Endocarditis: Difference between revisions
 
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==Background==
==Background==
*Consider in pts w/ unexplained fever and known risk factors
*Defined as an infection of the endocardial surface of the heart, affecting native (or prosthetic) heart valves as well as in-dwelling cardiac devices
*Consider in patients with known risk factors and unexplained fever
*Mitral valve most commonly affected overall; tricuspid valve most common in IVDA
*Mitral valve most commonly affected overall; tricuspid valve most common in IVDA
*Noninfectious vegetations can arise in pts w/ malignancy and SLE
*Noninfectious vegetations can arise in patients with malignancy/[[SLE]]/Hypercoagulable state ("Marantic" endocarditis)
*S. aureus is single most common cause
*[[S. aureus]] is single most common cause (accounts for 1/3 of all cases)<ref>Selton-Suty C, Célard M, Le Moing V, et al. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Clin Infect Dis. 2012;54(9):1230-1239. doi:10.1093/cid/cis199</ref>
*Blood cultures are falsely negative ~5% (think HACEK organisms)
*[[Strep viridans]] is the most common cause of native valve endocarditis, excluding risk factors below
*[[Blood cultures]] are falsely negative ~5% (think HACEK organisms)
*Only 20% have an increase in a known murmur and only 48% have a new murmur<ref name="Hoen">Hoen, B. et al. Infective Endocarditis. NEJM. 2013. 368;15. 1425-1433 [http://www.cardioaragon.es/web/pdf/InfectiveEndocarditisNEJM2013.pdf PDF]</ref>


==Risk Factors==
===Prophylaxis===
#IVDA
{{Endocarditis prophylaxis}}
##Tricuspid valve most commonly affected
 
#Prosthetic heart valve
===Risk Factors===
#Structural heart disease
*[[IVDA]]
##Rheumatic heart disease
**Tricuspid valve most commonly affected
##Mitral valve prolapse
*Prosthetic heart valve
##Bicuspid aortic valve
**Coagulase negative [[staph]]ylcocci are substantial etiologies in this patient population<ref>Lalani T et al. Prosthetic valve endocarditis due to coagulase-negative staphylococci: findings from the International Collaboration on Endocarditis Merged Database. Eur J Clin Microbiol Infect Dis. 2006 Jun;25(6):365-8.</ref>
#Hemodialysis
*Structural heart disease
#HIV infection
**Rheumatic heart disease (biggest risk factor in low-income countries)
**Mitral valve prolapse
**Bicuspid aortic valve
*[[Hemodialysis]]
*[[HIV]] infection
*[[Fungal infections|Fungal]] endocarditis risk factors, with [[Candida]] most common
**Prolonged antibiotics
**TPN through central line


==Clinical Features==
==Clinical Features==
*Fever
[[File:Splinter hemorrhage.jpg|thumb|Splinter hemorrhage]]
**Present in almost all cases
[[File:Osler Nodules Hand.jpg|thumb|Osler's nodes.]]
*Heart murmur
[[File:PMC5072319 12879 2016 1912 Fig2 HTML.png|thumb|Janeway lesions]]
**Preexisting murmur found in 85% of cases; new murmur only found in 5%
[[File:PMC5059132 kjtcv-49-408f1.png|thumb|Roth spots on fundoscopy (A); 2 weeks after treatment (B); 6 weeks after treatment.]]
*CHF
*[[Fever]]
**Present in 80% of cases
*Heart [[murmur]]
**Preexisting murmur found in 85% of cases; new murmur found in 48%
*[[CHF]]
**Acute or progressive (70%)
**Acute or progressive (70%)
*Embolization manifestations
*Derm
**CNS
**Osler nodes
***MCA stroke
***Tender red/purple nodules on distal finger and toes
***Central retinal artery occlusion
**Splinter hemorrhages
**Pulmonary
***Nail bed hemorrhages not extending the length of the nail
***PNA
**Janeway lesions
***Empyema
***Non-tender, small erythematous or hemorrhagic macular, papular or nodular lesions on the palms or soles only a few millimeters in diameter
**Cardiac
*CNS
***MI
**65% of emboli involve the CNS<ref>Mylonakis. E, Calderwood S. Infective endocardidits in adults. NEJM. 2001;345(18):138-1330</ref>
***Myocarditis
**[[Central retinal artery occlusion]]
*Pulmonary
**[[Pneumonia]]
**[[Empyema]]
**[[Pulmonary emboli]]
*Cardiac
**[[MI]]
**[[Myocarditis]]
*Abdominal
**Bowel, renal, splenic infarcts
**Bowel, renal, splenic infarcts
**Derm
*Ophtho
***Osler nodes, splinter hemorrhages, Janeway lesions
**Roth spots
***White centered retinal hemorrhage
***Associated with multiple systemic illnesses, most commonly bacterial endocarditis
 
==Differential Diagnosis==
{{Acute Fever DDX}}
{{Septic Embolus DDX}}
 
==Evaluation==
[[File:PMC4497914 kjim-30-434-g003.png|thumb|Echocardiography showing typical vegetation on aortic valve (arrow).]]
[[File:PMC2649868 ymj-50-152-g001.png|thumb|Transthoracic echocardiography shows vegetations (arrows) on both mitral leaflets; (A) Diastole. (B) Systole. LA, left atrium; LV, left ventricle; Ao, aorta.]]
[[File:PMC5412748 JCE-27-33-g010.png|thumb|Vegetations in infective endocarditis (arrows). (a) Transthoracic echocardiogram parasternal long-axis view showing vegetation on native aortic valve; (b) transesophageal echocardiography long axis of endocarditis of native aortic valve; (c) transesophageal echocardiography visualization of vegetation on the atrial side of mechanical mitral valve; (d) transesophageal echocardiography showing endocarditis of bioprosthetic mitral valve. LA: Left atrium; LV: Left ventricle.]]
[[File:PMC5087261 JCHIMP-6-32827-g001.png|thumb|CT chest: Multiple cavitary (a) and pre-cavitary lesions (b) in both lung fields consistent septic emboli from pulmonary valve endocarditis.]]
===Work-Up===
*[[Blood culture]] (from 3 separate sites)<ref name="cultures">Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of bloodstream infections in adults: how many blood cultures are needed? J Clin Microbiol 2007;45:
3546 – 3548</ref>
*CBC
**Staphylococcal endocarditis: [[Leukocytosis]] +/- [[thrombocytopenia]]
**Subacute endocarditis: WBC may be normal or elevated
*[[Urinalysis]]
**[[Hematuria]]
*ESR
**Elevated in >90% of cases
*[[ECG]]
**Ischemia, [[heart block]]
*[[CXR]]
**Pulmonary emboli, [[CHF]]
*[[Cardiac ultrasound|Ultrasound]]
**Obtain as soon as possible
**TEE may be required for:
***Prosthetic valves
***Difficulty obtaining clear TTE images (obesity, COPD)
***High clinical probability of endocarditis
 
===Diagnosis===
*Inpatient diagnosis is based on the Duke's Criteria although many of the criteria are not filled in the ED
**Heightened clinical suspicion is necessary even if diagnosis does not meet the official criteria.<ref>Durack D, Lukes A, Bright D "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med. 1994. 96 (3): 200–9</ref>


==Diagnosis==
====Modified Duke Criteria<ref>Li, JS et al. "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases. 2000. 30(4). 633.</ref>====
#Modified Duke Criteria
*2 major criteria '''OR'''
## 2 major criteria OR
*1 major and 3 minor criteria '''OR'''
## 1 major and 3 minor criteria OR
*5 minor criteria
## 5 minor criteria
====Major Criteria====
# Major Criteria
*Positive blood culture with typical IE microorganism, defined as one of the following:
## Positive blood culture for typical IE organisms
**Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
### S. aureus, S. viridans, S. bovis, Enterococci, HACEK
***[[Streptococcus viridans|Viridans-group streptococci]], or
## Evidence of endocardial involvement
***''[[Streptococcus bovis]]'' including nutritional variant strains, or
### TEE+ or ''new ''valvular regurgitation
***[[HACEK]] group, or
# Minor Criteria
***''[[Staphylococcus aureus]]'', or
## Predisposition: predisposing heart condition or IVDA
***Community-acquired ''[[Enterococci]]'', in the absence of a primary focus
## Fever: 38.0 C (100.4 F)
**Microorganisms consistent with IE from persistently positive blood cultures defined as:
## Vascular phenomena
***Two positive cultures of blood samples drawn >12 hours apart, or
### Arterial emboli, pulmonary infarcts, mycotic aneurysm, ICH, conjunctival hemorrhage, Janeway lesions
***All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
## Immunologic phenomena - glomerulonephritis, Osler's nodes, Roth spots, rheumatoid factor
***''[[Coxiella burnetii]]'' detected by one positive blood culture or IgG
## Microbiologic evidence - positive blood culture but not meeting major criterion as noted previously
***Staphylococus lugdunensis should raise concerns for endocarditis with a single positive blood culture<ref>Liu Po-Yen et al. Staphylococcus lugdunensis Infective Endocarditis: A Literature Review and Analysis of Risk Factors. Journal of Microbiology, Immunology and Infection
Volume 43, Issue 6, December 2010, Pages 478-484.</ref>
*Evidence of endocardial involvement with positive echocardiogram defined as:
**Valvular mass or supporting structures or
**Abscess, or
**New disruption of a prosthetic valve or new valvular regurgitation


==Work-Up==
====Minor Criteria====
#Blood culture (from 3 separate sites)
*Predisposing factor: known cardiac lesion, recreational drug injection
#CBC
*Fever >38°C
##Staphylococcal endocarditis: Leukocytosis +/- thrombocytopenia
*Evidence of emboli: arterial emboli,pulmonary infarcts, [[Eponyms_(F-L)*Janeway_lesions|Janeway lesions]], conjunctival hemorrhage
##Subacute endocarditis: WBC may be normal or elevated
*[[Glomerulonephritis]], [[Eponyms_(M-P)*Osler.27s_nodes|Osler's nodes]]
#UA
*Positive blood culture (that does not meet a major criterion) or serologic evidence of infection
##Hematuria
#ESR
##Elevated in >90% of cases
#ECG
##Ischemia, heart block
#CXR
##Pulmonary emboli, CHF
#Ultrasound
##Obtain as soon as possible
##TEE may be required for:
###Prosthetic valves
###Difficulty obtaining clear TTE images (obesity, COPD)
###High clinical probability of endocarditis


==Management==
==Management==
#Initial stabilization
;Initial management should focus on early blood cultures and antibiotics
##[[CHF]]/cardiogenic [[shock]] (due to valvular defects)
===[[CHF]]/[[Cardiogenic Shock]]===
##Pulmonary edema (left-sided valve rupture)
*Often due to valve failure, rupture, or a new defect.
###Manage w/ afterload reduction
===[[Pulmonary edema]]===
##Pulmonary failure (emboli)
*Often due to mitral or aortic valve rupture causing severe regurgitation
##Acidosis ([[sepsis]])
*Focus on after-load reduction
#[[Antibiotics]]
===[[Respiratory failure]] (emboli)===
##Start after blood cultures are obtained (if possible)
*Often requires [[intubation]] with failure either due to [[CHF]] or [[Pneumonia]]
##Uncomplicated history
*Multi-lobar [[pneumonia]] suggests a tricuspid or pulmonary valve lesion with emboli to lungs
###Gentamicin 1-3mg/kg IV + ([[ceftriaxone]] or nafcillin or oxacillin or [[vancomycin]])
 
##IVDA, congenital heart disease, already on oral antibiotic
==[[Antibiotics]]==
###Nafcillin + gentamicin 1-3mg/kg IV + [[vancomycin]]
''Start after 3 sets of blood cultures are obtained (if possible)<ref name="cultures"></ref>''
##Prosthetic heart valve
 
###Rifampin 300mg PO + gentamicin 1-3mg/kg IV + [[vancomycin]]
Therapy should be based on:
*Whether the patient has received prior antibiotic therapy
*Prosthetic valves
*Local antibiotic resistance patterns or knowledge of prior endocarditis cultures
*Prior hospitalizations and risk of MRSA
 
{{Endocarditis_Empiric_Antibiotics}}


==Disposition==
==Disposition==
*Admit all suspected cases
Admit all suspected cases and consult Cardiothoracic surgery for endocarditis complicated by:<ref name="Hoen"></ref>
*New Heart failure suspected due to severe regurgitation
*Cardiogenic Shock
*Echocardiography demonstrating a new fistula
*Surgery indicated for<ref>Kosowsky JM, Takhar SS: Infective Endocarditis and Valvular Heart Disease in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 84: pp 1113-1123.</ref>:
**Acute heart failure
**Periannular extension
**Recurrent emboli
**Large mobile vegetations
**Persistent bacteremia
**Fungal endocarditis (penetration of antifungals into vegetation walls poor)<ref>British Society for Antimicrobial Chemotherapy. Guidelines for the antibiotic treatment of endocarditis in adults: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J. Antimicrob. Chemother. (December 2004) 54 (6): 971-981.</ref>
***IV [[amphotericin B]]
***Lifelong PO antifungal
 
 
==Miscellaneous==
*No therapeutic anticoagulation necessary
**Anticoagulation carries higher risk of bleeding without delivering mortality benefit or reducing embolic complication<ref>Elkaryoni A et al. ANTICOAGULATION IN INFECTIVE ENDOCARDITIS: INSIGHTS FROM NATIONWIDE INPATIENT SAMPLE. Journal of the American College of Cardiology. Volume 73, Issue 9 Supplement 1, March 2019.</ref>
*[[Septic pulmonary embolism]]
**Most common culture growths are MSSA, MRSA, and candida<ref>Li Zhao RY et al. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respiratory Medicine. Volume 108, Issue 1, January 2014, Pages 1-8.</ref>
**Furthermore, therapeutic anticoagulation not indicated for [[septic pulmonary embolism]]


==Complications==
==Complications==
#Cardiac
===Cardiac===
##Heart Failure
*[[Congestive Heart Failure (CHF)|Heart Failure]]
###Most common cause of death due to IE
**Most common cause of death due to IE
## Perivalvular Abscess
*Perivalvular Abscess
# Embolic
===Embolic===
## CVA
*[[CVA]]
## Blindness
*[[Vision loss|Blindness]]
## Painful, ischemic extremities
*Painful, ischemic extremities
## Unusual pain sydromes (due to splenic or renal infarction)
*Unusual pain syndromes (due to splenic or renal infarction)
## Hypoxia
*[[Mycotic aneurysm]]
## Paralysis
*[[Hypoxia]]
## MI
*[[MI]]
# Neurologic
 
## Embolic stroke
===Neurologic===
## Acute encephalopathy
*[[CVA|Embolic stroke]]
## Meningoencephalitis
*Acute [[encephalopathy]]
## Purulent or aseptic meningitis
*[[Meningitis|Meningoencephalitis]]
## Cerebral hemorrhage
*Purulent or aseptic [[meningitis]]
## Seizure
*[[ICH|Cerebral hemorrhage]]
# Renal
*[[Seizure]]
## Infarction
*[[Epidural abscess|Spinal abscess]]
## Glomerulonephritis
===Renal===
# Musculoskeletal
*[[Renal infarction]]
## Vertebral osteomyelitis
*[[Glomerulonephritis]]
===Musculoskeletal===
*[[Vertebral osteomyelitis]]
 
==See Also==
*[[Fever]]
*[[In-training exam review]]
 
==External Links==
*[http://www.mdcalc.com/duke-criteria-for-infective-endocarditis/ MDCalc - Duke Criteria]
*[https://emcrit.org/ibcc/endo/ EMCrit - Endocarditis]


==Source==
==References==
*UpToDate
<references/>
*Harwood-Nuss
*Tintinalli


[[Category:ID]]
[[Category:ID]] [[Category:Cardiology]]

Latest revision as of 17:29, 4 January 2023

Background

  • Defined as an infection of the endocardial surface of the heart, affecting native (or prosthetic) heart valves as well as in-dwelling cardiac devices
  • Consider in patients with known risk factors and unexplained fever
  • Mitral valve most commonly affected overall; tricuspid valve most common in IVDA
  • Noninfectious vegetations can arise in patients with malignancy/SLE/Hypercoagulable state ("Marantic" endocarditis)
  • S. aureus is single most common cause (accounts for 1/3 of all cases)[1]
  • Strep viridans is the most common cause of native valve endocarditis, excluding risk factors below
  • Blood cultures are falsely negative ~5% (think HACEK organisms)
  • Only 20% have an increase in a known murmur and only 48% have a new murmur[2]

Prophylaxis

  • No longer recommended at all in the United Kingdom[3]
  • In United States, only recommended for invasive dental procedures (not routine cleanings) and invasive respiratory procedures in setting of: [4][5]
  1. Prosthetic valves
  2. Prior endocarditis
  3. Un-repaired congenital cyanotic heart disease
  4. Repaired congenital heart disease/valvulopathy with prosthetic material

Risk Factors

  • IVDA
    • Tricuspid valve most commonly affected
  • Prosthetic heart valve
    • Coagulase negative staphylcocci are substantial etiologies in this patient population[6]
  • Structural heart disease
    • Rheumatic heart disease (biggest risk factor in low-income countries)
    • Mitral valve prolapse
    • Bicuspid aortic valve
  • Hemodialysis
  • HIV infection
  • Fungal endocarditis risk factors, with Candida most common
    • Prolonged antibiotics
    • TPN through central line

Clinical Features

Splinter hemorrhage
Osler's nodes.
Janeway lesions
Roth spots on fundoscopy (A); 2 weeks after treatment (B); 6 weeks after treatment.
  • Fever
    • Present in 80% of cases
  • Heart murmur
    • Preexisting murmur found in 85% of cases; new murmur found in 48%
  • CHF
    • Acute or progressive (70%)
  • Derm
    • Osler nodes
      • Tender red/purple nodules on distal finger and toes
    • Splinter hemorrhages
      • Nail bed hemorrhages not extending the length of the nail
    • Janeway lesions
      • Non-tender, small erythematous or hemorrhagic macular, papular or nodular lesions on the palms or soles only a few millimeters in diameter
  • CNS
  • Pulmonary
  • Cardiac
  • Abdominal
    • Bowel, renal, splenic infarcts
  • Ophtho
    • Roth spots
      • White centered retinal hemorrhage
      • Associated with multiple systemic illnesses, most commonly bacterial endocarditis

Differential Diagnosis

Fever

Infectious

Non-infectious

Evaluation

Echocardiography showing typical vegetation on aortic valve (arrow).
Transthoracic echocardiography shows vegetations (arrows) on both mitral leaflets; (A) Diastole. (B) Systole. LA, left atrium; LV, left ventricle; Ao, aorta.
Vegetations in infective endocarditis (arrows). (a) Transthoracic echocardiogram parasternal long-axis view showing vegetation on native aortic valve; (b) transesophageal echocardiography long axis of endocarditis of native aortic valve; (c) transesophageal echocardiography visualization of vegetation on the atrial side of mechanical mitral valve; (d) transesophageal echocardiography showing endocarditis of bioprosthetic mitral valve. LA: Left atrium; LV: Left ventricle.
CT chest: Multiple cavitary (a) and pre-cavitary lesions (b) in both lung fields consistent septic emboli from pulmonary valve endocarditis.

Work-Up

Diagnosis

  • Inpatient diagnosis is based on the Duke's Criteria although many of the criteria are not filled in the ED
    • Heightened clinical suspicion is necessary even if diagnosis does not meet the official criteria.[9]

Modified Duke Criteria[10]

  • 2 major criteria OR
  • 1 major and 3 minor criteria OR
  • 5 minor criteria

Major Criteria

  • Positive blood culture with typical IE microorganism, defined as one of the following:
    • Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
    • Microorganisms consistent with IE from persistently positive blood cultures defined as:
      • Two positive cultures of blood samples drawn >12 hours apart, or
      • All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
      • Coxiella burnetii detected by one positive blood culture or IgG
      • Staphylococus lugdunensis should raise concerns for endocarditis with a single positive blood culture[11]
  • Evidence of endocardial involvement with positive echocardiogram defined as:
    • Valvular mass or supporting structures or
    • Abscess, or
    • New disruption of a prosthetic valve or new valvular regurgitation

Minor Criteria

  • Predisposing factor: known cardiac lesion, recreational drug injection
  • Fever >38°C
  • Evidence of emboli: arterial emboli,pulmonary infarcts, Janeway lesions, conjunctival hemorrhage
  • Glomerulonephritis, Osler's nodes
  • Positive blood culture (that does not meet a major criterion) or serologic evidence of infection

Management

Initial management should focus on early blood cultures and antibiotics

CHF/Cardiogenic Shock

  • Often due to valve failure, rupture, or a new defect.

Pulmonary edema

  • Often due to mitral or aortic valve rupture causing severe regurgitation
  • Focus on after-load reduction

Respiratory failure (emboli)

  • Often requires intubation with failure either due to CHF or Pneumonia
  • Multi-lobar pneumonia suggests a tricuspid or pulmonary valve lesion with emboli to lungs

Antibiotics

Start after 3 sets of blood cultures are obtained (if possible)[8]

Therapy should be based on:

  • Whether the patient has received prior antibiotic therapy
  • Prosthetic valves
  • Local antibiotic resistance patterns or knowledge of prior endocarditis cultures
  • Prior hospitalizations and risk of MRSA

Native Valves

Options:[12]

Suspected MRSA:[12]

Prosthetic Valves (Early)

Early prosthetic valve endocarditis defined as < 12 months post surgery[12]

IV Drug User without Prosthetic Valve

Prosthetic Valve (Late)

Late prosthetic valve endocarditis defined as ≥ 12 months post surgery[12]
  • Same as native valve endocarditis empiric therapy

Dental Procedure Prophylaxis

All antibiotics options are given as a single dose 1 hour prior to the dental procedure

Options:[13]

Disposition

Admit all suspected cases and consult Cardiothoracic surgery for endocarditis complicated by:[2]

  • New Heart failure suspected due to severe regurgitation
  • Cardiogenic Shock
  • Echocardiography demonstrating a new fistula
  • Surgery indicated for[14]:
    • Acute heart failure
    • Periannular extension
    • Recurrent emboli
    • Large mobile vegetations
    • Persistent bacteremia
    • Fungal endocarditis (penetration of antifungals into vegetation walls poor)[15]


Miscellaneous

  • No therapeutic anticoagulation necessary
    • Anticoagulation carries higher risk of bleeding without delivering mortality benefit or reducing embolic complication[16]
  • Septic pulmonary embolism

Complications

Cardiac

  • Heart Failure
    • Most common cause of death due to IE
  • Perivalvular Abscess

Embolic

Neurologic

Renal

Musculoskeletal

See Also

External Links

References

  1. ↑ Selton-Suty C, Célard M, Le Moing V, et al. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Clin Infect Dis. 2012;54(9):1230-1239. doi:10.1093/cid/cis199
  2. ↑ 2.0 2.1 Hoen, B. et al. Infective Endocarditis. NEJM. 2013. 368;15. 1425-1433 PDF
  3. ↑ Wilson W. et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116(15):e376-e377.
  4. ↑ Richey R, Wray D, Stokes T. Prophylaxis against infective endocarditis: summary of NICE guidance. BMJ 2008;336: 770-1.
  5. ↑ Wilson W, et al. Prevention of Infective Endocarditis: Guidelines from the American Heart Association. Circulation. 2007;116:1736-1754
  6. ↑ Lalani T et al. Prosthetic valve endocarditis due to coagulase-negative staphylococci: findings from the International Collaboration on Endocarditis Merged Database. Eur J Clin Microbiol Infect Dis. 2006 Jun;25(6):365-8.
  7. ↑ Mylonakis. E, Calderwood S. Infective endocardidits in adults. NEJM. 2001;345(18):138-1330
  8. ↑ 8.0 8.1 Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of bloodstream infections in adults: how many blood cultures are needed? J Clin Microbiol 2007;45: 3546 – 3548
  9. ↑ Durack D, Lukes A, Bright D "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med. 1994. 96 (3): 200–9
  10. ↑ Li, JS et al. "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases. 2000. 30(4). 633.
  11. ↑ Liu Po-Yen et al. Staphylococcus lugdunensis Infective Endocarditis: A Literature Review and Analysis of Risk Factors. Journal of Microbiology, Immunology and Infection Volume 43, Issue 6, December 2010, Pages 478-484.
  12. ↑ 12.0 12.1 12.2 12.3 ESC Task Force Guidelines on the prevention, diagnosis, and treatment of infective endocarditis. European Heart Journal (2009) 30, 2369–2413 doi:10.1093/eurheartj/ehp285 PDF
  13. ↑ AHA Pocket Card Dental Prophylaxis Endocarditis
  14. ↑ Kosowsky JM, Takhar SS: Infective Endocarditis and Valvular Heart Disease in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 84: pp 1113-1123.
  15. ↑ British Society for Antimicrobial Chemotherapy. Guidelines for the antibiotic treatment of endocarditis in adults: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J. Antimicrob. Chemother. (December 2004) 54 (6): 971-981.
  16. ↑ Elkaryoni A et al. ANTICOAGULATION IN INFECTIVE ENDOCARDITIS: INSIGHTS FROM NATIONWIDE INPATIENT SAMPLE. Journal of the American College of Cardiology. Volume 73, Issue 9 Supplement 1, March 2019.
  17. ↑ Li Zhao RY et al. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respiratory Medicine. Volume 108, Issue 1, January 2014, Pages 1-8.
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