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Infective endocarditis is an uncommon infection with a high mortality rate. It requires prompt identification and carefully selected antibiotic therapy. This activity outlines the general antibiotic principles associated with treating infective endocarditis and highlights the importance of the interprofessional team in caring for patients with this condition. Objectives: Identify treatment considerations for patients with infective endocarditis. Review the classic presentation of infective endocarditis. Describe the etiology of infective endocarditis. Outline important interprofessional management considerations for infective endocarditis treatment. Access free multiple choice questions on this topic.

Endocarditis is an uncommon infection occurring every 3 to 7 per 100000 person-years. Yet, it is also the fourth most common life-threatening infection after sepsis, pneumonia, and intraabdominal abscess, with an estimated inpatient mortality rate between 15 to 30%. When endocarditis was first widely studied in the 1960s, streptococcus viridian was the most commonly identified pathogen. However, the epidemiology has shifted, with Staphylococcus aureus being the most frequently identified pathogen. While this shift is partially attributable to an increased rate of intravenous drug abuse in North America, the healthcare-associated infection has become increasingly common, representing about 30% of all endocarditis cases. The management of endocarditis requires an interprofessional approach by infectious disease, cardiology, and cardiac surgery to manage antimicrobial therapy and assess for possible surgical intervention.[1] Early consultation with cardiothoracic surgery has been shown to improve mortality and is mandatory in patients presenting with complications. Approximately 50% of patients with endocarditis will require some form of surgical intervention.[2] According to the American Heart Association recommendation, a consult with an infectious disease expert should occur before initiating empiric antibiotic therapy due to the many nuances associated with treating endocarditis. Vegetations contain densely packed bacteria interlocked within a biofilm composed of fibrin and platelets, which creates a mechanical barrier limiting antibiotic penetration. Each antibiotic class has differing pharmacological properties which influence the rate of diffusion, distribution, and ability of the antibiotic to penetrate the vegetation, which ultimately determines the bactericidal efficacy. The duration of therapy for successfully eradicating bacteria has its basis in the bactericidal action of the specific antibiotic, minimal inhibitory concentration, pathogen, vegetation burden, and area of involvement. The duration of treatment can range from 2 to 6 weeks.

The management of endocarditis requires an interprofessional approach by infectious disease, cardiology, and cardiac surgery to manage antimicrobial therapy and assess for possible surgical intervention.[1] Early consultation with cardiothoracic surgery has been shown to improve mortality and is mandatory in patients presenting with complications. Approximately 50% of patients with endocarditis will require some form of surgical intervention.[2] According to the American Heart Association recommendation, a consult with an infectious disease expert should occur before initiating empiric antibiotic therapy due to the many nuances associated with treating endocarditis. Vegetations contain densely packed bacteria interlocked within a biofilm composed of fibrin and platelets, which creates a mechanical barrier limiting antibiotic penetration. Each antibiotic class has differing pharmacological properties which influence the rate of diffusion, distribution, and ability of the antibiotic to penetrate the vegetation, which ultimately determines the bactericidal efficacy. The duration of therapy for successfully eradicating bacteria has its basis in the bactericidal action of the specific antibiotic, minimal inhibitory concentration, pathogen, vegetation burden, and area of involvement. The duration of treatment can range from 2 to 6 weeks. The American Heart Association 2015 Adult Infective Endocarditis guidelines and European Society of Cardiologists 2015 management of infective endocarditis guidelines serve as the basis for the following recommendation.[2][3] The treatment of endocarditis should be pathogen-directed and directed by blood cultures and antibiotic sensitivities. Therefore it is imperative to obtain at least two separate blood cultures (preferably three) from two different venous sites for targeted antibiotic therapy before administering antibiotics. Blood cultures ideally should be repeated every 24 to 48hrs until they are negative. Patients should undergo assessment for clinical response to antibiotics. Most patients become afebrile within 3 to 5 days of appropriate antibiotics.

The American Heart Association 2015 Adult Infective Endocarditis guidelines and European Society of Cardiologists 2015 management of infective endocarditis guidelines serve as the basis for the following recommendation.[2][3] The treatment of endocarditis should be pathogen-directed and directed by blood cultures and antibiotic sensitivities. Therefore it is imperative to obtain at least two separate blood cultures (preferably three) from two different venous sites for targeted antibiotic therapy before administering antibiotics. Blood cultures ideally should be repeated every 24 to 48hrs until they are negative. Patients should undergo assessment for clinical response to antibiotics. Most patients become afebrile within 3 to 5 days of appropriate antibiotics. In patients who present with an indolent, uncomplicated course, antibiotic therapy can be delayed until cultures and sensitivities are available. However, in patients with a more acute presentation or features of complicated endocarditis, prompt empiric treatment is often required to reduce the risk of complications. The recommendation is for an Infectious disease consultation when selecting empiric antibiotic therapy as various factors influence the choice of empiric antibiotics, including patients characteristics and risk factors, epidemiological factors, recent administration of antibiotics, whether the infection was healthcare-associated, and severity of presentation.

Selection of appropriate antibiotic regimens requires an interprofessional team approach involving physicians and nurses (particularly those with specialized infectious disease backgrounds), pharmacists, and primary care physicians. Further, consultation and coordination with an infectious disease specialist are usually necessary. [Level 5] Empirical antibiotic therapy is recommended if the suspicion of endocarditis is high; once culture results are obtained, the antibiotic selection can target the sensitivity of the organism. In general, the nurse practitioner or physician assistant will manage the empirical antibiotic selection and coordinate with the physician regarding antibiotic prophylaxis coverage. The pharmacist will review the selection, allergies, and indications to determine appropriate coverage. If there is a concern, the pharmacist should report back to the clinical team a need for an alternative selection. The medical team will need to monitor the patient for signs of endocarditis development and report back to the team leader as issues develop. Management of antibiotic regimens for infective endocarditis is best achieved with an interprofessional team involving physicians, infectious disease experts, specialty-trained nursing staff, and pharmacists all collaborating to manage the cases to an optimal patient outcome.[7][8] [Level 5]