Synopsis
Recognise infective endocarditis early, obtain microbiology before antibiotics when safe, sequence multimodality imaging, start specialist-selected bactericidal therapy and identify surgical emergencies.
- Think IE in unexplained fever or bacteraemia plus a prosthetic valve, previous IE, congenital lesion, intracardiac device, valve disease, haemodialysis, injection drug use or recent invasive infection.
- When clinically safe, take three sets of peripheral blood cultures at 30-minute intervals before antibiotics; never wait for fever spikes.
- Perform TTE promptly and TOE when TTE is negative/inconclusive but suspicion remains high, for prosthetic valves/devices, or to define complications.
Key red flags
New/changing murmur, new regurgitation, HF, prosthetic dysfunction or new conduction delay; new AV block suggests peri-annular abscess until proved otherwise.
Investigation priorities
Establish continuous bacteraemia and permit susceptibility-directed therapy.
Management branches
Compatible infection plus cardiac risk or embolic/valvular features.
- Admit, involve microbiology/infection and the Endocarditis Team early; assess haemodynamic, neurological and embolic complications.
- If stable, take three peripheral blood-culture sets at 30-minute intervals before antimicrobials. If unstable, draw cultures immediately and start treatment without avoidable delay.
Key medicines
Empirical community NVE/late PVE — ESC regimen example, not a universal UK prescriptionAmpicillin 12 g/day IV in 4–6 doses PLUS ceftriaxone 4 g/day IV/IM in 2 doses; OR flucloxacillin 12 g/day IV in 4–6 doses PLUS gentamicin 3 mg/kg IV/IM once daily.
Empirical early PVE/healthcare-associated IE — ESC regimen exampleVancomycin 30 mg/kg/day IV in 2 doses OR daptomycin 10 mg/kg IV once daily, PLUS gentamicin 3 mg/kg once daily PLUS rifampicin 900–1200 mg/day IV/PO in 2–3 doses.