aNdu IE presentation for seminar in .pptx

08/22/2025
Infective endocarditis
Presenter: Dr.Andualem (IMR3)
Moderator: Dr.Tilahun (Consultant Internist ,ID
Fellow)

08/22/2025
Outlines
• Introductions
• Epidemiology
• Etiology
• Pathogenesis
• Clinical manifestations
• Diagnosis
• Treatment
• Prevention
• Prognosis

08/22/2025
Introduction
• IE denotes infection of the endocardial surface of the heart
and implies the physical presence of microorganisms in the
lesion.
• The term infective endocarditis,first used by Thayer and later
popularized by Lerner and Weinstein, is preferable to the
former term bacterial endocarditis

08/22/2025
• Left vs right sided endocarditis
• CIED –related endocarditis
• Native vs prosthetic valve endocarditis
• Acute (days -6 wks) vs subacute endocarditis (6wks- 3 months)

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IE
left sided right sided
• TV/PV , Isolated rt 10%.
• Risks: 90% of rt sided IE,
(IDU),CIED or other intravascular
device and presences of an
underlying rt sided cardiac
anomaly.
• patho-
– injection of particulate matter (such
as talc) along with ilicit drugs and
in the process of IDU also inject
bacteria or fungi present on the
surface of skin ,in the drug itself

08/22/2025
• Microbilogy
– S.aureus,streptococci and enterococci
most common.
– vegetations tend to have lower
bacterial density.
• CM- septic pulmonary emboli are
common (53%) -cough, pleuritic
chest pain , hemoptysis and dyspnea.
– isolated rt IE often don’t have
detectable heart murmurs, periphera
emboli, immunologic /vascular
phenomenia
• DX: Modified Duke criteria - but less
sensitive.
• RX: IV abcs and removal of any
indwelling intravascuar devices .

08/22/2025
CIED –related endocarditis
• CIED-IE involves the device or the endothelium at points of
device contact.
• Occasionally, there is concurrent aortic or mitral valve infection.
• One-third of cases of CIED IE present within 3 months after
device implantation or manipulation, one-third between 4–12
months, and one-third >1 year.
• S. aureus and CoNS cause the majority of cases.

08/22/2025
Prosthetic Valve Endocarditis
• A microbial infection involving the valve prosthesis or repaired
native heart valve with placement of an annuloplasty ring, is an
uncommon but potentially lethal complication of prosthetic valve
surgery.
• Prosthetic valves
– During a person’s lifetime, the four heart valves have to open and close
approximately 2.5 billion times to maintain efficient unidirectional blood flow.
– In the developed world, age-related degenerative valve disease now is the
most common indication for valve replacement.

08/22/2025
• An ideal prosthetic valve is one that can be
– placed in the heart,
– is compatible with cardiac physiology, and
– is chemically inert,
– nonimmunogenic,
– nonthrombogenic, and
– durable for decades.

08/22/2025
Mechanical Valves
• Surgical valve replacement is performed with mechanical or
bioprosthetic valves
• The main problem with mechanical valves that remains to
date is the high rate of thromboembolic complications.
• Mechanical valves now come in three designs: ball cage, tilted
disk, and bileaflet.

08/22/2025
Bioprosthetic valves
• Include pericardial and xenograft
• Carpentier sought to improve durability while
maintaining low thrombogenicity by combining biologic
and mechanical structures.
• The durability of tissue valve was improved by
– chemical treatment of the porcine heart valve—washing the
valve in Hank’s solution and
– using an oxidizing agent to reduce antigenic components and
– glutaraldehyde treatment to stabilize collagen by
establishing cross-links.

08/22/2025
Microbiology
• The microbiology of PVE depends on
– (1) time of onset of PVE (early vs. late PVE) and
– (2) site of acquisition (community-acquired vs. health
care–associated PVE).

08/22/2025
Early-onset PVE (<1yr)
• Microorganisms acquired
intraoperatively or during the
immediate postoperative period.
• S. aureus and CoNS are the most
common pathogens in early PVE,
followed in incidence by
diphtheroids, fungi, and
nosocomial aerobic gram-
negative bacilli
• declines from 60% to 10-20% due
to IPC, apropriate use of
antimicrobial prophylaxis,
improvements in design of
prosthetic valves, and better
surgical techniques.
Late PVE (>1yr)
• Microorganisms is acquired
in the community, unrelated
to surgery or the
perioperative period,
resembling those of NVE.
• staphylococci have
surpassed streptococci as
the most frequent causative
organisms
• In some hospitals,
enterococci have surpassed
viridans-group streptococci

08/22/2025
Health Care–Associated Prosthetic
Valve Endocarditis
• constituted about 37% of all cases in a
prospective, multinational cohort.
• S. aureus is now the leading causative
organism of PVE, with increases in
frequency of MRSA across geographic
regions.
• Major risk factors include presence of
intravascular devices and hemodialysis.
• About 70% of cases are diagnosed within
the first year after prosthetic valve
implantation, and more than 60% occur
beyond 60 days after operation.
• Many aerobic gram-negative bacilli can
cause and multidrug resistance is
common.
– Pseudomonas, Serratia,
Acinetobacter,predominate.
Community-Acquired Prosthetic
Valve Endocarditis
• caused by enterococci,
viridans-group streptococci,
and fastidious organisms
including the HACEK group

08/22/2025
Epidiomology
• In a systematic review of IE epidemiology studies from 1980 to 2008,
crude incidence of IE ranged between 1.5 and 11.6 cases per 100,000
people.
• The mean age of patients with IE has increased gradually in the antibiotic
era.
• In 1926, the median age was younger than 30 years; by 1943, it was 39
years, and currently more than half of patients are older than 50 years.
• Male-to-female ratio is 1.7 : 1
• Among patients younger than 35 years, more cases occur in women.

08/22/2025
• In developed countries, 25–35% of cases of native-valve endocarditis (NVE) are
health care–associated.
• PVE accounts for 16% to 33% of all definite cases of infective endocarditis (IE).
• The cumulative risk of developing PVE is highest within the initial 12 months after
replacement surgery, with a peak during the first 2 months.
• The risk of PVE is higher in patients who undergo valve replacement surgery during
active IE, especially in the setting of an unknown pathogen or insufficient antibiotic
treatment.
• The cumulative risk of PVE appears similar between mechanical and bioprosthetic
valves.
• Pattern of Valvular Involvement
– Mitral valve – 28-45% ,Aortic -5-36%, combined -0-35%, TV-0-6%, PV - <1%.

08/22/2025
• While congenital heart diseases remain a constant
predisposition, predisposing conditions in developed
countries have shifted from chronic rheumatic heart disease
(still common in developing countries) to injection drug use,
degenerative valve disease, and intracardiac devices.

08/22/2025
• The three most common causes of IE worldwide are staphylococci,streptococci and
enterococci.
• Streptococci and staphylococci account for 80% to 90% of the cases in which an
identification is made.
• Streptococci were once the most common overall cause of IE and continue to be
the predominant etiologic agents in the developing world.
• Viridans streptococci are the most commonly isolated pathogens in IE cases
associated with mitral valve prolapse,and
• IE in young women with isolated mitral valve involvement is almost universally
caused by viridans streptococci.

08/22/2025
• About 5–15% of patients with IE have negative
blood cultures;
– in 1/3rd to 1/2 of these cases because of prior
antibiotic exposure.

08/22/2025
Pathogenesis
• The undamaged endothelium is resistant to infection by most bacteria.
• Endothelial injury allows either direct infection by virulent organisms or
the development of a platelet–fibrin thrombus—a condition called
nonbacterial thrombotic endocarditis(NBTE).
• The cardiac conditions most commonly resulting in NBTE are mitral
regurgitation, aortic stenosis, aortic regurgitation, ventricular septal
defects, and complex congenital heart disease.
• NBTE also arises as a result of a hypercoagulable state; gives rise to
marantic endocarditis and to bland vegetations complicating SLE and APS.

08/22/2025
• The organisms that commonly cause IE have surface adhesin molecules, collectively
called microbial surface components recognizing adhesin matrix molecules
(MSCRAMMs) that mediate adherence to NBTE sites or injured endothelium.
• FimA, a surface adhesin expressed by viridans streptococci, has been shown to
mediate the attachment of such organisms to platelet-fibrin matrices in vitro and to
experimental NBTE lesions in the animal model of IE
• It is underappreciated that platelets can actually phagocytose circulating
staphylococci into engulfment vacuoles, in which the organism can persist.
• Moreover, after specific exposure to thrombin (which is plentiful at the surface of
damaged endothelium), release of α-granule–derived platelet microbicidal proteins
(PMPs) or thrombocidins with bactericidal activity against most gram-positive cocci
that cause IE has been shown.

08/22/2025
• PVE can occur as a result of direct microbial contamination of a
prosthetic valve at the time of surgery or as a consequence of
secondary hematogenous seeding from a distant infectious
focus.
• The prosthetic valve and perivalvular tissue are vulnerable for
secondary microbial seeding during the early postimplantation
period, when they lack protective endothelial lining

08/22/2025
• The pathogenesis of PVE consists of several steps
including
1. microbial adherence to the prosthetic valve, damaged
endothelium, platelet-fibrin aggregate, and/or periprosthetic
tissue;
2. recruitment and activation of monocytes and platelets and
activation of extrinsic coagulation cascade, resulting in an
infected coagulum called a vegetation, the characteristic
lesion of endocarditis;
3. persistence and growth of the microorganism within cardiac
lesions, leading to local tissue destruction and invasion; and
4. dislodgement of the vegetations

08/22/2025
Microbial Adherence
• A critical step in the pathogenesis of endocarditis and involves
complex interactions between microbial surface proteins and
host extracellular matrix molecules.
• The foreign material is often coated with extracellular host
matrix molecules (e.g., fibrinogen, fibrin, fibronectin,
collagen, elastin, plasma proteins, platelet proteins) that can
serve as ligands for microorganisms.
• Microorganisms can also adhere to and infect the sterile
platelet-fibrin aggregate formed after injury or inflammation
of the endothelium.
• The aging bioprosthesis, sutures, and sewing cuff fabric of a
valve prosthesis are thrombogenic and favor deposition of
fibrinogen-fibrin, fibronectin, plasma proteins, and platelets

08/22/2025
Formation and Growth of Vegetations
• The microbial growth within a platelet-fibrin aggregate leads
to activation of the extrinsic coagulation cascade and
recruitment of monocytes and platelets that result in the
formation of vegetation.
• Microorganisms also engage and activate platelets either
directly or through bridging molecules.

08/22/2025
Persistence and Growth of Microorganisms
• Microorganisms are able to persist and grow within
vegetations by using many mechanisms to evade the host
defense system.
– ClfA of S. aureus inhibits phagocytosis by human
polymorphonuclear leukocytes in the absence of fibrinogen.
– Fibrin adherent streptococci are not engulfed by monocytes.
– S. aureus can internalize into intact endothelial cells through a
fibronectin bridge between FnBPA and the endothelial α5β1
integrins (fibronectin receptors).
• This internalization of S. aureus can lead to persistent or recurrent
infection by avoiding host defense and membrane-active
antimicrobial agents, such as β-lactams and glycopeptides.

08/22/2025
• The biofilm over the prosthetic valve also provides a
protective environment for the bacteria.
• The sessile bacteria within the biofilm are less susceptible
to the host immune system and antibiotics than the free-
floating (planktonic) bacteria.
• Bacteria within the biofilm exhibit an altered phenotype
with different patterns of growth, gene expression, and
protein production.
• Nutrient-deficient bacteria in the biofilm switch to a
slowgrowing metabolically quiescent persister phenotype,
which is less susceptible to antimicrobial agents

08/22/2025
Tissue Destruction and Invasion
• Microorganisms produce various toxins and tissue-degrading
enzymes that result in invasion and tissue destruction.
• The extent and rapidity of tissue destruction depend on the
virulence of the microorganisms.
• S. aureus,the most common pathogen of PVE, is a virulent
organism capable of inducing significant tissue destruction in
a short period of time.

08/22/2025
• The sizes and types of vegetations appear to be correlated with the
virulence of the causative microorganism.
• S. aureus usually results in smaller vegetations but causes significant
destruction and invasion of the tissue.
• Viridans-group streptococci have been associated with larger vegetations
with slower, milder destruction of tissue.
• Fungi form large, bulky vegetations.
• Large vegetations are also associated with the HACEK group of organisms.

1. Why do organisms lodge specifically on the cardiac valves rather than
elsewhere in the vascular tree?
2. What enables the microorganisms to survive on the valve surface after
colonization?
3. What are the primary host defenses against induction and progression
of the infection?
4. Why do only a relatively few strains of bacteria produce most cases of IE
whereas many others produce only bacteremia?
5. What factors are responsible for the marked variation in the
manifestations of IE?
6. Why is the infection so difficult to eradicate with antibiotics even
though the infecting organisms often are exquisitely sensitive to the
drugs in vitro?

08/22/2025
Clinical manifestations
Four processes contribute to the clinical picture
1. the infectious process on the valve, including the local
intracardiac complications;
2. bland or septic embolization to virtually any organ;
3. constant bacteremia, often with metastatic foci of
infection; and
4. circulating immune complexes and other
immunopathologic factors.

08/22/2025
• Aortic paravalvular infection may burrow into the upper
ventricular septum and interrupt the conduction system,
leading to varying degrees of heart block.
• Mitral paravalvular abscesses are more distant from the
conduction system and rarely cause conduction
abnormalities.

08/22/2025
Noncardiac Manifestations
• Three pathologic processes may be found in the kidney in patients with IE:
abscess, infarction, and glomerulonephritis.
• Cerebral emboli are the most common neurologic manifestation of IE. 20-
30% . MCA.MRI
– Cerebral infarction, arteritis, abscesses, mycotic aneurysms, intracerebral or
subarachnoid hemorrhage, encephalomalacia, cerebritis, and meningitis have
been reported
• Splenic infarctions have been reported in 44% of autopsy cases but often
are clinically silent.
• Lung: When right-sided IE is present, pulmonary embolism with or without
infarction, acute pneumonia, pleural effusion, or empyema is common.

08/22/2025
Increased risk of embolization associated with
– S. aureus IE,
– mobile vegetations >10 mm in diameter, and
– infection involving the mitral valve anterior leaflet

08/22/2025
Laboratory Findings
• CBC -NCNC anemia (70-90%) , thrombocytopenia(5-15%) ,
leukocytosis(20-30%), leukopenia(5-15%).
• ESR-60%, Hypergammaglobulinemia-20-
30% ,Hypocomplementemia 5-15%
• The urinalysis frequently is abnormal; proteinuria occurs in 50%
to 65% of cases, and microscopic hematuria occurs in 30% to
60% of cases.
• Red blood cell casts may be seen in 12% of cases.

08/22/2025
Blood culture
• no- of blood culture
– three blood cultures sets (each set consists of one aerobic bottle and anaerobic bottle)
detect 96 to 98 percent of bacteremia.
• Timing, volume (20ml)
• Interpretations- Most clinically significant bacteremias are detected within 48
hours; common and fastidious pathogens (such as members of the HACEK group)
are usually detected within five days of incubation
• Distinguishing between pathogenicity and contamination
– Cutibacterium acnes, Corynebacterium species, Bacillus species, and coagulase-negative
staphylococci.
– the likelihood of pathogenicity is increased if the organism is observed in multiple blood
cultures obtained by independent venipunctures.

08/22/2025
Echocardiography
• IE risk-prediction scoring systems have been developed to
identify patients, among those with one or more positive
monomicrobial blood cultures, who are at sufficient risk of IE
to justify echocardiographic assessment

08/22/2025
Staph; one of the list, E.faecalis and non-b hemolytic streptococci; 3 of the list

08/22/2025
• TEE is also more sensitive than conventional TTE in the detection of
intracardiac vegetations (approximately 95% vs. 60%–65%,
respectively), particularly in the setting of prosthetic valves
• The advantage of TEE was particularly evident for vegetations smaller
than 10 mm in diameter.
• If the clinical suspicion persists despite negative TEE, TEE should be
repeated after 7 days.
• TEE also has become the procedure of choice for the detection of
perivalvular extension of infection in patients with IE.

08/22/2025
• TEE is also superior to TTE for the detection of complications such
as perforations, prosthetic valve dehiscence, perivalvular
abscesses, and fistulas.
• Up to 30% of patients who undergo echocardiography have
inconclusive findings.
• To overcome this limitation, several nuclear medicine imaging
procedures have been examined over the past few years,
including
– WBC SPECT and
– fluorine-18 fluorodeoxyglucose positron emission
tomography (PET) with either computed tomography (F-FDG-
PET/CT) or computed tomography angiography (CTA)

08/22/2025
• PCR targeting 16S ribosomal RNA (or 28S rRNA, if fungi are
suspected) followed by sequencing for organism
identification.
• Next-generation (shotgun metagenomic) sequencing of
pathogen DNA from serum has emerged as a novel
nonculture technology capable of identifying a wide array of
organisms in blood culture–negative IE.

08/22/2025
Diagnosis
• Diagnostic Criteria
– the Beth Israel criteria-1982 Duke criteria -1994
Modiefied Duke criteria -2000 2023 Duke ISCVID

08/22/2025
Definite IE; 2 Major or 1 major and 3 minor or 5 minor
Possible IE : one major and one minor criteria or three minor criteria
IE is rejected if
 an alternative diagnosis is established,
 symptoms resolve and do not recur with ≤4 days of antibiotic therapy, or
 surgery or autopsy after ≤4 days of antimicrobial therapy yields no histologic
evidence of IE.

08/22/2025
WHAT IS NEW 2023 Duke-ISCVID?
• Changes in understanding of the epidemiology of IE.
– E. faecalis ,S. lugdunensis, all streptococci except S. pneumoniae and S.
pyogenes, Granulicatella spp, Abiotrophia spp, and Gemella spp.
• Advances in microbiologic diagnostic testing
– New major microbiologic criteria include:
 Blood PCR or amplicon/metagenomic sequencing identifying Coxiella burnetii,
Bartonella spp, or Tropheryma whipplei
 IFA for detection of antibodies to B. henselae or B. quintana, with IgG titer >1:800
 Advances in imaging
 cardiac CT and FDG PET/CT
 Value of operative findings

08/22/2025
Treatment
• To cure IE, all bacteria in the vegetation must be killed.
• The response to antimicrobial therapy for IE is unique among bacterial
infections.
1. The infection exists in an area of impaired host defense and is encased
tightly in a fibrin meshwork in which the bacterial colonies divide
relatively free from interference from phagocytic cells, and
2. The bacteria in these vegetations reach tremendous population
densities (often 10*9to 10*10CFUs/g).
less metabolicaly active and thus are less easily killed by antibiotics.

08/22/2025
General Principles
Intravenous
Longer durations
Bactericidal
Combinations synrgestic
 In every case of bacterial IE, the etiologic agent must be
isolated in pure culture and the MIC and MBC must be
determined for the usual antibiotics used

08/22/2025
Empirical Therapy and Treatment for Culture-Negative
IE
• In designing therapy to be administered before culture results are
known or when cultures are truly negative, clinical clues to etiology ;
• acute vs subacute presentation,
• NVE
• early or late PVE
• the patient’s predispositions
• epidemiologic clues
– (region of residence, animal exposure) must be considered

08/22/2025
• Empirical therapy for acute IE should cover MRSA and in a
PWID or for health care–associated NVE potentially antibiotic-
resistant gram-negative bacilli.
– Treatment with vancomycin plus gentamicin or cefepime, initiated
immediately after blood cultures are obtained, covers these organisms
• For empirical treatment of NVE with a subacute presentation,
vancomycin plus ceftriaxone is reasonable.

08/22/2025
• For early-onset PVE (<=1 year), the recommended empirical
regimen includes vancomycin, gentamicin, cefepime, and
rifampin, aiming to cover staphylococci, enterococci, and
aerobic gram-negative bacilli including Pseudomonas spp.
• Late onset of PVE (>1 year) is usually caused by staphylococci,
viridans-group streptococci, or enterococci.
– AHA and IDSA guidelines suggest a combination of vancomycin and
ceftriaxone.

08/22/2025
• In the absence of prior antibiotic therapy, it is unlikely that infection due to
S. aureus, CoNS, enterococci, or Enterobacterales will present with negative
blood cultures;
– recommended empirical therapy targets fastidious streptococci, Abiotrophia,
Granulicatella, the HACEK group, and Bartonella species.
Blood culture–negative subacute NVE is treated with vancomycin plus ampicillin-
sulbactam (12 g every 24 h) or ceftriaxone; doxycycline (100 mg twice daily) is added
for enhanced Bartonella coverage.
• If cultures are negative because of prior antibiotic administration, pathogens
likely to be inhibited by the specific prior therapy should be considered.

08/22/2025
• Outpatient parenteral antibiotic treatment (OPAT) or step-
down outpatient oral antibiotic treatment is used to
consolidate antimicrobial therapy once critical infection-
related complications are under control (e.g. perivalvular
abscesses, acute HF, septic emboli, and stroke) and the
patient is clinically stable.

08/22/2025
• The most common causes of death in IE, in approximate
order, are
– CHF,
– neurologic events,
– septic complications,embolic phenomena,
– rupture of a mycotic aneurysm,
– complications of cardiac surgery,
– lack of response to antimicrobial therapy, and
– prosthetic valve IE.

08/22/2025
SURGICAL INTERVENTION
• The goals of surgical intervention are to eliminate intracardiac foci of
infection with radical débridement and to restore hemodynamic stability
by placement of a new prosthesis.
• The optimal timing of surgical intervention is not clearly defined.
• Delaying surgery for additional days of antibiotics worsens the survival
rate and does not reduce the postoperative reinfection rate of the new
prosthetic valve.

08/22/2025
Management of specific situations

08/22/2025
Right-sided infective endocarditis
• The incidence of right-sided IE is increasing with time.
• Prognosis of such patients is better than left-sided IE, with the
exception of CIED- and indwelling catheter-related IE.

08/22/2025
Antithrombotic and anticoagulant therapy in infective
endocarditis
• Infective endocarditis by itself is not an indication for antithrombotics or
anticoagulants, and bleeding complications or stroke may justify
discontinuation or interruption of such therapies.
• Chronic anticoagulation is required for patients with mechanical
prostheses in order to prevent thromboembolic events.
• Anticoagulation may be continued with close clinical monitoring in the
setting of mechanical PVE because there is substantial risk of
thromboembolism if discontinued.
• Patients with a bioprosthetic valve do not require chronic anticoagulation
therapy.

08/22/2025
• In S. aureus left-sided PVE, anticoagulation therapy is
associated with increased risk of death due to neurologic
complications.
• Prior long-term administration of antiplatelet and/or statin
drugs before the onset of IE may reduce symptomatic embolic
events.
• Initiation of aspirin or statin in established IE to prevent
thromboembolic events is currently not recommended.

08/22/2025
Follow-up, outcome and long-term prognosis
• Patients should be monitored for signs of IE
recurrence, which includes relapse and reinfection.
• Relapse refers to a repeat episode of IE caused by the
same microorganism and represents a failure of
treatment.
• Reinfection describes an infection caused by a
different microorganism usually more than 6 months
after the initial episode, and is related to the patient’s
clinical and immunological profiles.
– It is also associated with worse outcomes.

08/22/2025
Monitoring Antimicrobial Therapy
• Blood tests to detect renal, hepatic, and hematologic toxicity should be
performed periodically.
• Serum concentrations of aminoglycosides and vancomycin should be
monitored and doses adjusted to optimize treatment and minimize
toxicity.
• Control of peripheral sites of infection—source control
• Blood cultures should be repeated daily until sterile in patients with IE due
to S. aureus or difficult-to-treat organisms, rechecked if there is
recrudescent fever, and performed again 4–6 weeks after therapy to
document cure.

08/22/2025
• Blood cultures become sterile after 2 days of appropriate therapy when
infection is caused by viridans streptococci, E. faecalis, or HACEK
organisms.
• In MSSA IE, β-lactam therapy results in sterile cultures in 3–5 days,
whereas in MRSA IE, the duration of bacteremia is often longer.
• When fever persists for 7 days despite appropriate antibiotic therapy,
patients should be evaluated further for
– paravalvular abscess,
– extracardiac abscesses (spleen, kidney), or
– complications (embolic events).

08/22/2025
• Death or poor outcome often is related not to failure of antibiotic
therapy but rather to the interactions of comorbidities and IE-related
end-organ complications.
• In developed countries, overall survival rates are 80–85%.
• About 85–90% of patients with NVE caused by viridans streptococci,
HACEK organisms, or enterococci (susceptible to synergistic therapy)
survive.
• For S. aureus NVE in patients who do not inject drugs, survival rates are
55–70%; rates are 85–90% among PWID.

08/22/2025
TAKE HOME MESSAGE
 Knowing the classifications of IE as (LIE vs RIE or both, NVE vs PVE, Acute
vs Subacute, CEID and epidemiological clues) important for empiric mng’t.
 what is new in 2023 duke ISCVID in additon to duke criteria -2000.
 IV,bactericidal,long duration and combination antibiotics to kill the hiden
microorganism
 up on specific microorganism treatment if possible try to avoid dual
nephhrotoxic drugs (vancomycin + gentamycin )
 Since RHD the main predisposing factors treat and prevention prevention
of acute rheumatic fever and RHD

08/22/2025
References
• MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF
INFECTIOUS DISEASES, NINTH EDITION.
• HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 21st
EDITION.
• 2023 ESC pocket guidelines for the management of endocarditis
• UPTODATE 2023
• Comprehensive Review of Infectious Diseases

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