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Infective Endocarditis – Adult – Inpatient

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1
Infective Endocarditis - Adult – Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY .............................................................................................................. 3
SCOPE ......................................................................................................................................... 5
METHODOLOGY ......................................................................................................................... 6
INTRODUCTION .......................................................................................................................... 7
RECOMMENDATIONS ................................................................................................................ 7
Diagnosis ............................................................................................................................................. 7
Blood Cultures, Antimicrobial Therapy, and Vascular Access ............................................................ 9
Echocardiography ............................................................................................................................... 9
Additional Evaluation and Management ............................................................................................ 10
Mycotic Aneurysms ........................................................................................................................... 11
Anticoagulation .................................................................................................................................. 11
Early Valve Surgery in Left-Sided NVE ............................................................................................. 11
Early Valve Surgery in PVE ............................................................................................................... 12
Valve Surgery in Patients with Prior Emboli/Hemorrhage/Stroke ..................................................... 12
Cardiovascular Implanted Electronic Device (CIED) Lead Extraction .............................................. 12
Discharge and Follow-up Care .......................................................................................................... 13
UW HEALTH IMPLEMENTATION ............................................................................................. 15
REFERENCES ........................................................................................................................... 15
UW Health Algorithm for Patients with Suspected Infective Endocarditis (Adult)………17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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2
CPG Contact for Content:
Name: Anne O’Connor, MD – Medicine – Cardiology
Phone Number: (608) 262-4917
Email Address: aoconnor@medicine.wisc.edu
CPG Contact for Changes:
Name: Janna Lind, MSN – Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6695
Email Address: jlind@uwhealth.org
Coordinating Team Members:
Patrick Hughes, MD – Medicine – Cardiology
Adam Gepner, MD – Medicine – Cardiology
Miguel Leal, MD – Medicine – Cardiology
Nilto De Oliveira, MD – Surgery – Cardiothoracic Surgery
David Andes, MD – Medicine – Infectious Diseases
Anthony Muchard, MD – Medicine – Hospitalists
Joshua Sebranek, MD – Anesthesia
Joshua Medow, MD – Neurological Surgery
Stephanie Kraus, CNS – Cardiology
Margaret Murray, DNP – Cardiothoracic Surgery
Cindy Gaston, PharmD – Drug Policy Program (DPP)
Lucas Schulz, PharmD – Anti-Infectives
Alana Sterkel, PhD – Pathology and Laboratory Medicine
Peter Rusch, RT – Respiratory Services
Teresa MacDonald, RN – Case Management
Brett Yancy-Weatherby, RN – Case Management
Review Individuals/Bodies:
Alexander Yevzlin, MD – Medicine – Nephrology
Anne Rose, Pharm D – Inpatient Anticoagulation Committee
James Van Gemert, DDS – General Surgery – Dental
James Stein, MD – Medicine – Cardiology
Barry Fox, MD – Medicine – Infectious Diseases
Peter Rahko, MD – Medicine – Cardiology
Committee Approvals/Dates:
Antimicrobial Use Subcommittee (01/14/2016)
Clinical Knowledge Management Council (01/28/2016)
Release Date: January 2016 | Next Review Date: January 2018
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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3
Executive Summary
Guideline Overview
This guideline is heavily based on the 2015 AHA Scientific Statement on Infective
Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of
Complications and the 2009 Heart and Rhythm Society Expert Consensus on
Transvenous Lead Extraction.
1,2

Key Practice Recommendations
1. Blood cultures should be drawn prior to antibiotic administration.
3
(UW Health Class I;
Level of Evidence C)
2. In clinically unstable patients, start empiric antibiotics consistent with the 2015 AHA
Scientific Statement on Infective Endocarditis in Adults and consult Infectious
Diseases.
4
(UW Health Class I; Level of Evidence B)
3. In the absence of sepsis or other defined source of infection (i.e. urinary tract
infection, pneumonia) and when infective endocarditis is suspected, antibiotics
should be withheld in clinically stable patients until a microorganism is identified.
3
(UW Health Class I; Level of Evidence C)
4. Transthoracic echocardiogram (TTE) should be performed in all cases of suspected
IE.
1
(ACC/AHA Class I; Level of Evidence B)
5. Transesophageal echocardiogram (TEE) should be done if initial TTE images are
negative or inadequate in patients for whom there is an ongoing suspicion for IE or
when there is concern for intracardiac complications in patients with an initial
positive TTE.
1
(ACC/AHA Class I; Level of Evidence B)
6. If there is a high suspicion of IE despite an initial negative TEE, then a repeat TEE is
recommended in 3 to 5 days or sooner if clinical findings change.
1
(ACC/AHA Class I;
Level of Evidence B)
7. It is reasonable to complete a TTE at the time of antimicrobial therapy completion
(typically 6-8 weeks postdischarge) to establish baseline features.
1
(ACC/AHA Class IIa;
Level of Evidence C)
8. Use of TEE for surveillance of interval change (e.g., resolution of thrombus after
anticoagulation, resolution of vegetation after antibiotic therapy) when no change in
therapy is anticipated is NOT recommended.
10
(UW Health Class III; Level of Evidence B)
9. Decisions on the indication and timing of surgical intervention should be determined
by a multispecialty team with expertise in cardiology, imaging, cardiothoracic
surgery, and infectious diseases.
1,5
(UW Health Class I; Level of Evidence B)
Companion Documents
1. Patients with Suspected Infective Endocarditis (Adult) Algorithm
2. Guideline for the Pharmacokinetic/Pharmacodynamic Dose Optimization of
Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of
Gram-Negative Infections – Adult – Inpatient Clinical Practice Guideline
3. Clinical Monitoring of Outpatient Parenteral Antimicrobial Therapy (OPAT) and
Selected Oral Antimicrobial Agents – Adult – Inpatient/Ambulatory Clinical Practice
Guideline
4. Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory Clinical
Practice Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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4
5. Best Practices for Blood Culturing (UWHC)
External Resources:
1. Revised and Updated Recommendations for the Establishment of Primary Stroke
Centers
Pertinent UW Health Policies & Procedures
1. UWHC Clinical Laboratories Policy 1507.P014: Blood Culture Collection
Patient Resources
Health Facts For You #5803 Special Precautions after Having a Heart Valve Replaced
Health Facts For You #7248 Homeward Bound
Health Facts For You #6154 Congestive Heart Failure for VAD Patients
Healthwise: Endocarditis
Healthwise: Endocarditis, Infective – National Organization for Rare Disorders, Inc.
Healthwise: People Who Need Antibiotics to Prevent Endocarditis
Healthwise: Procedures That May Require Antibiotics to Prevent Endocarditis
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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5
Scope
Disease/Condition(s):
Suspected and confirmed infective endocarditis.
Clinical Specialty: Cardiology, Infectious Diseases, Cardiothoracic Surgery,
Hospitalists, Neurosurgery, Internal Medicine, Family Medicine, Pharmacy
Intended Users: Physicians, Advanced Practice Providers, Pharmacists, Registered
Nurses
Objective(s): To provide evidence-based recommendations for the diagnosis and
treatment of infective endocarditis (IE).
Target Population: Adults with suspected or confirmed endocarditis.
Interventions and Practices Considered:
Surgery
Anti-microbial therapy
Major Outcomes Considered:
Reduced morbidity and mortality
Guideline Metrics:
o Number of cases of endocarditis per quarter (by encounter diagnosis)
Of the patients with endocarditis
o % with an ID Consult
o % with a Cardiology Consult
o % with a Cardiothoracic Surgery Consult
o % that had a cardiac surgery
o % mortality
o % had thoracic echocardiogram (TTE)
o % had transesophageal echocardiogram (TEE)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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6
Methodology
Methods Used to Collect/Select the Evidence: Electronic database searches
were conducted to collect evidence for review, in addition to review of the 2015 ACC/AHA
scientific statement. Expert opinion and clinical experience were also considered during review
of the evidence.
Methods Used to Formulate the Recommendations: The workgroup member
agreed to adopt recommendations developed by the ACC/AHA and/or arrived at a consensus
through discussion of the literature and expert experience. All recommendations endorsed or
developed by the guideline workgroup were reviewed and approved by other stakeholders or
committees (as appropriate).
Methods Used to Assess the Quality and Strength of the
Evidence/Recommendations: Recommendations developed by external
organizations (e.g., ACC/AHA) maintained the evidence grade assign within the original source
document and were adopted for use at UW Health. Internally developed recommendations were
evaluated by the guideline workgroups using the ACC/AHA grading scheme.
Rating Scheme for the Strength of the Evidence/Recommendations:
A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)
scheme developed by the American Heart Association and American College of Cardiology (see
Figure 1) was used to grade each recommendation.
Figure 1. ACC/AHA Grading Scheme
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7
Introduction
Infective endocarditis is a relatively uncommon disease with a high mortality rate.
Patients with infective endocarditis are a heterogenous group. A wide variety of
pathogens may cause infective endocarditis, and some cases are culture negative.
6
The
presentation, clinical course, and approach to treatment can vary widely based on
patient characteristics. Therefore, diagnosis and treatment require a collaborative
approach between many different disciplines including General Medicine, Infectious
Diseases, Microbiology, Cardiology, Cardiothoracic Surgery, Anesthesiology, and
Neurosurgery, among others.
7

Recommendations
Diagnosis
Definition of Infective Endocarditis (IE)
According to the Modified Duke Criteria
1

DEFINITE INFECTIVE ENDOCARDITIS
Pathologic criteria
(1) Microorganisms demonstrated by culture
or histologic examination of a vegetation, a
vegetation that has embolized, or an
intracardiac abscess specimen; or
(2) Pathologic lesions; vegetation or
intracardiac abscess confirmed by histologic
examination showing active endocarditis
Clinical criteria
(1) 2 major criteria; or
(2) 1 major and 3 minor criteria; or
(3) 5 minor criteria
POSSIBLE INFECTIVE ENDOCARDITIS
(1) 1 major criterion and 1 minor criterion; or
(2) 3 minor criteria
REJECTED
(1) Firm alternate diagnosis explaining evidence of infective endocarditis; or
(2) Resolution of infective endocarditis syndrome with antibiotic therapy for <4 days; or
(3) No pathologic evidence of infective endocarditis at surgery or autopsy, with antibiotic
therapy for <4 days; or
(4) Does not meet criteria for possible infective endocarditis, as above
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8
Definition of Terms Used in the Modified Duke Criteria for the
Diagnosis of Infective Endocarditis (IE)
1

MAJOR CRITERIA
Blood culture positive for IE
• Typical microorganisms consistent with IE from 2 separate blood cultures:
Viridans streptococci, Streptococcus bovis, HACEK* group, Staphylococcus aureus;
or Community-acquired enterococci, in the absence of a primary focus;
or
• Microorganisms consistent with IE from positive blood cultures greater than 2 days.
At least 2 positive cultures of blood samples drawn >12 h apart; or All of 3 or a
majority of >4 separate cultures of blood (with first and last sample drawn at least 1
h apart)
or
• Single positive blood culture for Coxiella burnetii or anti-phase 1 IgG antibody titer
≥1:800
Evidence of endocardial involvement
• Echocardiogram positive for IE:
Oscillating intracardiac mass on valve or supporting structures, in the path of
regurgitant jets, or on implanted material in the absence of an alternative anatomic
explanation; or
abscess; or new partial dehiscence of prosthetic valve
• New valvular regurgitation
MINOR CRITERIA
• Predisposition: predisposing heart condition or injection drug use
• Fever: temperature >38*C
• Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic
aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway’s
lesions
• Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and
rheumatoid factor
• Microbiological evidence: positive blood culture but does not meet a major
criterion as noted above or serological evidence of active infection with organism
consistent with IE.
NOTE. Excludes single positive cultures for organisms less likely to cause infective
endocarditis such as coagulase-negative staphylococci.
*HACEK = Haemophilus species, Aggregatibacter species, Cardiobacterium hominis,
Eikenella corrodens, and Kingella species.
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9
Blood Cultures, Antimicrobial Therapy, and Vascular Access
1. Blood cultures should be drawn prior to antibiotic administration.
3
(UW Health Class I;
Level of Evidence C) Patients with suspected endocarditis should have two sets of
blood cultures drawn from different venipuncture sites per UW Clinical Laboratories
policy 1507.P014, “Blood Culture Collection.” Collection of a full 10 mL of blood in
each vial is preferred for suspected infective endocarditis (IE).
8
(UW Health Class I;
Level of Evidence C)
2. In clinically unstable patients, start empiric antibiotics consistent with the 2015 AHA
Scientific Statement on Infective Endocarditis in Adults and consult Infectious
Diseases.
4
(UW Health Class I; Level of Evidence B)
3. In the absence of sepsis or other defined source of infection (i.e. urinary tract
infection, pneumonia) and when infective endocarditis is suspected, antibiotics
should be withheld in clinically stable patients until a microorganism is identified.
3
(UW Health Class I; Level of Evidence C)
4. Once an organism is identified, consult Infectious Diseases (if not already done) to
begin an antimicrobial regimen consistent with the 2015 AHA Scientific Statement on
Infective Endocarditis in Adults.
1
5. Pharmacokinetic/pharmacodynamics (PK/PD) principles should be used to optimize
(improve efficacy and minimize toxicity) antimicrobial utilization when possible per
Guidelines for the Pharmacokinetic/Pharmacodynamic Dose Optimization of
Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of
Gram-Negative Infections – Adult – Inpatient Clinical Practice Guideline and
Intravenous Vancomycin Use – Adult – Inpatient. For patients with renal impairment,
make antimicrobial therapy dose adjustments per Renal Function-Based Dose
Adjustments – Adult – Inpatient/Ambulatory Clinical Practice Guideline.
6. It is reasonable to obtain at least 2 sets of blood cultures every 24 to 48 hours until
bloodstream infection has cleared.
1
(ACC/AHA Class IIa, Level of Evidence C)
7. If a patient has a glomerular filtration rate (GFR) less than 30 mL/minute, it is
recommended to avoid placement of a peripherally inserted central catheter (PICC)
and instead to place a tunneled internal or external jugular PICC which preserves
the patient’s basilic and cephalic veins for future arteriovenous access.
9
(UW Health
Class I; Level of Evidence C)
Echocardiography
1. Echocardiography should be performed expeditiously in patients suspected of
having IE.
1
(ACC/AHA Class I; Level of Evidence A)
2. Transthoracic echocardiogram (TTE) should be performed in all cases of suspected
IE.
1
(ACC/AHA Class I; Level of Evidence B)
3. Transesophageal echocardiogram (TEE) should be done if initial TTE images are
negative or inadequate in patients for whom there is an ongoing suspicion for IE or
when there is concern for intracardiac complications in patients with an initial
positive TTE.
1
(ACC/AHA Class I; Level of Evidence B)
4. If there is a high suspicion of IE despite an initial negative TEE, then a repeat TEE is
recommended in 3 to 5 days or sooner if clinical findings change.
1
(ACC/AHA Class I;
Level of Evidence B)
5. Repeat TEE should be done after an initially positive TEE if clinical features suggest
a new development of intracardiac complications.
1
(ACC/AHA Class I; Level of Evidence B)
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10
6. It is reasonable to complete a TTE at the time of antimicrobial therapy completion
(typically 6-8 weeks postdischarge) to establish baseline features.
1
(ACC/AHA Class IIa;
Level of Evidence C)
7. Use of TEE for surveillance of interval change (e.g., resolution of thrombus after
anticoagulation, resolution of vegetation after antibiotic therapy) when no change in
therapy is anticipated is NOT recommended.
10
(UW Health Class III; Level of Evidence B)



Figure 2. An Approach to the Diagnostic Use of Echocardiography in Suspected Infective
Endocarditis


Adapted from the 2015 AHA Scientific Statement on Infective Endocarditis in Adults.
1



Additional Evaluation and Management
1. Decisions on the indication and timing of surgical intervention should be determined
by a multispecialty team with expertise in cardiology, imaging, cardiothoracic
surgery, and infectious diseases.
1,5
(UW Health Class I; Level of Evidence B)
2. Metastatic foci of infection are common. In symptomatic patients, diagnositic
evaluation is vital, especially in patients who require valve surgery. The choice of
diagnositic procedure (e.g. CT, MRI, ultrasonography) varies and the selection
should be individualized for each patient.
1
(ACC/AHA Class I, Level of evidence C).
3. A thorough dental evaluation is reasonable, especially in patients deemed likely to
require valve replacement, with all active sources of oral infection eradicated.
1

(ACC/AHA Class IIa; Level of Evidence C) Inpatient dental evaluation may be achieved by
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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11
placing a consult to Dental (Inpatient) and completing Panorex x-rays. If deemed
necessary, tooth extraction can be done on either an inpatient or outpatient basis
with physician referral.


Mycotic Aneurysms
1. Cerebrospinal imaging should be performed to detect intracranial mycotic
aneurysms (ICMA) or central nervous system (CNS) bleeding in all patients with IE
or contiguous spread of infection who develop severe, localized headache,
neurological deficits, or meningeal signs.
1
(ACC/AHA Class I; Level of Evidence B)
2. Cerebrovascular imaging (CT angiography, magnetic resonance angiography, or
digital subtraction angiography) may be considered in all patients with left-sided IE
who have no CNS signs or symptoms.
1
(ACC/AHA Class IIb; Level of Evidence C) At UW
Health cerebrovascular imaging is recommended for all patients with left-sided
infective endocarditis as the results may impact the choice and duration of
antimicrobial therapy.
11
(UW Health Class I; Level of Evidence C)

Anticoagulation
1. Discontinuation of all forms of anticoagulation in patients with mechanical valve IE
who have experienced a CNS embolic event for at least 2 weeks is reasonable.
1

(ACC/AHA Class IIa; Level of Evidence C)
2. Initiation of aspirin or other antiplatelet agents as adjunctive therapy in IE is not
recommended.
1
(ACC/AHA Class III; Level of Evidence B)
3. The continuation of long-term antiplatelet therapy at the time of development of IE
with no bleeding complications may be considered.
1
(ACC/AHA Class IIb; Level of
Evidence B)

Early Valve Surgery in Left-Sided Native Valve Endocarditis (NVE)
1. Early surgery (during initial hospitalization and before completion of a full course of
antibiotics) is indicated in patients with IE who present with valve dysfunction
resulting in symptoms or signs of heart failure.
1
(ACC/AHA Class I; Level of Evidence B)
2. Early surgery should be considered particularly in patients with IE caused by fungi or
highly resistant organisms (eg, vancomycin-resistant Enterococcus, multidrug-
resistant Gram-negative bacilli).
1
(ACC/AHA Class I ;Level of Evidence B)
3. Early surgery is indicated in patients with IE complicated by heart block, annular or
aortic abscess, or destructive penetrating lesions.
1
(ACC/AHA Class I; Level of Evidence B)
4. Early surgery is indicated for evidence of persistent infection (manifested by
persistent bacteremia or fever lasting >5–7 days and provided that other sites of
infection and fever have been excluded) after the start of appropriate antimicrobial
therapy.
1
(ACC/AHA Class I; Level of Evidence B)
5. Early surgery is reasonable in patients who present with recurrent emboli and
persistent or enlarging vegetations despite appropriate antibiotic therapy.
1
(ACC/AHA
Class IIa; Level of Evidence B)
6. Early surgery is reasonable in patients with severe valve regurgitation and mobile
vegetations >10 mm.
1
(ACC/AHA Class IIa, Level of Evidence B)
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12
7. Early surgery may be considered in patients with mobile vegetations >10 mm,
particularly when involving the anterior leaflet of the mitral valve and associated with
other relative indications for surgery.
1
(ACC/AHA Class IIb; Level of Evidence C)
8. Further recommendations on the surgical management of conditions not specifically
addressed in this guideline (i.e., right-sided endocarditis) are available in the 2015
ACC/AHA Scientific Statement on Infective Endocarditis in Adults.

Early Valve Surgery in Prosthetic Valve Endocarditis (PVE)
1. Early surgery is indicated in patients with symptoms or signs of heart failure resulting
from valve dehiscence, intracardiac fistula, or severe prosthetic valve dysfunction.
1

(ACC/AHA Class I; Level of Evidence B)
2. Early surgery should be done in patients who have persistent bacteremia despite
appropriate antibiotic therapy for 5 to 7 days in whom other sites of infection have
been excluded.
1
(ACC/AHA Class I; Level of Evidence B)
3. Early surgery is indicated when IE is complicated by heart block, annular or aortic
abscess, or destructive penetrating lesions.
1
(ACC/AHA Class I; Level of Evidence B)
4. Early surgery is indicated in patients with PVE caused by fungi or highly resistant
organisms.
1
(ACC/AHA Class I; Level of Evidence B) Antibiotics may be considered as first
line therapy for patients with prosthetic valve endocarditis associated with small
vegetations and without significant valve destruction.
12
(UW Health Class IIb; Level of
Evidence C)
5. Early surgery is reasonable for patients with PVE who have recurrent emboli despite
appropriate antibiotic treatment.
1
(ACC/AHA Class IIa; Level of Evidence B)
6. Early surgery is reasonable for patients with relapsing PVE.
1
(ACC/AHA Class IIa; Level
of Evidence C)
7. Early surgery may be considered in patients with mobile vegetations >10 mm.
1

(ACC/AHA Class IIb; Level of Evidence C)
8. Further recommendations on the surgical management of conditions not specifically
addressed in this guideline (i.e., right-sided endocarditis) are available in the 2015
ACC/AHA Scientific Statement on Infective Endocarditis in Adults.

Valve Surgery in Patients with Prior Emboli/Hemorrhage/Stroke
1. Valve surgery may be considered in IE patients with stroke or subclinical cerebral
emboli and residual vegetation without delay if intracranial hemorrhage has been
excluded by imaging studies and neurological damage is not severe (i.e., coma).
1

(ACC/AHA Class IIb; Level of Evidence B)
2. In patients with major ischemic stroke or intracranial hemorrhage, it is reasonable to
delay valve surgery for at least 4 weeks.
1
(ACC/AHA Class IIa; Level of Evidence B) A
small ischemic stroke is not a contraindication for surgery for the appropriately
selected patient.

Cardiovascular Implanted Electronic Device (CIED) Lead Extraction
1. Complete device and lead removal is recommended in all patients with definite CIED
system infection, as evidenced by valvular endocarditis, lead endocarditis or sepsis.
2

(ACC/AHA Class I; Level of Evidence B)
2. Complete device and lead removal is recommended in all patients with valvular
endocarditis without definite involvement of the lead(s) and/or device.
2
(ACC/AHA
Class I; Level of Evidence B)
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13
3. Complete device and lead removal is recommended in patients with occult gram-
positive bacteremia (not contaminant).
2
(ACC/AHA Class I; Level of Evidence B)
4. Complete device and lead removal is reasonable in patients with persistent occult
gram-negative bacteremia.
2
(ACC/AHA Class IIa; Level of Evidence B)
5. For every patient with bacteremia and a suspicion of infective endocarditis who also
has a CIED, early consultation with the Electrophysiology Service is recommended.
(UW Health Class I; Level of Evidence C)
6. Further recommendations on device and lead removal, as well as replacement after
infected removal, are available in the 2009 Heart and Rhythm Society Expert
Consensus on Transvenous Lead Extraction.
2


Discharge and Follow-up Care
1. Prior to discharge from the hospital, a follow-up provider should be identified and
initial follow up visit arranged for 5 days to 2 weeks post-discharge, depending on
the prescribed anti-microbial agent. This provider is responsible for ensuring
monitoring and continued follow up per Clinical Monitoring of Outpatient Parenteral
Antimicrobial Therapy (OPAT) – Adult – Inpatient/Ambulatory. (UW Health Class I; Level
of Evidence C)
2. It is reasonable to complete a TTE at the time of antimicrobial therapy completion
(typically 6-8 weeks postdischarge) to establish baseline features.
1
(ACC/AHA Class IIa;
Level of Evidence C)
3. Use of TEE for surveillance of interval change (e.g., resolution of thrombus after
anticoagulation, resolution of vegetation after antibiotic therapy) when no change in
therapy anticipated is NOT recommended.
10
(UW Health Class III; Level of Evidence B)
4. Patients with significant valve lesion (i.e. moderate or greater valve regurgitation)
should have cardiology follow up 6-8 weeks after discharge, following or in
conjunction with the TTE at end of antimicrobial therapy. (UW Health Class I; Level of
Evidence C)
5. Prior to discharge, inpatients with IE should be thoroughly evaluated by a dentist to
identify and eliminate oral diseases that predispose to bacteremia and may therefore
contribute to the risk for recurrent IE.
1
(ACC/AHA Class I; Level of Evidence C) At UW
Health, inpatient dental evaluation may be achieved by completing Panorex x-rays
and placing a Health Link consult to Dental (Inpatient). A dentist is on call 24/7. The
evaluation would typically be performed during regular dental clinic hours if possible.
If deemed necessary, tooth extraction can be done on either an inpatient or
outpatient basis. The dental clinic at University Hospital does not provide general
dentistry services, for example, cleaning, fillings, crowns, or root canals. The dental
clinic phone number is available via paging.
6. Daily dental hygiene should be stressed, with serial evaluations by a dentist or
dental hygienist (e.g., biannual cleanings) who is familiar with this patient
population.
1
(ACC/AHA Class I; Level of Evidence C). Access to dental care for uninsured
and Medicaid patients is a challenge. A phone call from a physician or nurse may
expedite follow up care. Dane County dental resources. Dental resources in
surrounding counties.
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14
7. Prophylaxis against endocarditis is recommended for patients with a previous
endocarditis, including those with and without prosthetic valve replacement or repair,
only prior to specific dental and invasive procedures as outlined in the 2008
ACC/AHA Guideline Update on Valvular Heart Disease: Focused Update on IE.
13

(UW Health Class I; Level of Evidence B)


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15
UW Health Implementation
Potential Benefits:
• Reduced morbidity and mortality

Potential Harms:
• Harms associated with valve replacement surgery
• Toxic effects of some antimicrobial agents

Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Physician/APP Briefing.
3. Development of appropriate Health Link tools such as an order set.
4. Development of tools for early identification of patients at high risk for infective
endocarditis.

Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
References
1. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults:
Diagnosis, Antimicrobial Therapy, and Management of Complications: A
Scientific Statement for Healthcare Professionals From the American Heart
Association. Circulation. 2015;132(15):1435-1486.
2. Wilkoff BL, Love CJ, Byrd CL, et al. Transvenous lead extraction: Heart Rhythm
Society expert consensus on facilities, training, indications, and patient
management: this document was endorsed by the American Heart Association
(AHA). Heart Rhythm. 2009;6(7):1085-1104.
3. Werner AS, Cobbs CG, Kaye D, Hook EW. Studies on the bacteremia of
bacterial endocarditis. Jama. 1967;202(3):199-203.
4. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of
effective antimicrobial therapy is the critical determinant of survival in human
septic shock. Crit Care Med. 2006;34(6):1589-1596.
5. Chirillo F, Scotton P, Rocco F, et al. Impact of a multidisciplinary management
strategy on the outcome of patients with native valve infective endocarditis. Am J
Cardiol. 2013;112(8):1171-1176.
6. Thuny F, Grisoli D, Collart F, Habib G, Raoult D. Management of infective
endocarditis: challenges and perspectives. Lancet. 2012;379(9819):965-975.
7. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the
management of infective endocarditis: The Task Force for the Management of
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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16
Infective Endocarditis of the European Society of Cardiology (ESC)Endorsed by:
European Association for Cardio-Thoracic Surgery (EACTS), the European
Association of Nuclear Medicine (EANM). Eur Heart J. 2015.
8. Weinstein MP. Current blood culture methods and systems: clinical concepts,
technology, and interpretation of results. Clin Infect Dis. 1996;23(1):40-46.
9. McLennan G. Vein Preservation: An Algorithmic Approach to Vascular Access
Placement in Patients With Compromised Renal Function. The Journal of the
Association for Vascular Access. 2007;12(2):89-91.
10. Saric M, Armour AC, Arnaout MS, et al. Guidelines for the Use of
Echocardiography in the Evaluation of a Cardiac Source of Embolism. Journal of
the American Society of Echocardiography.29(1):1-42.
11. Kearney BP, Aweeka FT. The penetration of anti-infectives into the central
nervous system. Neurol Clin. 1999;17(4):883-900.
12. Hill EE, Herregods M-C, Vanderschueren S, Claus P, Peetermans WE, Herijgers
P. Management of Prosthetic Valve Infective Endocarditis. The American Journal
of Cardiology. 2008;101(8):1174-1178.
13. Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 Guideline update
on valvular heart disease: focused update on infective endocarditis: a report of
the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines endorsed by the Society of Cardiovascular
Anesthesiologists, Society for Cardiovascular Angiography and Interventions,
and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(8):676-685.

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Suspected Infective Endocarditis
Draw Blood Cultures
Consult ID
In clinically unstable patients, start empiric antimicrobial therapy.
In clinically stable patients, HOLD antimicrobial therapy until organism identified.
A
Transesophageal echo (TEE) if any of the following:
1. High risk clinical features.
B
2. Suboptimal TTE images.
3. High risk TTE findings.
C
ECHO ATTENDING (OR FELLOW)
reports critical findings to primary team
Additional Evaluation & Management
ξ Repeat blood cultures every 24-48 hours until negative.
ξ Continue antimicrobial therapy as per Infectious Disease.
ξ Repeat TTE/TEE if clinical features suggest development of new cardiac complications.
ξ Cerebrovascular imaging to detect ICMA or CNS bleed in symptomatic patients.
ξ Evaluation for metastatic foci of infection in symptomatic patients.
ξ Dental evaluation for pre-valve surgical patients, and upon discharge of all confirmed IE cases.
Positive
Echo?
Reference: Infective Endocarditis – Adult
– Inpatient Clinical Practice Guideline
Inpatient Management of Adult Patients with
Suspected Infective Endocarditis Algorithm
YES NO
Additional Details
A. In the absence of sepsis or
other defined source of
infection (i.e., UTI, pneumonia)
and high suspicion of IE.
B. High risk clinical features:
Prosthetic heart valves, most
congenital heart diseases,
previous IE, heart failure, or
other stigmata of endocarditis.
C. High risk echo findings:
Large or mobile vegetations,
valvular insufficiency,
suggestion of perivalvular
extension, or secondary
ventricular dysfunction.
D. Cardiology consult service
will assess patient for
appropriateness of transfer to
inpatient cardiology service.
E. Potential surgical indications:
Left sided vegetation > 1 cm,
recurrent embolic events, heart
failure, perivalvular extension
or abscess, prosthetic heart
valve, persistently positive
cultures.
ξ Look for alternate sources of infection
ξ Repeat TEE in 3-5 days if suspicion remains high
IE CONSULT PANEL INITIATED
¨ ID (if not already consulted)
¨ Cardiology
D
(if potential surgical indication
E
)
¨ CT Surgery (if potential surgical indication
E
)
¨ EP if patient has cardiac implanted device
Discharge and Follow Up
Notes regarding IE Consult Panel:
ξ The echo staff will communicate the critical echo
findings to the primary team.
ξ The echo attending will prompt the primary team to use
the IE Consult order.
ξ The consult orders will be placed by the primary team.
ξ On a case by case basis, the echo staff/fellow will
directly communicate the critical echo findings to the
consulting service(s).
Transthoracic echo (TTE)
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Empiric Anti micro bial The rapy for Infe c tive Endocard itis

Fo r use in the absenc e of sepsis or othe r defined so u rce of infec ti o n (i. e. UTI, pneumonia ) and high suspi cion
of IE:
- In clini cally uns table patients, start empiric an timi cr o bial therapy as outline d below. (UW Health Class I; Level of
Evidence B)
- In clini cally stable patient s, withhold antibioti cs until an organis m is identif ie d. (UW Health Class I; Level of
Evidence C)
-Dose adjustments may be warranted per collateral guidelines: Vancomycin Use, Renal Dosing, and
Pharmacokinetic/Pharmacodynamic Dose Optimization.
Native Valve Endocardi tis (acute clinical presentation )
Comment: Most common organisms include Staphylococcus aureus ,
β - hemolytic Streptococc i, and aerobic Gram –neg ative bacilli 1
(ACC/AHA Class IIa, Level of Evidence C)
- Vancomycin 20mg/kg I V x1, then 15mg /kg
IV every 12 hours
- Cefepime 2g IV every 8 ho urs pro longe d
infusio n
Native Valve Endocardi tis (suba cute pre sentation )
Comment: Most common organisms include Staphylococcus aureus ,
nutritionally variant Streptococc i, HACE K organisms, and Enterococci
sp .
1
(ACC/AHA Class IIa, Level of Evidence C)
- Vancomycin 20mg/kg IV x1, then 15mg /kg
IV every 12 hours
- Ampi cillin/s ulbacta m 3g IV every 6 hou rs
Pro sthetic Va lve Endocar di tis
(< 1 year fro m valve replacement surge ry)
Comment: Most common organism s include Staphylococcus aureus ,
nutritionally variant Streptococc i, HACE K organisms, Enterococci sp . ,
and pseudomonas
1
(ACC/AHA Class IIa, Level of Evidence C)
- Vancomycin 20mg/kg IV x1, then 15mg /kg
IV every 12 hours
- Cefepime 2g IV every 8 ho urs pro longe d
infusio n
- Tobra mycin 5mg/kg IV x1 OR Ci pro flo xacin
400 mg IV eve ry 8 hours
Pro sthetic Va lve Endocar di tis
(> 1 year fro m valve replacement surge ry)
Comment: Most common organisms include Staphylococcus (MRSE ,
MRSA, and MSSA ), nutritionally variant Streptoc occ i, and Enterococci
sp.
1
(ACC/AHA Class IIa, Level of Evidence C)
- Vancomycin 20mg/kg IV x1, then 15mg /kg
IV every 12 hours
- Ceftria xone 2g IV every 24 hours


Dis charge & Follow - Up

- Iden tify and schedul e initi al visit with the health care tea m respo nsible for ad ministration and moni toring
OPAT per Cli nical Monitor ing of Outpa t ient Paren ter al Antimicrob ial Therapy (OPAT) – Adul t . Initial visit is
typically 5 da ys to 2 wee ks post - disc harge, dependi n g on antimi cr o bial agents used.
- Schedule TTE at the time of completio n of anti micr o bial therapy , usually 6 - 8 weeks pos t - d ischarge (TEE
usua lly not warr anted)
- Schedule Cardiolo gy follo w up for pati ents with sig nificant valve lesio n (sched ule after or in conju n c tion with
TTE)
- Arra nge for dental evalua tion if not complet ed whil e IP. Dane County dental reso urces
Dental reso ur ces in surr o u nding cou nties
- Pa tient edu c ation: Sig ns & symptoms of IE, daily dent al hygiene, dental vis its every 6 mon ths , and antibio t ic
prophylaxis prio r to specifi c dental and inva siv e pro cedures as outli ned in the 200 8 AHA/AC C Guideline
Updat e on Valvula r Heart Disea se: Focu sed Upda te on IE .
1. Baddour LM, Wilso n WR, Bayer AS, et al. Infective End o carditis in Adults: Diag nos is, Antimi crobial
Therapy, an d Manage men t of Co mplica t ions : A Scien t ifi c State men t for Heal thca re Pro fess iona ls Fro m the
American Hea rt Asso ciatio n. Circulation. 201 5;13 2(1 5):1435 -1486.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org