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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Infective endocarditis

Cardiology · UK scope · Sources checked 25 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Suspected IE with shock, refractory pulmonary oedema, acute severe valve regurgitation, new high-grade AV block, persistent sepsis, stroke or major embolism needs immediate admission, blood cultures, IV treatment and Endocarditis Team/cardiac-surgical review. Do not delay resuscitation or antibiotics in an unstable patient.

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.
  • If initial echo is negative but suspicion remains high, repeat TTE/TOE in 5–7 days; cardiac CT, FDG-PET/CT or WBC SPECT/CT is especially useful for prosthetic/perivalvular/device disease.
  • Empirical IV therapy depends on native versus prosthetic valve, time since surgery, healthcare acquisition, prior antibiotics, allergy, renal function and local resistance—there is no universal UK regimen.
  • Change empirical treatment to susceptibility-directed therapy as soon as the organism is identified, usually within 24–48 hours; NVE courses range 2–6 weeks and PVE usually requires at least 6 weeks.
  • Emergency surgery within 24 hours is indicated for aortic/mitral NVE or PVE causing refractory pulmonary oedema or cardiogenic shock; urgent surgery is generally within 3–5 days for other uncontrolled HF/infection/embolism indications.
  • NICE says antibiotic prophylaxis is not routinely offered for dental, GI/GU or respiratory procedures; prioritise oral health and shared specialist/dental consideration in exceptional high-risk circumstances.

Key red flags

Cardiac clues

New/changing murmur, new regurgitation, HF, prosthetic dysfunction or new conduction delay; new AV block suggests peri-annular abscess until proved otherwise.

Embolic/immunological clues

Stroke, splenic/renal infarct, limb ischaemia, vertebral pain, pulmonary septic emboli in right-sided IE, glomerulonephritis, splinter haemorrhages, Janeway lesions or Osler nodes.

Surgical emergency

Refractory pulmonary oedema/cardiogenic shock from valve dysfunction, abscess/fistula, enlarging vegetation, prosthetic dehiscence, persistent sepsis or recurrent emboli requires immediate surgical discussion.

Investigation priorities

01
Three sets of peripheral blood cultures before antibioticsFirst step

Establish continuous bacteraemia and permit susceptibility-directed therapy.

Management branches

First hourSuspected IE

Compatible infection plus cardiac risk or embolic/valvular features.

  1. Admit, involve microbiology/infection and the Endocarditis Team early; assess haemodynamic, neurological and embolic complications.
  2. 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.
  3. Obtain ECG, baseline renal/liver/haematology tests and urgent TTE; proceed to TOE for prosthesis/device, inadequate TTE, high suspicion or complication mapping.
  4. Repeat cultures until clearance and repeat echo in 5–7 days if initial imaging is negative but probability remains high.

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.Use only after cultures and specialist review; beta-lactam allergy, renal function, weight, prior therapy and local resistance change the regimen. Gentamicin requires levels and renal monitoring.
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.Low-level evidence and not universally appropriate; follow local microbiology, renal adjustment and therapeutic drug monitoring. Daptomycin needs CK monitoring. Rifampicin has major interactions/hepatotoxicity and, for foreign material, is generally delayed until bacteraemia clears.
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Sources and review status5 sources · checked 25 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 25 Aug 2026; clinical approval remains outstanding.

  • 2023 ESC Guidelines for management of endocarditisPrimary diagnostic, antimicrobial and surgical source.
  • ESC Endocarditis guideline hub
  • 2025 correction to the 2023 ESC Endocarditis guidelineCorrected adult/paediatric dosing entries including ampicillin/amoxicillin.
  • NICE CG64: Prophylaxis against infective endocarditis—recommendationsCurrent UK ‘not routinely’ prophylaxis position.
  • NICE 2024 exceptional surveillance of CG64Explains retention of NICE wording and high-risk dental context.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom