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cardio.infective-endocarditis.core.v1

Infective endocarditis (Duke-ISCVID)

cardiologyacutesubacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

4-step pathogen-directed regimen (empirical → directed → POET → surgery) authored without RxCUIs (would need RxNav lookup); ED + inpatient setting playbooks; six severity triggers including ESC surgical indications, CIED infection, persistent bacteremia, large vegetation, septic shock, embolic stroke. No `_design-brief.md` in src/lib/tier3/problem-package/packages/infective-endocarditis — author one before promoting to PRODUCTION. Manifest cites 2023 ESC, AHA/ACC 2023 IE update, POET (Iversen NEJM 2019), ENDOVAL, ICE-PCS, EURO-ENDO, AATS 2024 — without inline PMIDs; backfill on next research pass. Add a Duke-ISCVID criteria calculator + ENDOVAL surgical-benefit calculator into clinical-tools-registry.ts before PRODUCTION.

Entry points (5)

  • symptom
    Fever + new murmur / vegetation (ACC/AHA 2022)
    fever_plus_murmur
  • lab_abnormality
    Persistent bacteremia (≥2 sets, typical organism) (ACC/AHA 2022)
    persistent_bacteremia
  • symptom
    Embolic stroke, septic emboli, Janeway / Osler / Roth (ACC/AHA 2022)
    embolic_phenomena
  • imaging
    TTE/TEE vegetation, abscess, prosthetic dehiscence (ACC/AHA 2022)
    echo_vegetation
  • problem_list
    CIED or prosthetic valve with infection concern (ACC/AHA 2022)
    cied_or_prosthetic_valve

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Age-related epidemiology + drug dosing (ACC/AHA 2022)
  • temprequired
    vital • used at RED_FLAGS
    Fever pattern + sepsis screen (ACC/AHA 2022)
  • sbprequired
    vital • used at RED_FLAGS
    Sepsis / septic shock detection (ACC/AHA 2022)
  • blood_culturesrequired
    lab • used at INITIAL_WORKUP
    Three sets BEFORE empirical abx (Duke major criterion) (ACC/AHA 2022)
  • tterequired
    imaging • used at INITIAL_WORKUP
    First-line; TEE for prosthetic / CIED / non-diagnostic TTE (ACC/AHA 2022)
  • tee
    imaging • used at INITIAL_WORKUP
    Required for prosthetic valve / CIED / suspected abscess (ACC/AHA 2022)
  • fdg_pet_ct
    imaging • used at BRANCHING_WORKUP
    2023 ESC modified criteria — prosthetic valve / CIED diagnostic
  • creatininerequired
    lab • used at TREATMENT
    Vancomycin / aminoglycoside / β-lactam dosing (ACC/AHA 2022)
  • prosthetic_valve
    history • used at CONTEXT
    Drives empirical abx + abscess risk + surgery threshold (ACC/AHA 2022)
  • cied
    history • used at CONTEXT
    CIED IE → complete extraction (ACC/AHA 2022)
  • pwid
    history • used at CONTEXT
    Right-sided IE; typically S. aureus (ACC/AHA 2022)
  • allergies
    history • used at CONTEXT
    β-lactam / vancomycin allergy alters regimen (ACC/AHA 2022)

12-phase flow (12)

  1. 1FRAME
    Activate Endocarditis Team (cards, ID, CT surgery) per 2023 ESC
    inputs: blood_cultures, tte
    advance: Endocarditis Team engaged
  2. 2ENTRY
    Recognize IE features (fever, murmur, embolic, persistent bacteremia) (ACC/AHA 2022)
    inputs: age, temp
    advance: IE suspicion established
  3. 3CONTEXT
    Risk factors (prosthetic, CIED, IVDU, dental, recent procedure), allergies, prior IE (ACC/AHA 2022)
    inputs: prosthetic_valve, cied, pwid, allergies
    advance: context complete
  4. 4RED_FLAGS
    Sepsis / septic shock; HF from valvular destruction; embolic stroke; uncontrolled infection (ACC/AHA 2022)
    inputs: sbp, temp
    actions: sepsis_bundle, cellulitis_necfasc
    advance: shock + HF + stroke screened
  5. 5INITIAL_WORKUP
    3 BC sets (different sites, ≥1 hour apart) BEFORE abx; CBC, BMP, CRP, ESR, UA, ECG; STAT TTE (ACC/AHA 2022)
    inputs: blood_cultures, tte, creatinine
    actions: panel.cardiac, panel.renal, panel.cbc, panel.inflammation, endocarditis
    advance: baseline workup + first echo done
  6. 6BRANCHING_WORKUP
    TEE if prosthetic / CIED / inconclusive TTE; FDG-PET/CT for prosthetic / CIED per 2023 ESC; cardiac CT for abscess; cerebral MRI for embolic; dental panoramic; CT C/A/P for embolic foci
    inputs: tee, fdg_pet_ct
    advance: modified Duke-ISCVID criteria evaluated
  7. 7DIFFERENTIAL
    Definite vs possible IE per Duke-ISCVID; native vs prosthetic vs CIED; left- vs right-sided; organism-specific phenotype (ACC/AHA 2022)
    advance: classification documented
  8. 8RISK_STRATIFICATION
    Surgical indications (HF, uncontrolled infection, large vegetation >10 mm with embolic risk, prosthetic, abscess, perivalvular extension, persistent bacteremia) (ACC/AHA 2022)
    actions: calc.sofa
    advance: surgical risk + ENDOVAL documented
  9. 9TREATMENT
    Empirical abx (vanc + ceftriaxone ± ampicillin) AFTER cultures; pathogen-directed at speciation; native S. aureus — no routine gentamicin; partial oral switch (POET) once stable on left-sided IE; CIED → complete extraction; surgery per ≥1 of 8 ESC indications
    inputs: creatinine, allergies
    actions: protocol.septic_shock
    advance: pathogen-directed regimen + surgical plan documented
  10. 10DISPOSITION
    ICU if hemodynamically unstable; cardiothoracic transfer for surgery; OPAT planning if low-risk + responsive (ACC/AHA 2022)
    advance: unit + service alignment
  11. 11MONITORING
    Daily blood cultures until sterile; weekly CRP / ESR trend; vanc trough/AUC monitoring; ophtho for embolic; weekly creatinine (ACC/AHA 2022)
    inputs: creatinine
    actions: panel.renal
    advance: sterile cultures and clinical response documented
  12. 12FOLLOWUP
    Post-treatment echo; dental clearance; long-term IE prophylaxis per AHA/ESC indications
    advance: long-term plan in place