Infectious Endocarditis: Diagnosis and

Treatment
DEBORAH PIERCE, MD, MPH; BETHANY C. CALKINS, MD; and KRISTEN THORNTON, MD
University of Rochester School of Medicine and Dentistry, Rochester, New York

Infectious endocarditis results from bacterial or fungal infection of the endocardial surface of the heart and is associated with significant morbidity and mortality. Risk factors include the presence of a prosthetic heart valve, structural
or congenital heart disease, intravenous drug use, and a recent history of invasive procedures. Endocarditis should
be suspected in patients with unexplained fevers, night sweats, or signs of systemic illness. Diagnosis is made using
the Duke criteria, which include clinical, laboratory, and echocardiographic findings. Antibiotic treatment of infectious endocarditis depends on whether the involved valve is native or prosthetic, as well as the causative microorganism and its antibiotic susceptibilities. Common blood culture isolates include Staphylococcus aureus, viridans
Streptococcus, enterococci, and coagulase-negative staphylococci. Valvular structural and functional integrity may
be adversely affected in infectious endocarditis, and surgical consultation is warranted in patients with aggressive or
persistent infections, emboli, and valvular compromise or rupture. After completion of antibiotic therapy, patients
should be educated about the importance of daily dental hygiene, regular visits to the dentist, and the need for antibiotic prophylaxis before certain procedures. (Am Fam Physician. 2012;85(10):981-986. Copyright 2012 American
Academy of Family Physicians.)

he incidence of endocarditis is
approximately 5 to 7.9 cases per
100,000 persons per year in the
United States,1 and has been stable
over time. Risk factors for infectious endocarditis include hemodialysis (7.9 percent), intravenous drug use (9.8 percent), degenerative
valvular disease (mitral regurgitation in 43.4
percent; aortic regurgitation in 26.3 percent),
and rheumatic heart disease (3.3 percent).2
The International Collaboration on Endocarditis was formed in 1999; it consists of 58
hospitals in 25 countries. From 2000 to 2005,
it studied 2,781 consecutive cases of endocarditis as defined by the modified Duke criteria.2 The median age of affected patients was
57.9 years, and 72.1 percent had endocarditis
of the native valve.
Pathophysiology
The development of infectious endocarditis
requires the presence of bacteria or fungi
in the blood and an intracardiac surface
on which these microorganisms can attach.
Mechanical and biomechanical prosthetic
heart valves can serve as foci for platelet
adhesion and thrombus formation. These
sites in turn provide extra surface area to

which microorganisms can adhere and form

vegetations3 (Figure 1).
Early infection, which occurs within two
months of valve placement, is generally the
result of intraoperative contamination of the
prosthesis or of postoperative infection. Late
infection, which occurs at least 12 months
after placement of the prosthesis, involves
microbes and entry portals similar to those
of native valve endocarditis.3 Late prosthetic
valve endocarditis can also cause perivalvular invasion and extension into nearby

Figure 1. Transesophageal echocardiogram

showing aortic valve vegetation (arrow).

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Infectious Endocarditis

tissue, potentially evolving into myocardial

abscess, pericarditis, or conduction system
disruption and heart block.
Diagnosis
Endocarditis should be suspected in any
patient with unexplained fevers, night sweats,
or signs of systemic illness, particularly if

Table 1. The Duke Criteria for the Clinical Diagnosis

of Infectious Endocarditis
Major criteria
Positive blood culture
Two separate blood cultures positive for microorganism consistent with
infectious endocarditis (viridans Streptococcus, Streptococcus bovis, gramnegative HACEK bacilli, Staphylococcus aureus, or community-acquired
enterococci in the absence of a primary focus)
or
Recovery of a microorganism consistent with infectious endocarditis from
blood cultures drawn more than 12 hours apart
or
Recovery of a microorganism consistent with infectious endocarditis from all
of three or most of four or more blood cultures, with first and last drawn
more than one hour apart
or
Single positive blood culture for Coxiella burnetii or phase 1 immunoglobulin G
antibody titer greater than 1:800
Evidence of endocardial involvement
Positive echocardiography (oscillating intracardiac mass on valve or
supporting structures, or in the path of regurgitant jets, or on implanted
material in the absence of an alternative anatomic explanation; intracardiac
abscess; new partial dehiscence of prosthetic valve)
New valvular regurgitation (increase or change in preexisting murmur not
sufficient)
Minor criteria
Fever of at least 38.0C (100.4F)
Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots,
rheumatoid factor
Microbiologic evidence: positive blood culture that does not meet major
criteria, serologic evidence of active infection with organism consistent with
infectious endocarditis
Predisposing heart condition or history of injection drug use
Vascular phenomena: major arterial emboli, septic pulmonary infarctions,
mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages,
Janeway lesions
A definitive diagnosis of endocarditis can be made in patients with two major
criteria, one major and three minor criteria, or five minor criteria.
NOTE:

HACEK = Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae.
Adapted with permission from Durack DT, Lukes AS, Bright DK; Duke Endocarditis
Service. New criteria for diagnosis of infective endocarditis: utilization of specific
echocardiographic findings. Am J Med. 1994;96(3):203.

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any of the following risk factors are present1: a prosthetic heart valve, structural or
congenital heart disease, intravenous drug
use, and a recent history of invasive procedures (e.g., wound care, hemodialysis).
Clinical history consistent with infectious
endocarditis includes the combination of a
prior cardiac lesion and evidence of a recent
source of bacteremia.
The diagnosis of infectious endocarditis requires multiple clinical, laboratory,
and imaging findings. Overdiagnosis and
underdiagnosis of infectious endocarditis can be problematic; a missed diagnosis
could prove fatal, whereas overdiagnosis
can result in weeks of unnecessary antibiotic treatment.
The widely accepted Duke criteria use a set
of major and minor clinical and pathologic
criteria to classify infectious endocarditis as
definite, possible, or rejected (Table1).4 Direct
evidence of endocarditis can be obtained
from histologic specimens collected during
surgery or autopsy, or from a combination
of two major clinical criteria, one major and
three minor criteria, or five minor criteria.
Possible endocarditis is defined as the presence of one major and one or two minor criteria, or three minor criteria.4
Clinical Presentation
Preexisting structural abnormalities of the
heart are present in 75 percent of patients
with infectious endocarditis.5 Historically,
rheumatic heart disease was the most common cardiac abnormality in infectious
endocarditis6 ; however, degenerative lesions
such as mitral valve prolapse are becoming
an increasingly prevalent cause.5 Aortic valve
disease and congenital heart disease in the
setting of bacteremia are also common risk
factors.
Fewer than one-half of persons with infectious endocarditis who use injection drugs
have evidence of a structural or congenital valvular lesion, with estimates between
6 and 40 percent.7,8 Instead, injection of
microorganisms or particulate matter from
the skin itself or from within the drug material may generate transient or permanent
endothelial damage to the tricuspid valve,
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Infectious Endocarditis

thus providing an area for vegetations to

develop.7 In addition, particulates smaller
than 10 micrometers may cross pulmonary capillaries and damage surfaces of the
aortic and mitral valves.9 In general, rightsided infectious endocarditis is far less common than left-sided, and most cases occur
on the tricuspid valve in persons who use
injection drugs.8 Pulmonic valve involvement is rare. Tricuspid valve endocarditis
does not usually result in any detectable
murmur,7 which complicates diagnosis.
Endocarditis in persons who use injection drugs is likely to be right-sided; therefore, septic pulmonary emboli are common,
whereas manifestations of endocarditis (e.g.,
splinter and conjunctival hemorrhages) are
less likely.10 Because blood cultures in these
patients are usually positive, it is appropriate to draw blood in febrile patients and consider starting empiric antibiotics, depending
on the clinical severity of illness.9,10
Nosocomial infectious endocarditis is
defined as a new diagnosis of infectious
endocarditis made three to 60 days after
admission to a hospital or long-term care
unit, during which there was risk of bacteremia. It is generally a complication of bacteremia introduced by an invasive procedure
or indwelling catheter.11 In some areas, up to
20 percent of infectious endocarditis cases
are nosocomial.12 Patients receiving chronic
hemodialysis are also at risk of developing
infectious endocarditis because of chronic
intravenous access, immune system impairment, and calcific valvular disease.13
Evaluation
Physical examination should focus on cardiac auscultation for signs of a new regurgitant murmur or heart failure, as well as
classical clinical stigmata of endocarditis,
such as petechiae of the mucous membranes,
retina (e.g., Roth spots [retinal hemorrhages
with pale centers]), or extremities (e.g.,
splinter hemorrhages, Janeway lesions [macular or nodular hemorrhagic lesions on the
palms or soles], Osler nodes [painful raised
lesions on the palms and soles]).4
Blood cultures should be obtained before
initiation of antibiotic therapy.14 In critically
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Volume 85, Number 10

ill patients, a minimum of three cultures

from different venipuncture sites should be
drawn over one hour before starting empiric
therapy.3 In noncritically ill patients in
whom endocarditis is suspected, therapy
may be delayed until the results
of blood cultures and echoPreexisting structural
cardiography are available.
abnormalities of the heart
Obtaining more than three
are present in 75 percent
blood cultures typically yields
only minimal additional diagof patients with infectious
nostic information.15
endocarditis.
Other laboratory findings,
such as elevated erythrocyte
sedimentation rate and C-reactive protein
levels, are relatively nonspecific3 ; urinalysis
may show evidence of gross or microscopic
hematuria, proteinuria, or pyuria caused by
the immunologic effects of endocarditis on
the kidneys. White blood cell count may be
normal or elevated.
Baseline electrocardiography should be
performed in patients with infectious endocarditis so that new cardiac manifestations
can be recognized early (e.g., extension of
valvular disease into the conduction system, ischemia secondary to emboli to the
coronary circulation).3 If tricuspid valve
endocarditis is suspected in persons who
use injection drugs, chest radiography may
reveal evidence of septic pulmonary emboli.
The American College of Cardiology and
the American Heart Association recommend
that echocardiography be performed to identify valvular abnormalities in all patients in
whom there is moderate or high suspicion of
endocarditis.16 Transthoracic echocardiography is usually the initial imaging modality.
However, transesophageal echocardiography
may be necessary in some patients, such as
those with staphylococcus bacteremia, limited transthoracic windows because of obesity or mechanical ventilation, a prosthetic
valve that renders visualization difficult secondary to shadowing, a history of endocarditis, or a structural valve abnormality.
Treatment
ANTIBIOTICS

Successful treatment requires appropriate

antibiotic therapy. Initial empiric therapy
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American Family Physician983

Table 2. Microbiology of Infectious Endocarditis

Organism

Frequency (%)

Organism

Frequency (%)

Staphylococcus aureus

31

Other streptococci

Viridans Streptococcus

17

Fungi

Coagulase-negative staphylococci

11

Gram-negative HACEK bacilli

Enterococci

11

Gram-negative non-HACEK bacilli

Streptococcus bovis

HACEK = Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae.
Information from reference 2.

Table 3. Treatment Regimens for Infectious Endocarditis

Microorganism

Parenteral antibiotic regimen

Penicillin-susceptible
viridans Streptococcus or
Streptococcus bovis

Penicillin G or ceftriaxone (Rocephin) for four

weeks
or
Penicillin G plus gentamicin for two weeks
or
Ceftriaxone plus gentamicin for two weeks
or
Vancomycin for four weeks

Relatively penicillin-resistant
viridans Streptococcus or
S. bovis

Penicillin G or ceftriaxone for four weeks, plus

gentamicin for two weeks
or
Vancomycin for four weeks

Penicillin-resistant viridans
Streptococcus or S. bovis

Ampicillin plus gentamicin for four to six weeks

or
Penicillin G plus gentamicin for four to six weeks
or
Vancomycin for six weeks

Oxacillin-susceptible
staphylococci

Nafcillin or oxacillin for six weeks, plus

gentamicin for three to five days (optional)
or
Cefazolin for six weeks, plus gentamicin for
three to five days (optional)

Oxacillin-resistant
staphylococci

Vancomycin for six weeks

Enterococcus strains
susceptible to penicillin,
gentamicin, and
vancomycin

Ampicillin plus gentamicin for four to six weeks

or
Penicillin plus gentamicin for four to six weeks
or
Vancomycin and gentamicin for six weeks

Enterococcus strains
susceptible to penicillin,
streptomycin, and
vancomycin, and resistant
to gentamicin

Ampicillin or penicillin plus streptomycin for four

to six weeks
or
Vancomycin plus streptomycin for six weeks

Enterococcus strains
resistant to penicillin, but
susceptible to aminogly
cosides and vancomycin

Ampicillin/sulbactam (Unasyn) plus gentamicin

for a minimum of six weeks
or
Vancomycin plus gentamicin for six weeks

Information from reference 16.

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may include vancomycin or ampicillin/

sulbactam (Unasyn) plus an aminoglycoside
(plus rifampin in patients with prosthetic
valves).1 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. Table 2 shows the incidence
of various microorganisms identified in a
long-term multicenter study of infectious
endocarditis.2 Table 3 summarizes antibiotic
recommendations from the American Heart
Association.16
For the purposes of determining duration
of therapy, the first day in which negative
blood cultures are obtained is considered
the first day of therapy. At least two sets of
blood cultures should be obtained every
24 to 48 hours until the infection has cleared
the bloodstream.17
SURGERY

The structural and functional integrity of

cardiac valves may be damaged by infection.7 This may lead to valvular regurgitation
or flow obstruction in valves with large vegetations.7 Surgery may need to be considered
in selected patients; the benefits are greatest in patients with the most indications.18
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.17 Surgical intervention is warranted
for valve dehiscence, perforation, rupture
or fistula, or a large perivalvular abscess.17
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Table 4. Antibiotic Prophylaxis for Patients with Previous Infectious

Endocarditis Undergoing Dental* or Other Procedures
Indication

Recommended antibiotic regimen

Standard

Amoxicillin (adults: 2 g; children: 50 mg per kg) taken orally one hour

before procedure

Unable to take oral medications

Ampicillin (adults: 2 g; children: 50 mg per kg) IM or IV within

30 minutes of procedure

Penicillin allergy

Clindamycin (adults: 600 mg; children: 20 mg per kg) or azithromycin

(Zithromax) or clarithromycin (Biaxin; adults: 500 mg; children:
15 mg per kg) taken orally one hour before procedure

Penicillin allergy and unable to

take oral medications

Clindamycin (adults: 600 mg; children: 20 mg per kg) IV within

30 minutes of procedure

Penicillin allergy (not anaphylaxis,

angioedema, or urticaria)

Cefazolin (adults: 1 g; children: 50 mg per kg) IM or IV or cephalexin

(Keflex; adults: 2 g; children: 50 mg per kg) taken orally

IM = intramuscularly; IV = intravenously.
*All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth, or perforation
of oral mucosa.
Antibiotic prophylaxis may be reasonable for procedures involving the respiratory tract or infected skin, skin structures, or musculoskeletal tissue. Antibiotic prophylaxis solely to prevent endocarditis is not recommended for genitourinary or gastrointestinal procedures.
Adapted with permission from Wilson W, Taubert KA, Gewitz M, et al.; American Heart Association Rheumatic Fever,
Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the
Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis [published correction appears in Circulation. 2007;116(15):e376-377]. Circulation. 2007;116(15):1747.

Periannular extension of infection into the

myocardium is associated with increased
mortality and should be suspected in patients
presenting with new atrioventricular block.7
ANTICOAGULATION

Anticoagulation in patients with infectious

endocarditis is controversial, particularly in
those with mechanical valve endocarditis.
In general, anticoagulation should be discontinued for at least the first two weeks of
antibiotic therapy in patients with Staphylococcus aureus prosthetic valve endocarditis
who have experienced a recent central nervous system embolic event.3
FOLLOW-UP AND PATIENT EDUCATION

Intravenous catheters should be removed

promptly after antibiotic therapy is complete.
Transthoracic echocardiography should be
performed to establish a new baseline. In
patients with a history of infectious endocarditis, three sets of blood cultures should be
obtained from separate sites before antibiotics are initiated for febrile illness.
Patients should receive information about
daily dental hygiene, regular visits to the dentist, and the need for antibiotic prophylaxis
for certain procedures (Table 4).19
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Volume 85, Number 10

Figure 1 provided by J. Chad Teeters, MD.

The Authors
DEBORAH PIERCE, MD, MPH, is a clinical associate professor at the University of Rochester (NY) School of Medicine
and Dentistry.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
rating

References

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.

18

Patients who have been successfully treated

for infectious endocarditis in the past require
antimicrobial prophylaxis before certain
dental and other procedures.

19

Clinical recommendation

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limitedquality patient-oriented evidence; C = consensus, disease-oriented evidence, usual
practice, expert opinion, or case series. For information about the SORT evidence
rating system, go to http://www.aafp.org/afpsort.xml.

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Infectious Endocarditis

BETHANY C. CALKINS, MD, is a fellow in palliative care

at the University of Rochester School of Medicine and
Dentistry.
KRISTEN THORNTON, MD, is a senior instructor of family
medicine at the University of Rochester School of Medicine
and Dentistry.
Address correspondence to Deborah Pierce, MD, MPH,
University of Rochester School of Medicine and Dentistry, 777 S. Clinton Ave., Rochester, NY 14620 (e-mail:
[email protected]). Reprints are not
available from the authors.
Author disclosure: No relevant financial affiliations to
disclose.
REFERENCES
1. Habib G, Hoen B, Tornos P, et al. Guidelines on the
prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the
Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC).
Eur Heart J. 2009;30(19):2369-2413.
2. Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis
in the 21st century: the International Collaboration on
Endocarditis-Prospective Cohort Study. Arch Intern Med.
2009;169(5):463-473.
3. Karchmer AW. Infectious endocarditis. In: Fauci AS,
Braunwald E, Kasper DL, et al., eds. Harrisons Principles
of Internal Medicine. 17th ed. New York, NY: McGrawHill; 2008:789-797.
4. Durack DT, Lukes AS, Bright DK; Duke Endocarditis Service. New criteria for diagnosis of infective endocarditis:
utilization of specific echocardiographic findings. Am J
Med. 1994;96(3):200-209.
5. McKinsey DS, Ratts TE, Bisno AL. Underlying cardiac
lesions in adults with infective endocarditis. The changing spectrum. Am J Med. 1987;82(4):681-688.
6. Cherubin CE, Neu HC. Infective endocarditis at the Presbyterian Hospital in New York City from 1938-1967.
Am J Med. 1971;51(1):83-96.
7. Sande MA, Lee BL, Mills J, Chambers HF. Endocarditis in
intravenous drug users. In: Kaye D, ed. Infective Endocarditis. New York, NY: Raven Press; 1992:345.
8. Brusch JL, Weinstein WL. Infective Endocarditis. New
York, NY: Oxford University Press; 1996.
9. Mathew J, Addai T, Anand A, Morrobel A, Maheshwari
P, Freels S. Clinical features, site of involvement, bacteriologic findings, and outcome of infective endocarditis

986 American Family Physician

www.aafp.org/afp

in intravenous drug users. Arch Intern Med. 1995;

155(15):1641-1648.
10. Chambers HF, Korzeniowski OM, Sande MA. Staphylococcus aureus endocarditis: clinical manifestations in
addicts and nonaddicts. Medicine (Baltimore). 1983;
62(3):170-177.
11. Martn-Dvila P, Fortn J, Navas E, et al. Nosocomial
endocarditis in a tertiary hospital: an increasing trend in
native valve cases. Chest. 2005;128(2):772-779.
12. Fernndez-Hidalgo N, Almirante B, Tornos P, et al.

Contemporary epidemiology and prognosis of health
care-associated infective endocarditis. Clin Infect Dis.
2008;47(10):1287-1297.
13. Robinson DL, Fowler VG, Sexton DJ, Corey RG, Conlon
PJ. Bacterial endocarditis in hemodialysis patients. Am J
Kidney Dis. 1997;30(4):521-524.
14. Houpikian P, Raoult D. Blood culture-negative endocarditis in a reference center: etiologic diagnosis of 348
cases. Medicine (Baltimore). 2005;84(3):162-173.
15. Werner AS, Cobbs CG, Kaye D, Hook EW. Studies on
the bacteremia of bacterial endocarditis. JAMA. 1967;
202(3):199-203.
16. Bonow RO, Carabello BA, Chatterjee K, et al.; American College of Cardiology; American Heart Association
Task Force on Practice Guidelines (Writing Committee
to revise the 1998 guidelines for the management of
patients with valvular heart disease); Society of Cardiovascular Anesthesiologists. ACC/AHA 2006 guidelines
for the management of patients with valvular heart
disease [published correction appears in J Am Coll
Cardiol. 2007;49(9):1014]. J Am Coll Cardiol. 2006;
48(3):e1-e148.
17. de Sa DD, Tleyjeh IM, Anavekar NS, et al. Epidemiological trends of infective endocarditis: a population-based
study in Olmsted County, Minnesota [published correction appears in Mayo Clin Proc. 2010;85(8):772]. Mayo
Clin Proc. 2010:85(5):422-426.
18. Cabell CH, Abrutyn E, Fowler VG Jr, et al. Use of surgery in patients with native valve infective endocarditis:
Results from the International Collaboration on Endocarditis Merged Database. Am Heart J. 2005;150(5):
1092-1098.
19. Wilson W, Taubert KA, Gewitz M, et al.; American

Heart Association Rheumatic Fever, Endocarditis, and
Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young;
American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and
Outcomes Research Interdisciplinary Working Group.
Prevention of infective endocarditis [published correction appears in Circulation. 2007;116(15):e376-377].
Circulation. 2007;116(15):1736-1754.

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