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cardio.infective-endocarditis.core.v1PRODUCTION
cardio.infective-endocarditis.core.v1

Infective endocarditis (Duke-ISCVID)

cardiologyacutesubacuteadult
Hard-required inputs
0 / 6
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Activate Endocarditis Team (cards, ID, CT surgery) per 2023 ESC

Inputs
2
Actions
0
Advance rule
Set
Advance when

Endocarditis Team engaged

Patient inputs (12)

Age-related epidemiology + drug dosing (ACC/AHA 2022)

Three sets BEFORE empirical abx (Duke major criterion) (ACC/AHA 2022)

First-line; TEE for prosthetic / CIED / non-diagnostic TTE (ACC/AHA 2022)

Fever pattern + sepsis screen (ACC/AHA 2022)

Sepsis / septic shock detection (ACC/AHA 2022)

Vancomycin / aminoglycoside / β-lactam dosing (ACC/AHA 2022)

2023 ESC modified criteria — prosthetic valve / CIED diagnostic

Drives empirical abx + abscess risk + surgery threshold (ACC/AHA 2022)

CIED IE → complete extraction (ACC/AHA 2022)

Right-sided IE; typically S. aureus (ACC/AHA 2022)

β-lactam / vancomycin allergy alters regimen (ACC/AHA 2022)

Required for prosthetic valve / CIED / suspected abscess (ACC/AHA 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningseptic_shock_in_ie
    IE complicated by septic shock (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningembolic_stroke
    Acute stroke as IE complication (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereesc_surgical_indications
    ≥1 of: HF from valve destruction / uncontrolled infection / abscess / persistent bacteremia >5 d / vegetation >10 mm + embolic / prosthetic / perivalvular extension (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecied_infection
    CIED system infection (pocket, lead, valve) (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_bacteremia
    BCs positive >5 d on appropriate abx (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelarge_vegetation_embolic_risk
    Vegetation >10 mm + ≥1 embolic event OR vegetation >15 mm (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
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Recommended regimen

IE pathogen-directed antibiotics + surgical decision (2023 AHA/ACC + ESC)
axis: ie_pathogen_directed_abxstep 1 - Step 1 — Empirical (after 3 BC sets, before culture results)
Selected step "Step 1 — Empirical (after 3 BC sets, before culture results)" — Suspected IE with hemodynamic instability or rapidly progressive
  • vancomycin
    first line
    glycopeptide
    25–30 mg/kg load IV → 15–20 mg/kg q8–12h targeting AUC24 400–600 • IV • q8–12h
    triggers: empirical_native_IE
    Covers MRSA + Streptococci; AUC-guided dosing (ACC/AHA 2022)
    rxcui 11124
  • ceftriaxone
    first line
    cephalosporin_3rd_gen
    2 g IV q24h • IV • q24h
    triggers: empirical_native_IE
    Covers Streptococci, HACEK (ACC/AHA 2022)
    rxcui 2193
  • ampicillin
    add on
    aminopenicillin
    2 g IV q4h • IV • q4h
    triggers: empirical_with_enterococcal_risk, prosthetic_valve_IE
    Covers Enterococci (ACC/AHA 2022)
    rxcui 733
  • gentamicin
    add on
    aminoglycoside
    3 mg/kg/d IV (divided q8h or once daily) — synergy • IV • q8h
    triggers: enterococcal_synergy, prosthetic_valve_with_specific_organisms
    AHA 2015 — no longer routine for native S. aureus IE
    rxcui 1596450

ed playbook — drug actions (3)

  1. 1. empirical vancomycin + ceftriaxone
    Vanc 25–30 mg/kg load + ceftriaxone 2 g IV • IV • load now
    trigger: Hemodynamic instability or rapidly progressive after BCs drawn (ACC/AHA 2022)
    Cover MRSA + Strep + HACEK (ACC/AHA 2022)
  2. 2. add ampicillin if enterococcal risk
    2 g IV q4h • IV • q4h
    trigger: Older / GU instrumentation / prosthetic valve (ACC/AHA 2022)
    Cover Enterococci (ACC/AHA 2022)
  3. 3. sepsis bundle if septic
    Per SSC 2026 • IV • per protocol
    trigger: Septic shock from IE (ACC/AHA 2022)
    Hour-1 bundle (ACC/AHA 2022)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Fever + new murmur / vegetation (ACC/AHA 2022); Persistent bacteremia (≥2 sets, typical organism) (ACC/AHA 2022); Embolic stroke, septic emboli, Janeway / Osler / Roth (ACC/AHA 2022).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Infective endocarditis (Duke-ISCVID)** (cardio.infective-endocarditis.core.v1).
Phenotype framing: Definite vs possible IE per Duke-ISCVID; native vs prosthetic vs CIED; left- vs right-sided; organism-specific phenotype (ACC/AHA 2022)
Scope: Activate Endocarditis Team (cards, ID, CT surgery) per 2023 ESC

No severity triggers fired against current inputs.

Plan

Regimen axis: **IE pathogen-directed antibiotics + surgical decision (2023 AHA/ACC + ESC)** — step "Step 1 — Empirical (after 3 BC sets, before culture results)".
1. vancomycin 25–30 mg/kg load IV → 15–20 mg/kg q8–12h targeting AUC24 400–600 IV q8–12h (glycopeptide, first line) — Covers MRSA + Streptococci; AUC-guided dosing (ACC/AHA 2022)
2. ceftriaxone 2 g IV q24h IV q24h (cephalosporin_3rd_gen, first line) — Covers Streptococci, HACEK (ACC/AHA 2022)
3. ampicillin 2 g IV q4h IV q4h (aminopenicillin, add on) — Covers Enterococci (ACC/AHA 2022)
4. gentamicin 3 mg/kg/d IV (divided q8h or once daily) — synergy IV q8h (aminoglycoside, add on) — AHA 2015 — no longer routine for native S. aureus IE

Setting playbook (ed) — Recognise IE features, draw 3 BCs BEFORE empirical abx, perform STAT TTE, activate Endocarditis Team if criteria met (ACC/AHA 2022)
5. empirical vancomycin + ceftriaxone Vanc 25–30 mg/kg load + ceftriaxone 2 g IV IV load now — Hemodynamic instability or rapidly progressive after BCs drawn (ACC/AHA 2022) (Cover MRSA + Strep + HACEK (ACC/AHA 2022))
6. add ampicillin if enterococcal risk 2 g IV q4h IV q4h — Older / GU instrumentation / prosthetic valve (ACC/AHA 2022) (Cover Enterococci (ACC/AHA 2022))
7. sepsis bundle if septic Per SSC 2026 IV per protocol — Septic shock from IE (ACC/AHA 2022) (Hour-1 bundle (ACC/AHA 2022))

Non-pharmacologic actions:
- Endocarditis Team consult (cards + ID + CT surgery) (ACC/AHA 2022)
- TEE if prosthetic valve / CIED / inconclusive TTE (ACC/AHA 2022)
- Cardiothoracic surgery if HF / abscess / large vegetation (ACC/AHA 2022)
- Admit telemetry / ICU per stability (ACC/AHA 2022)

AVOID / contraindication checks:
- Vancomycin_AUC_monitoring_targeted (ACC/AHA 2022)
- Gentamicin_renal_otoxicity_monitor (ACC/AHA 2022)
- Rifampin_drug_drug_warfarin_DOAC_protease (ACC/AHA 2022)
- Daptomycin_NOT_for_pneumonia_surfactant_inactivation (ACC/AHA 2022)
- Linezolid_serotonin_+_thrombocytopenia_>2wk (ACC/AHA 2022)

Monitoring

Regimen monitoring:
- daily BC until sterile (ACC/AHA 2022)
- weekly CBC BMP LFT (ACC/AHA 2022)
- vanc AUC q3-5 days (ACC/AHA 2022)
- gentamicin peak trough (ACC/AHA 2022)
- CK weekly on daptomycin (ACC/AHA 2022)
- CRP ESR trend (ACC/AHA 2022)
- serial TTE then TEE at 7-10d per response (ACC/AHA 2022)
- echo pre-discharge for residual lesion (ACC/AHA 2022)

Setting (ed) monitoring:
- Vitals continuous (ACC/AHA 2022)
- Repeat BCs every 24 h (ACC/AHA 2022)
- CRP / ESR baseline (ACC/AHA 2022)

Follow-up plan: Post-treatment echo; dental clearance; long-term IE prophylaxis per AHA/ESC indications
- Close-out criterion: long-term plan in place

Monitoring phase: Daily blood cultures until sterile; weekly CRP / ESR trend; vanc trough/AUC monitoring; ophtho for embolic; weekly creatinine (ACC/AHA 2022)

Disposition

Current setting: ed — Recognise IE features, draw 3 BCs BEFORE empirical abx, perform STAT TTE, activate Endocarditis Team if criteria met (ACC/AHA 2022)

Disposition criteria:
- Admit telemetry: hemodynamically stable, on IV abx (ACC/AHA 2022)
- Admit ICU: septic shock, HF from IE, embolic stroke (ACC/AHA 2022)

Escalation triggers (move to higher acuity):
- Septic shock → ICU + hour-1 bundle (ACC/AHA 2022)
- HF from valvular destruction → STAT cardiothoracic surgery (ACC/AHA 2022)
- Embolic stroke → stroke unit + neurosurgical considerations (ACC/AHA 2022)
- Persistent bacteremia >5 d → reassess source, source control, possibly surgery (ACC/AHA 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] IE complicated by septic shock (ACC/AHA 2022)
- [LIFE_THREATENING] Acute stroke as IE complication (ACC/AHA 2022)
- [SEVERE] ≥1 of: HF from valve destruction / uncontrolled infection / abscess / persistent bacteremia >5 d / vegetation >10 mm + embolic / prosthetic / perivalvular extension (ACC/AHA 2022)

Citations

- 2023 AHA/ACC IE focused update + ESC 2023 IE Guidelines + Duke-ISCVID 2023 + POET (NEJM 2019) [PMID:30152252](https://pubmed.ncbi.nlm.nih.gov/30152252/)
- Cited evidence (PMID 37622656) [PMID:37622656](https://pubmed.ncbi.nlm.nih.gov/37622656/)
- Cited evidence (PMID 26373316) [PMID:26373316](https://pubmed.ncbi.nlm.nih.gov/26373316/)
- Cited evidence (PMID 37138445) [PMID:37138445](https://pubmed.ncbi.nlm.nih.gov/37138445/)
- Cited evidence (PMID 31504413) [PMID:31504413](https://pubmed.ncbi.nlm.nih.gov/31504413/)

Last reconciled with current guidelines: 2026-05-10.
References