Patient handout

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

PRODUCTION

1. Your condition

This handout is for infective endocarditis (native / prosthetic / cied / right-sided). Your care team identified this based on: ≥ 2 separate blood cultures positive with ie-suggestive species (s. aureus, viridans strep, hacek, enterococcus, coxiella) (aha 2015; duke 2023).

Other reasons your team may use this plan: fever + new regurgitant murmur (duke minor + lr+ ≈ 6 per fowler 2003); vegetation on tte/tee, paravalvular abscess, pseudoaneurysm, valve dehiscence (aha 2015; esc 2023; habib 2015 imaging position paper); prosthetic valve / cied + bacteremia (esc 2023 class i).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
vancomycin	25-30 mg/kg IV load × 1 → 15-20 mg/kg IV q8-12 h targeting AUC24 400-600 mg·h/L	IV	q8-12h (AUC-titrated)	AHA 2015 + ESC 2023 + Rybak ASHP/IDSA 2020 — covers MRSA + CoNS + viridans strep + most Enterococcus; AUC-targeted dosing 2026 standard (PMID 32191793)
ceftriaxone	2 g IV q24h (q12h for HACEK/enterococcal AMPI-CEFTRI regimen)	IV	q24h (q12h for AMPI-CEFTRI)	AHA 2015 + ESC 2023 — first-line for viridans strep / HACEK; AMPI-CEFTRI partner for E. faecalis (Fernández-Hidalgo CID 2013 PMID 23392394)
cefepime	2 g IV q8h (extended infusion 3-4 h preferred in shock)	IV	q8h	AHA 2015 — anti-pseudomonal cover for acute/septic native valve IE; IDU phenotype; renal adjust for CrCl < 60
gentamicin	3 mg/kg/d IV single daily dose	IV	daily	AHA 2015 — synergy for enterococcal IE when isolate susceptible (not HLAR/HLGR); ESC 2023 drops gent for staph IE due to nephrotoxicity outweighing benefit; weekly CrCl + audiogram

Plan: Native valve IE empiric — vancomycin AUC + ceftriaxone (subacute) OR vancomycin + cefepime (acute septic) (AHA 2015; ESC 2023)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Heart failure from valvular dysfunction (acute regurgitation, dehiscence, or obstruction) — Class I indication for emergent cardiothoracic surgical evaluation within 24-48 h; mortality if delayed (AHA 2015; ESC 2023)(life-threatening)
Prosthetic valve IE within 12 mo of implantation — early PVE; CoNS / S. aureus / GNR dominant; vancomycin + gentamicin + rifampin + emergent cardiothoracic surgical consultation; high mortality without surgery (AHA 2015; ESC 2023)(life-threatening)
Vegetation > 10 mm + ≥ 1 embolic event OR vegetation > 15 mm without embolic — Class I indication for surgical evaluation per AHA 2015 + ESC 2023 (embolic prevention)
Blood cultures still positive ≥ 5 d on susceptibility-directed regimen → abscess workup + repeat TEE + emergent cardiothoracic surgical evaluation; routes to id.sepsis.core.v1 for persistent-bacteremia management (AHA 2015; ESC 2023; Fowler 2003)
Cardiac implantable electronic device + vegetation on lead → device extraction by electrophysiology / cardiothoracic surgery (ESC 2023 Class I); targeted antibiotics ≥ 4-6 wk after extraction; routing to interventional EP / CT surgery (ESC 2023)(life-threatening)
IDU history + tricuspid vegetation OR septic pulmonary emboli → vancomycin + cefepime (cover S. aureus + Gram-negative incl. P. aeruginosa); surgical evaluation for persistent bacteremia or large vegetation; OUD linkage to psych.opioid_use_disorder.core.v1 (AHA 2015)
Stroke during IE (ischemic or hemorrhagic) — emergent neurologic evaluation + brain imaging; surgical timing for IE controversial post-stroke (post-stroke surgery acceptable for non-hemorrhagic + neurologic improvement per ESC 2023; defer 2-4 wk if hemorrhagic); routes to neuro engine if exists (AHA 2015; ESC 2023)(life-threatening)
Septic emboli → vascular wall infection → mycotic aneurysm — CT angiography + interventional radiology / neurosurgery consult; surgical / endovascular treatment (AHA 2015; ESC 2023)(life-threatening)
Negative blood cultures despite high clinical suspicion (typically prior abx OR atypical pathogens) → empiric for atypicals (doxycycline for Coxiella/Bartonella + HCQ); serologic + molecular workup (Bartonella IgG + Coxiella phase-I IgG + Brucella serology + Tropheryma 16S rRNA PCR on excised valve tissue) (AHA 2015; Duke 2023)
IE complication: splenic abscess / vertebral osteomyelitis / hepatic abscess / brain abscess from embolic + seeding → cross-sectional imaging + extended treatment + surgical drainage if drainable (AHA 2015)
Candida or Aspergillus on blood culture or excised-valve histopathology → echinocandin (caspofungin / micafungin / anidulafungin) → lipid AmB + flucytosine for severe; voriconazole for Aspergillus; emergent cardiothoracic surgery; lifelong PO azole suppression if cannot surgicate; routes to id.candidemia.core.v1 or id.invasive-aspergillosis.core.v1 (Pappas IDSA 2016; AHA 2015)(life-threatening)

5. Follow-up

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)

6. Sources

Guideline: AHA Infective Endocarditis 2015 (Baddour, Circulation 2015 PMID 26373316) + ESC Endocarditis 2023 (Delgado, Eur Heart J 2023 PMID 37622656) — co-canonical US + European 2026 standards. Supplemented by POET trial (Iversen NEJM 2019 PMID 30152252) for PO step-down, modified Duke criteria 2023 (Fowler CID 2023) for diagnostic definition, IDSA Candidiasis 2016 (Pappas PMID 26679628) for fungal IE, ASHP/IDSA Vancomycin AUC 2020 (Rybak PMID 32191793) for vanco dosing, Fernández-Hidalgo AMPI-CEFTRI 2013 (PMID 23392394) for E. faecalis.