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id.endocarditis.core.v1

Infective endocarditis (native / prosthetic / CIED / right-sided)

infectious_diseaseacutesubacuteadultacuteinpatient
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New engine authored 2026-05-15 (shard-5-obped-id Phase C wave 4) — closes the narrative-only routing references from id.crbsi.core.v1 (sibling-differentiation features + S. aureus CRBSI → endocarditis sub-pathway) and id.candidemia.core.v1 (fungal IE sub-pathway, TEE indication). Manifest pointer reuses prisma/seed/manifests/id.sepsis.core.v1.ts as the nearest-ID precedent per shard authoring instruction; dedicated endocarditis manifest deferred to a future Phase D wave. Backbone evidence: AHA Endocarditis 2015 (PMID 26373316) + ESC Endocarditis 2023 (PMID 37622656) co-canonical. ESC 2023 introduces CIED-IE expansion, earlier surgery indications, OPAT formalisation, PET-CT imaging algorithm, and drops gent for staph IE due to nephrotoxicity outweighing benefit. POET trial (PMID 30152252) is wired as the ie_poet_oral_step_down regimen axis for eligible stable left-sided IE after ≥ 10 d IV. Phenotype-driven empiric regimens: native subacute (vanco + ceftriaxone); native acute septic (vanco + cefepime); prosthetic early < 12 mo (vanco + gent + rifampin); prosthetic late ≥ 12 mo (vanco + ceftriaxone + rifampin); CIED (vanco + cefepime + rifampin + device extraction Class I); IDU right-sided (vanco + cefepime + OUD linkage). Surgical indications Class I per AHA 2015 + ESC 2023: heart failure from valvular dysfunction, persistent bacteremia despite appropriate abx, paravalvular abscess, large vegetation > 10 mm + embolic OR > 15 mm without embolic, prosthetic dehiscence, fungal IE, CIED-IE (device extraction). Bayesian linkage (per §5.5.2): TEE LR+ ≈ 10 / LR− ≈ 0.1 (Habib 2015); TTE LR+ ≈ 5; ≥ 2 separate cultures + IE-suggestive species LR+ ≈ 8 (Duke major); persistent bacteremia ≥ 5 d LR+ ≈ 4 (Fowler 2003); new murmur LR+ ≈ 6 (Fowler 2003); PET-CT on prosthetic/CIED LR+ ≈ 8 (ESC 2023). T_treat ≈ 15-20%; T_test ≈ 5%. Cross-dossier routing edges to id.crbsi.core.v1, id.candidemia.core.v1, id.sepsis.core.v1, psych.opioid_use_disorder.core.v1, neuro.ischaemic-stroke.v1, id.opportunistic-infection.hiv-transplant.v1. Pathogen-targeted axis: penicillin G or ceftriaxone for viridans strep PCN-S (4 wk native / 6 wk prosthetic); nafcillin or cefazolin for MSSA (6 wk); vanco or dapto for MRSA (6 wk); AMPI-CEFTRI for E. faecalis (6 wk; Fernández-Hidalgo 2013); ceftriaxone for HACEK; echinocandin → lipid AmB + flucytosine → fluconazole lifelong for fungal IE; doxycycline + HCQ ≥ 18 mo for Coxiella; daptomycin or linezolid for VRE. POET PO step-down axis (Iversen NEJM 2019) for eligible stable left-sided IE: amoxicillin (strep/enterococcus), linezolid + rifampin (staph), moxifloxacin + rifampin (HACEK); excludes right-sided IE, IDU, paravalvular abscess, Candida, unstable patients; weekly OPAT-clinic monitoring required. IDU + right-sided IE pathway routes bidirectionally to psych.opioid_use_disorder.core.v1 for OUD linkage + harm reduction + naloxone distribution + addiction medicine consult. S. gallolyticus IE triggers mandatory colonoscopy (colon cancer association) per AHA 2015; captured as safety rule in pathogen-targeted regimen contraindication_rules. Pediatric IE (congenital heart disease overlay), cardiac transplant IE, and right-sided POET extension deferred to future Phase C/D waves; current dossier scoped to adult native / prosthetic / CIED / IDU phenotypes. Registry batch-add deferred per shard authoring instruction: this dossier is NOT yet wired into src/lib/dossiers/_registry.ts — the main session will batch-add post-wave.

Entry points (6)

  • lab_abnormality
    ≥ 2 separate blood cultures positive with IE-suggestive species (S. aureus, viridans strep, HACEK, enterococcus, Coxiella) (AHA 2015; Duke 2023)
    persistent_bacteremia_with_ie_suggestive_species
  • symptom
    Fever + new regurgitant murmur (Duke minor + LR+ ≈ 6 per Fowler 2003)
    fever_plus_new_regurgitant_murmur
  • imaging
    Vegetation on TTE/TEE, paravalvular abscess, pseudoaneurysm, valve dehiscence (AHA 2015; ESC 2023; Habib 2015 imaging position paper)
    echocardiographic_vegetation
  • problem_list
    Prosthetic valve / CIED + bacteremia (ESC 2023 Class I)
    prosthetic_valve_or_cied_with_bacteremia
  • symptom
    Embolic phenomena (stroke, splenic infarct, mycotic aneurysm, Janeway/Osler/Roth) with bacteremia (Duke 2023 minor)
    embolic_phenomena_with_bacteremia
  • problem_list
    IDU + fever or septic pulmonary emboli — right-sided IE workup (AHA 2015)
    idu_with_fever_or_tricuspid_signs

Required inputs (24)

  • temperaturerequired
    vital • used at ENTRY
    Fever is a Duke minor criterion + universal IE sentinel sign (AHA 2015; Duke 2023)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension from valvular HF or septic shock drives ICU + emergent surgical evaluation (AHA 2015; ESC 2023)
  • heart_rate
    vital • used at RED_FLAGS
    Tachycardia component of qSOFA / SIRS; HF tachycardia (AHA 2015)
  • valve_type_native_vs_prostheticrequired
    history • used at CONTEXT
    Drives empiric regimen (native vs prosthetic vs CIED) + duration + surgical threshold (AHA 2015; ESC 2023)
  • time_since_prosthetic_implant
    history • used at CONTEXT
    Early (< 12 mo) vs late (≥ 12 mo) prosthetic IE drives empirics + rifampin role (AHA 2015; ESC 2023)
  • cardiac_implantable_electronic_device
    history • used at CONTEXT
    CIED-IE → device extraction Class I + targeted abx (ESC 2023)
  • idu_active_or_recent
    history • used at CONTEXT
    Right-sided IE phenotype; S. aureus dominant + GNR/Candida possible; OUD linkage (AHA 2015)
  • dental_or_gu_or_gi_procedure
    history • used at CONTEXT
    Source consideration for viridans strep / enterococcus / S. gallolyticus (which mandates colonoscopy) (AHA 2015)
  • prior_ie_history
    history • used at CONTEXT
    Strong predisposing condition; Duke minor criterion (AHA 2015; Duke 2023)
  • immunocompromised_or_dialysis
    history • used at CONTEXT
    Broader empirics + higher mortality + special pathogens (AHA 2015; ESC 2023)
  • blood_cultures_3_setsrequired
    lab • used at INITIAL_WORKUP
    Duke major criterion; obtain ≥ 3 sets over ≥ 1 h from separate sites BEFORE first abx unless shock (AHA 2015; ESC 2023)
  • creatininerequired
    lab • used at TREATMENT
    Vanco AUC dosing, gentamicin renal clearance, dapto CrCl < 30 q48 h, AmB nephrotoxicity (Rybak 2020; DailyMed)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis Duke minor; cytopenia from linezolid; baseline for vanco/dapto monitoring (AHA 2015)
  • lft
    lab • used at MONITORING
    Hepatotoxicity monitoring (linezolid, dapto, rifampin) + sepsis bilirubin (AHA 2015)
  • esr_crp
    lab • used at INITIAL_WORKUP
    Inflammatory markers for response monitoring (AHA 2015; ESC 2023)
  • creatine_kinase
    lab • used at MONITORING
    Daptomycin weekly CK for rhabdomyolysis (DailyMed dapto label)
  • urinalysis
    lab • used at INITIAL_WORKUP
    Hematuria / glomerulonephritis (Duke minor immunologic) (AHA 2015; Duke 2023)
  • serologies_culture_negative_panel
    lab • used at BRANCHING_WORKUP
    Coxiella phase-I IgG ≥ 1:800 (Duke major), Bartonella IgG ≥ 1:800, Brucella, Tropheryma 16S rRNA on excised valve (AHA 2015; Duke 2023)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    New AV block suggests paravalvular abscess (high specificity); baseline for QTc monitoring on QT-prolonging agents (AHA 2015)
  • echocardiogram_tterequired
    imaging • used at INITIAL_WORKUP
    Initial screen; LR+ ≈ 5 for vegetation; rapid bedside availability (AHA 2015; Habib 2015)
  • echocardiogram_tee
    imaging • used at BRANCHING_WORKUP
    Preferred for IE diagnosis; LR+ ≈ 10, LR− ≈ 0.1; mandatory for prosthetic valve + suspected paravalvular complication (AHA 2015; ESC 2023; Habib 2015)
  • pet_ct_or_cardiac_ct
    imaging • used at BRANCHING_WORKUP
    PET-CT LR+ ≈ 8 for prosthetic / CIED when TEE equivocal; cardiac CT for paravalvular complications (ESC 2023)
  • brain_mri_or_ct
    imaging • used at BRANCHING_WORKUP
    Suspected embolic stroke; mycotic aneurysm (AHA 2015; ESC 2023)
  • ct_chest_abdomen_pelvis
    imaging • used at BRANCHING_WORKUP
    Septic emboli (pulmonary in right-sided IE; splenic / hepatic / renal infarcts in left-sided) (AHA 2015)

12-phase flow (12)

  1. 1FRAME
    Confirm infective endocarditis scope per modified Duke 2023 criteria (definite / possible / rejected) (AHA 2015; Duke 2023 Fowler)
    advance: scope confirmed: clinical compatibility + ≥ 1 Duke major OR ≥ 3 Duke minor
  2. 2ENTRY
    Bacteremia with IE-suggestive species + clinical compatibility OR echocardiographic vegetation OR fever + new murmur OR CIED/prosthetic-valve bacteremia OR IDU+fever (AHA 2015; ESC 2023)
    inputs: temperature
    advance: entry trigger validated
  3. 3CONTEXT
    Capture valve type (native / prosthetic), time-since-implant for prosthetic, CIED presence, IDU status, source (dental / GI / GU / skin / line), prior IE, immunocompromise, dialysis (AHA 2015; ESC 2023)
    inputs: valve_type_native_vs_prosthetic
    advance: phenotype matrix populated; empiric regimen selectable
  4. 4RED_FLAGS
    Heart failure from valvular dysfunction (Class I surgery), persistent bacteremia ≥ 5 d, large vegetation > 10 mm + embolic, paravalvular abscess, fungal IE, prosthetic dehiscence, embolic stroke, CIED with lead vegetation (AHA 2015; ESC 2023)
    inputs: sbp
    actions: calc.qsofa
    advance: surgical/ICU stratification made; cardiothoracic surgery activated if Class I
  5. 5INITIAL_WORKUP
    ≥ 3 sets of blood cultures over ≥ 1 h from separate sites BEFORE first abx (unless septic shock); TTE; ECG; CBC; BMP; LFT; ESR/CRP; UA (AHA 2015; ESC 2023)
    inputs: blood_cultures_3_sets, cbc, creatinine, ecg, echocardiogram_tte
    advance: baseline diagnostic set complete; empirics started if high pretest + cultures drawn
  6. 6BRANCHING_WORKUP
    TEE within 12-24 h (preferred over TTE for any non-low pretest); PET-CT or cardiac CT for prosthetic / CIED if TEE equivocal; brain MRI for stroke; CT chest/abdomen/pelvis for embolic; culture-negative serology panel (Coxiella, Bartonella, Brucella) + 16S PCR on excised valve (AHA 2015; ESC 2023; Habib 2015)
    inputs: echocardiogram_tee
    advance: TEE result + ancillary imaging + culture-negative workup complete or deferred per pathogen
  7. 7DIFFERENTIAL
    Distinguish IE from non-bacterial thrombotic endocarditis (marantic, Libman-Sacks SLE), atrial myxoma, acute rheumatic fever, valve calcification, false-positive vegetation; refine pathogen category (typical vs HACEK vs atypical vs fungal vs culture-negative) (AHA 2015; Duke 2023)
    advance: IE confirmed (definite / possible) or alternative dx established
  8. 8RISK_STRATIFICATION
    Duke criteria 2023; PALSUSE score for in-hospital mortality; vegetation size; valve function (TTE); embolic risk (vegetation > 10 mm + ≥ 1 embolic, > 15 mm without); HF risk; surgical threshold (AHA 2015; ESC 2023; Duke 2023)
    inputs: sbp, heart_rate
    actions: calc.qsofa, calc.sofa
    advance: severity tier + surgical decision made
  9. 9TREATMENT
    Phenotype-driven empirics (native / prosthetic-early / prosthetic-late / CIED / IDU); pathogen-targeted post-cultures; surgical evaluation in parallel; POET PO step-down if eligible after ≥ 10 d IV (stable left-sided + susceptible Streptococcus / E. faecalis / MSSA / CoNS; excludes right-sided / IDU / abscess / Candida / unstable) (AHA 2015; ESC 2023; Iversen NEJM 2019)
    inputs: creatinine
    advance: empirics active within 1 h of recognition (or after cultures if not in shock); pathogen-targeted de-escalation at species + susceptibility result
  10. 10DISPOSITION
    ICU if shock / valvular HF / embolic stroke; cardiothoracic surgical service if Class I surgical; inpatient + ID consult for medical management; OPAT after stable + susceptible + reliable (AHA 2015; ESC 2023; Norris IDSA OPAT 2018)
    inputs: sbp
    advance: level of care set; ID consulted; cardiothoracic surgery activated if surgical
  11. 11MONITORING
    Daily blood cultures until 2 consecutive negatives; weekly TTE if vegetation; vanco AUC q3-5 d; gent CrCl + audiogram weekly; dapto CK weekly; LFT q3-7 d on rifampin / linezolid / dapto; new AV block → repeat TEE for abscess (AHA 2015; ESC 2023; Rybak 2020)
    inputs: lft, creatinine, creatine_kinase
    actions: panel.lft, panel.renal
    advance: cultures cleared at 48-72 h; otherwise re-evaluate source (abscess, retained device, metastatic seeding)
  12. 12FOLLOWUP
    OPAT 2-4 wk after stable; outpatient cardiology + ID; repeat TTE at 4-6 wk + post-treatment baseline; IE-prophylaxis counseling (dental procedures with high-risk cardiac conditions per AHA 2007); OUD linkage if IDU; recurrence prevention (AHA 2015; AHA prophylaxis 2007; ESC 2023)
    advance: OPAT + ID + cardiology f/u scheduled; IE-prophylaxis education delivered