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id.endocarditis.core.v1PRODUCTION
id.endocarditis.core.v1

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

infectious_diseaseacutesubacuteadult
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Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm infective endocarditis scope per modified Duke 2023 criteria (definite / possible / rejected) (AHA 2015; Duke 2023 Fowler)

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scope confirmed: clinical compatibility + ≥ 1 Duke major OR ≥ 3 Duke minor

Patient inputs (24)

Drives empiric regimen (native vs prosthetic vs CIED) + duration + surgical threshold (AHA 2015; ESC 2023)

Fever is a Duke minor criterion + universal IE sentinel sign (AHA 2015; Duke 2023)

Duke major criterion; obtain ≥ 3 sets over ≥ 1 h from separate sites BEFORE first abx unless shock (AHA 2015; ESC 2023)

Leukocytosis Duke minor; cytopenia from linezolid; baseline for vanco/dapto monitoring (AHA 2015)

New AV block suggests paravalvular abscess (high specificity); baseline for QTc monitoring on QT-prolonging agents (AHA 2015)

Initial screen; LR+ ≈ 5 for vegetation; rapid bedside availability (AHA 2015; Habib 2015)

Hypotension from valvular HF or septic shock drives ICU + emergent surgical evaluation (AHA 2015; ESC 2023)

Vanco AUC dosing, gentamicin renal clearance, dapto CrCl < 30 q48 h, AmB nephrotoxicity (Rybak 2020; DailyMed)

Coxiella phase-I IgG ≥ 1:800 (Duke major), Bartonella IgG ≥ 1:800, Brucella, Tropheryma 16S rRNA on excised valve (AHA 2015; Duke 2023)

Preferred for IE diagnosis; LR+ ≈ 10, LR− ≈ 0.1; mandatory for prosthetic valve + suspected paravalvular complication (AHA 2015; ESC 2023; Habib 2015)

PET-CT LR+ ≈ 8 for prosthetic / CIED when TEE equivocal; cardiac CT for paravalvular complications (ESC 2023)

Suspected embolic stroke; mycotic aneurysm (AHA 2015; ESC 2023)

Septic emboli (pulmonary in right-sided IE; splenic / hepatic / renal infarcts in left-sided) (AHA 2015)

Early (< 12 mo) vs late (≥ 12 mo) prosthetic IE drives empirics + rifampin role (AHA 2015; ESC 2023)

CIED-IE → device extraction Class I + targeted abx (ESC 2023)

Right-sided IE phenotype; S. aureus dominant + GNR/Candida possible; OUD linkage (AHA 2015)

Source consideration for viridans strep / enterococcus / S. gallolyticus (which mandates colonoscopy) (AHA 2015)

Strong predisposing condition; Duke minor criterion (AHA 2015; Duke 2023)

Broader empirics + higher mortality + special pathogens (AHA 2015; ESC 2023)

Inflammatory markers for response monitoring (AHA 2015; ESC 2023)

Hematuria / glomerulonephritis (Duke minor immunologic) (AHA 2015; Duke 2023)

Hepatotoxicity monitoring (linezolid, dapto, rifampin) + sepsis bilirubin (AHA 2015)

Daptomycin weekly CK for rhabdomyolysis (DailyMed dapto label)

Tachycardia component of qSOFA / SIRS; HF tachycardia (AHA 2015)

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

Severity triggers (11)

11 need judgement
  • informationallife_threateningendocarditis_with_heart_failure_class_i_surgery
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningprosthetic_valve_endocarditis_early_post_op
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcied_endocarditis_with_lead_vegetation
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningembolic_complication_neurologic
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmycotic_aneurysm_with_rupture_risk
    Septic emboli → vascular wall infection → mycotic aneurysm — CT angiography + interventional radiology / neurosurgery consult; surgical / endovascular treatment (AHA 2015; ESC 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningfungal_endocarditis_almost_always_surgical
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelarge_vegetation_with_embolic_event
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_bacteremia_despite_appropriate_abx
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereidu_right_sided_endocarditis
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereculture_negative_endocarditis
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresplenic_abscess_or_vertebral_osteo
    IE complication: splenic abscess / vertebral osteomyelitis / hepatic abscess / brain abscess from embolic + seeding → cross-sectional imaging + extended treatment + surgical drainage if drainable (AHA 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSrequiredDrives severity classification
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Recommended regimen

Native valve IE empiric — vancomycin AUC + ceftriaxone (subacute) OR vancomycin + cefepime (acute septic) (AHA 2015; ESC 2023)
axis: ie_empiric_native_valve
Selected axis "Native valve IE empiric — vancomycin AUC + ceftriaxone (subacute) OR vancomycin + cefepime (acute septic) (AHA 2015; ESC 2023)" by default fallback (first axis)
  • vancomycin
    first line
    glycopeptide
    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)
    triggers: empiric_IE_native_valve, MRSA_coverage, CoNS_coverage, enterococcus_partial_coverage
    AHA 2015 + ESC 2023 + Rybak ASHP/IDSA 2020 — covers MRSA + CoNS + viridans strep + most Enterococcus; AUC-targeted dosing 2026 standard (PMID 32191793)
    rxcui 11124
  • ceftriaxone
    first line
    cephalosporin_3rd_gen
    2 g IV q24h (q12h for HACEK/enterococcal AMPI-CEFTRI regimen) • IV • q24h (q12h for AMPI-CEFTRI)
    triggers: empiric_IE_subacute_native_valve, viridans_strep_coverage, HACEK_coverage, AMPI_CEFTRI_partner_for_E_faecalis
    AHA 2015 + ESC 2023 — first-line for viridans strep / HACEK; AMPI-CEFTRI partner for E. faecalis (Fernández-Hidalgo CID 2013 PMID 23392394)
    rxcui 2193
  • cefepime
    first line
    cephalosporin_4th_gen
    2 g IV q8h (extended infusion 3-4 h preferred in shock) • IV • q8h
    triggers: empiric_IE_acute_septic_native_valve, IDU_right_sided_IE, anti_pseudomonal_coverage_required
    AHA 2015 — anti-pseudomonal cover for acute/septic native valve IE; IDU phenotype; renal adjust for CrCl < 60
    rxcui 20481
  • gentamicin
    add on
    aminoglycoside
    3 mg/kg/d IV single daily dose • IV • daily
    triggers: enterococcal_IE_synergy_when_susceptible, HLAR_excluded
    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
    rxcui 1596450

ed playbook — drug actions (3)

  1. 1. vancomycin
    rxcui 11124
    25-30 mg/kg IV load × 1 • IV • q8-12h (AUC-titrated thereafter)
    trigger: Suspected IE within 1 h of recognition if in shock; otherwise after ≥ 3 sets cultures drawn (AHA 2015; Kumar CCM 2006)
    Empiric MRSA + CoNS + viridans strep + most Enterococcus cover; AUC-guided per Rybak 2020
  2. 2. ceftriaxone OR cefepime (per phenotype)
    rxcui 2193
    ceftriaxone 2 g IV q24h (subacute / native) OR cefepime 2 g IV q8h (acute septic / IDU / CIED) • IV • per agent
    trigger: Empiric β-lactam partner — viridans/HACEK (ceftriaxone) vs anti-Pseudomonal (cefepime) per phenotype (AHA 2015)
    Phenotype-driven β-lactam selection per AHA 2015 + ESC 2023
  3. 3. gentamicin (selective)
    rxcui 1596450
    3 mg/kg IV single daily dose • IV • daily
    trigger: Prosthetic valve early (< 12 mo) OR enterococcal IE if susceptible (AHA 2015)
    Synergy add-on for PVE-early or enterococcal; ESC 2023 drops for staph IE; weekly CrCl + audiogram

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: ≥ 2 separate blood cultures positive with IE-suggestive species (S. aureus, viridans strep, HACEK, enterococcus, Coxiella) (AHA 2015; Duke 2023); 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).

Objective

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

Assessment

**Infective endocarditis (native / prosthetic / CIED / right-sided)** (id.endocarditis.core.v1).
Phenotype framing: 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)
Scope: Confirm infective endocarditis scope per modified Duke 2023 criteria (definite / possible / rejected) (AHA 2015; Duke 2023 Fowler)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Native valve IE empiric — vancomycin AUC + ceftriaxone (subacute) OR vancomycin + cefepime (acute septic) (AHA 2015; ESC 2023)**.
1. 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) (glycopeptide, first line) — AHA 2015 + ESC 2023 + Rybak ASHP/IDSA 2020 — covers MRSA + CoNS + viridans strep + most Enterococcus; AUC-targeted dosing 2026 standard (PMID 32191793)
2. ceftriaxone 2 g IV q24h (q12h for HACEK/enterococcal AMPI-CEFTRI regimen) IV q24h (q12h for AMPI-CEFTRI) (cephalosporin_3rd_gen, first line) — AHA 2015 + ESC 2023 — first-line for viridans strep / HACEK; AMPI-CEFTRI partner for E. faecalis (Fernández-Hidalgo CID 2013 PMID 23392394)
3. cefepime 2 g IV q8h (extended infusion 3-4 h preferred in shock) IV q8h (cephalosporin_4th_gen, first line) — AHA 2015 — anti-pseudomonal cover for acute/septic native valve IE; IDU phenotype; renal adjust for CrCl < 60
4. gentamicin 3 mg/kg/d IV single daily dose IV daily (aminoglycoside, add on) — 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

Setting playbook (ed) — Recognise IE in bacteremic / febrile patient with predisposing condition (prosthetic valve, CIED, IDU, prior IE, dental procedure); draw ≥ 3 sets of blood cultures over ≥ 1 h from separate sites BEFORE first abx (unless shock); start phenotype-driven empirics within 1 h of recognition if shock; admit + ID consult (AHA 2015; ESC 2023)
5. vancomycin 25-30 mg/kg IV load × 1 IV q8-12h (AUC-titrated thereafter) — Suspected IE within 1 h of recognition if in shock; otherwise after ≥ 3 sets cultures drawn (AHA 2015; Kumar CCM 2006) (Empiric MRSA + CoNS + viridans strep + most Enterococcus cover; AUC-guided per Rybak 2020)
6. ceftriaxone OR cefepime (per phenotype) ceftriaxone 2 g IV q24h (subacute / native) OR cefepime 2 g IV q8h (acute septic / IDU / CIED) IV per agent — Empiric β-lactam partner — viridans/HACEK (ceftriaxone) vs anti-Pseudomonal (cefepime) per phenotype (AHA 2015) (Phenotype-driven β-lactam selection per AHA 2015 + ESC 2023)
7. gentamicin (selective) 3 mg/kg IV single daily dose IV daily — Prosthetic valve early (< 12 mo) OR enterococcal IE if susceptible (AHA 2015) (Synergy add-on for PVE-early or enterococcal; ESC 2023 drops for staph IE; weekly CrCl + audiogram)

Non-pharmacologic actions:
- Do NOT delay culture draws — ≥ 3 sets over ≥ 1 h is the diagnostic foundation (AHA 2015)
- Notify ID consult and inpatient admission; cardiothoracic surgery service if Class I surgical features (HF, embolic, large vegetation, abscess, fungal) (AHA 2015; ESC 2023)
- For IDU patient: initiate OUD-linkage discussion + harm-reduction counseling; route to psych.opioid_use_disorder.core.v1 (AHA 2015)

AVOID / contraindication checks:
- Vanco auc monitoring 400 600 (Rybak ASHP/IDSA 2020 PMID 32191793)
- Gentamicin nephrotoxicity ototoxicity weekly cr audiogram (DailyMed gent label)
- Gentamicin avoid pregnancy fetal ototoxicity (DailyMed gent label)
- Gentamicin hlar or hlgr isolate block (AHA 2015; ESC 2023)
- Ceftriaxone biliary sludge with prolonged use (DailyMed ceftriaxone)
- Cefepime neurotoxicity elderly or CKD (DailyMed cefepime)
- Blood cultures 3 sets before abx unless shock (AHA 2015)
- Tee within 12 24h when suspected IE (AHA 2015; ESC 2023)
- Repeat blood cultures 48 72h to document clearance (AHA 2015)

Monitoring

Regimen monitoring:
- repeat blood cultures q48 72h until two consecutive negatives (AHA 2015)
- vanco AUC q3 5d target 400 600 (Rybak ASHP/IDSA 2020)
- creatinine weekly on vanco or gent (Rybak 2020; DailyMed)
- gent audiogram weekly if continued beyond 2 weeks (DailyMed gent)
- LFT q3 7d on ceftriaxone with hepatic risk (DailyMed)
- TTE repeat at 4 6 weeks post treatment baseline (AHA 2015)
- TEE repeat if new AV block or persistent bacteremia (AHA 2015)

Setting (ed) monitoring:
- Vitals q30 min until disposition (AHA 2015)
- Lactate at 2-4 h to assess response if shock (SSC 2026)

Follow-up plan: 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)
- Close-out criterion: OPAT + ID + cardiology f/u scheduled; IE-prophylaxis education delivered

Monitoring phase: 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)

Disposition

Current setting: ed — Recognise IE in bacteremic / febrile patient with predisposing condition (prosthetic valve, CIED, IDU, prior IE, dental procedure); draw ≥ 3 sets of blood cultures over ≥ 1 h from separate sites BEFORE first abx (unless shock); start phenotype-driven empirics within 1 h of recognition if shock; admit + ID consult (AHA 2015; ESC 2023)

Disposition criteria:
- All suspected IE patients admitted to inpatient ward or ICU per qSOFA / shock / HF / embolic status; NEVER discharged home from ED (AHA 2015; ESC 2023)

Escalation triggers (move to higher acuity):
- qSOFA ≥ 2 + hypotension + lactate > 2 → ICU; SSC Hour-1 bundle + emergent cardiothoracic surgery consult if HF/embolic (AHA 2015; SSC 2026)
- Embolic stroke during workup → emergent neurology + brain imaging + nuanced surgical timing decision (AHA 2015; ESC 2023)
- New AV block on ECG → repeat TEE for paravalvular abscess; cardiothoracic surgery consult (AHA 2015)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] 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)

Citations

- 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. [PMID:26373316](https://pubmed.ncbi.nlm.nih.gov/26373316/)
- Cited evidence (PMID 37622656) [PMID:37622656](https://pubmed.ncbi.nlm.nih.gov/37622656/)
- Cited evidence (PMID 30152252) [PMID:30152252](https://pubmed.ncbi.nlm.nih.gov/30152252/)
- Cited evidence (PMID 30699315) [PMID:30699315](https://pubmed.ncbi.nlm.nih.gov/30699315/)
- Cited evidence (PMID 26679628) [PMID:26679628](https://pubmed.ncbi.nlm.nih.gov/26679628/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 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. — PMID:26373316
  • Cited evidence (PMID 37622656) — PMID:37622656
  • Cited evidence (PMID 30152252) — PMID:30152252
  • Cited evidence (PMID 30699315) — PMID:30699315
  • Cited evidence (PMID 26679628) — PMID:26679628