Zapalenie wsierdzia paciorkowcowe

Zapalenie wsierdzia gronkowcowe

Zapalenie wsierdzia enterokokowe

Zapalenie wsierdzia wywołane przez grupę HACEK

Zapalenie wsierdzia grzybicze

Monitorowanie leczenia przeciwdrobnoustrojowego

Doustna antybiotykoterapia w zapaleniu wsierdzia

Leczenie chirurgiczne zapalenia wsierdzia

Wskazania do leczenia chirurgicznego

Czas wykonania operacji

Rodzaje zabiegów chirurgicznych

Leczenie zapalenia wsierdzia związanego z urządzeniami wszczepianymi

Leczenie podtrzymujące i zapobiegawcze

Leczenie powikłań zapalenia wsierdzia

Profilaktyka antybiotykowa

Opieka długoterminowa

Rokowanie i efekty leczenia zapalenia wsierdzia

Podsumowanie i przyszłe kierunki

Kolejne rozdziały

Materiały źródłowe

#1 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelfhttps://www.ncbi.nlm.nih.gov/books/NBK542162/

#1 Antimicrobial therapy of prosthetic valve endocarditis – UpToDatehttps://www.uptodate.com/contents/antimicrobial-therapy-of-prosthetic-valve-endocarditis

#2 2023 ESC Guidelines for the management of endocarditishttps://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Endocarditis-Guidelines

#3 Endocarditis: Causes, Symptoms and Treatmenthttps://my.clevelandclinic.org/health/diseases/16957-endocarditis

#4 Overview of management of infective endocarditis in adults – UpToDatehttps://www.uptodate.com/contents/overview-of-management-of-infective-endocarditis-in-adults

#5 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelfhttps://www.ncbi.nlm.nih.gov/books/NBK542162/

#6 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelfhttps://www.ncbi.nlm.nih.gov/books/NBK542162/

#7 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelfhttps://www.ncbi.nlm.nih.gov/books/NBK542162/

#8 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Editionhttps://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis

#9 Endocarditis – Diagnosis & treatment – Mayo Clinichttps://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

#10https://www.nhs.uk/conditions/endocarditis/treatment/

#11 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#12 Infective endocarditis: diagnosis, treatment and prevention – The Pharmaceutical Journalhttps://pharmaceutical-journal.com/article/ld/infective-endocarditis-diagnosis-treatment-and-prevention

#13 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#14 Endocarditis Diagnosis and Treatment : Emergency Care BChttps://emergencycarebc.ca/clinical_resource/clinical-summary/endocarditis-diagnosis-and-treatment/

#15 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelfhttps://www.ncbi.nlm.nih.gov/books/NBK542162/

#16 Endocarditis Diagnosis and Treatment : Emergency Care BChttps://emergencycarebc.ca/clinical_resource/clinical-summary/endocarditis-diagnosis-and-treatment/

#17 Infectious Endocarditis: Diagnosis and Treatment | AAFPhttps://www.aafp.org/pubs/afp/issues/2012/0515/p981.html

#18 Infectious Endocarditis: Diagnosis and Treatment | AAFPhttps://www.aafp.org/pubs/afp/issues/2012/0515/p981.html

#19 Infective Endocarditis Diagnosis and Managementhttps://www.uspharmacist.com/article/infective-endocarditis-diagnosis-and-management

#20 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#21 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#22 Management of Bacterial Endocarditis | AAFPhttps://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#23 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#24 Management of Bacterial Endocarditis | AAFPhttps://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#25 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#26 Diagnosing and Treating Acute Infective Endocarditis | Journal of Ethics | American Medical Associationhttps://journalofethics.ama-assn.org/article/diagnosing-and-treating-acute-infective-endocarditis/2010-10

#27 Diagnosing and Treating Acute Infective Endocarditis | Journal of Ethics | American Medical Associationhttps://journalofethics.ama-assn.org/article/diagnosing-and-treating-acute-infective-endocarditis/2010-10

#28 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#29 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#30 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#31 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#32 Management of Bacterial Endocarditis | AAFPhttps://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#33 Management of Bacterial Endocarditis | AAFPhttps://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#34 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#35 Management of Bacterial Endocarditis | AAFPhttps://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#36 Management of Bacterial Endocarditis | AAFPhttps://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#37 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#38 Endocarditis – Diagnosis & treatment – Mayo Clinichttps://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

#39 Endocarditis – Diagnosis & treatment – Mayo Clinichttps://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

#40 Endocarditis â a rare but serious heart condition | healthdirecthttps://www.healthdirect.gov.au/endocarditis

#41 Treatment of Infectious Endocarditishttps://www.uspharmacist.com/article/treatment-of-infectious-endocarditis

#42 Treatment of Infectious Endocarditishttps://www.uspharmacist.com/article/treatment-of-infectious-endocarditis

#43 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Editionhttps://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis

#44 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#45 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#46 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#47 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#48 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#49 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#50 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#51 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

#52 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremiahttps://emedicine.medscape.com/article/216650-treatment

Zapalenie wsierdzia
Leczenie

#1 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/

#1 Antimicrobial therapy of prosthetic valve endocarditis – UpToDate
https://www.uptodate.com/contents/antimicrobial-therapy-of-prosthetic-valve-endocarditis

#2 2023 ESC Guidelines for the management of endocarditis
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Endocarditis-Guidelines

#3 Endocarditis: Causes, Symptoms and Treatment
https://my.clevelandclinic.org/health/diseases/16957-endocarditis

#4 Overview of management of infective endocarditis in adults – UpToDate
https://www.uptodate.com/contents/overview-of-management-of-infective-endocarditis-in-adults

#5 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/

#6 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/

#7 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/

#8 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis

#9 Endocarditis – Diagnosis & treatment – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

#10
https://www.nhs.uk/conditions/endocarditis/treatment/

#11 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#12 Infective endocarditis: diagnosis, treatment and prevention – The Pharmaceutical Journal
https://pharmaceutical-journal.com/article/ld/infective-endocarditis-diagnosis-treatment-and-prevention

#13 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#14 Endocarditis Diagnosis and Treatment : Emergency Care BC
https://emergencycarebc.ca/clinical_resource/clinical-summary/endocarditis-diagnosis-and-treatment/

#15 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/

#16 Endocarditis Diagnosis and Treatment : Emergency Care BC
https://emergencycarebc.ca/clinical_resource/clinical-summary/endocarditis-diagnosis-and-treatment/

#17 Infectious Endocarditis: Diagnosis and Treatment | AAFP
https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html

#18 Infectious Endocarditis: Diagnosis and Treatment | AAFP
https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html

#19 Infective Endocarditis Diagnosis and Management
https://www.uspharmacist.com/article/infective-endocarditis-diagnosis-and-management

#20 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#21 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#22 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#23 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#24 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#25 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#26 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

#27 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

#28 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#29 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#30 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#31 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#32 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#33 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#34 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#35 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#36 Management of Bacterial Endocarditis | AAFP
https://www.aafp.org/pubs/afp/issues/2000/0315/p1725.html

#37 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#38 Endocarditis – Diagnosis & treatment – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

#39 Endocarditis – Diagnosis & treatment – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

#40 Endocarditis â a rare but serious heart condition | healthdirect
https://www.healthdirect.gov.au/endocarditis

#41 Treatment of Infectious Endocarditis
https://www.uspharmacist.com/article/treatment-of-infectious-endocarditis

#42 Treatment of Infectious Endocarditis
https://www.uspharmacist.com/article/treatment-of-infectious-endocarditis

#43 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis

#44 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#45 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#46 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#47 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#48 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#49 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#50 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#51 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#52 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#53 Current AATS guidelines on surgical treatment of infective endocarditis – Pettersson- Annals of Cardiothoracic Surgery
https://www.annalscts.com/article/view/16669/17073

#54 Current AATS guidelines on surgical treatment of infective endocarditis – Pettersson- Annals of Cardiothoracic Surgery
https://www.annalscts.com/article/view/16669/17073

#55 Recommendations for Surgical Treatment of Infective Endocarditis
https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2022/05/09/19/39/Current-Recommendations-and-Uncertainties

#56 Current AATS guidelines on surgical treatment of infective endocarditis – Pettersson- Annals of Cardiothoracic Surgery
https://www.annalscts.com/article/view/16669/17073

#57
https://www.nhs.uk/conditions/endocarditis/treatment/

#58
https://www.nhs.uk/conditions/endocarditis/treatment/

#59 Endocarditis Treatment Options | Temple Health
https://www.templehealth.org/services/conditions/endocarditis/treatment-options

#60 Endocarditis – Diagnosis & treatment – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/diagnosis-treatment/drc-20352582

#61
https://www.nhs.uk/conditions/endocarditis/treatment/

#62 Endocarditis Treatment Options | Temple Health
https://www.templehealth.org/services/conditions/endocarditis/treatment-options

#63 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis

#64 Infective Endocarditis – Cardiovascular Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis

#65 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#66 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#67 Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia
https://emedicine.medscape.com/article/216650-treatment

#68 Endocarditis – EMCrit Project
https://emcrit.org/ibcc/endo/

#69 Infective Endocarditis | American Heart Association
https://www.heart.org/en/health-topics/infective-endocarditis

#70 Endocarditis – Symptoms & causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/endocarditis/symptoms-causes/syc-20352576

#71 Infectious Endocarditis: Diagnosis and Treatment | AAFP
https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html

#72 Current AATS guidelines on surgical treatment of infective endocarditis – Pettersson- Annals of Cardiothoracic Surgery
https://www.annalscts.com/article/view/16669/html

#73 Infective Endocarditis – Heart and Blood Vessel Disorders – Merck Manual Consumer Version
https://www.merckmanuals.com/home/heart-and-blood-vessel-disorders/endocarditis/infective-endocarditis

#74 Infectious Endocarditis: Diagnosis and Treatment | AAFP
https://www.aafp.org/pubs/afp/issues/2012/0515/p981.html

#75 Treatment for Infective Endocarditis
https://umcno.staywellsolutionsonline.com/Wellness/Fitness/Tools/3,90503

#76 Endocarditis Antibiotic Regimens – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK542162/

#77 Endocarditis: Causes, Symptoms and Treatment
https://my.clevelandclinic.org/health/diseases/16957-endocarditis

#78 Endocarditis: Causes, Symptoms and Treatment
https://my.clevelandclinic.org/health/diseases/16957-endocarditis