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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e156

CLINICAL STATEMENTS AND GUIDELINES Recommendations for Diagnosis of IE (Continued)

COR LOE Recommendations

time, with a recent increased incidence of drug use–associated IE. IE is fatal unless treated appropriately, and there are no asymptomatic patients with endocarditis. The in-hospital mortality rate for IE is 15% to 20%, with a 1-year mortality rate approaching 40%. Noninfective types of endocarditis are not addressed in these guidelines.

12.2. Diagnosis of IE

Recommendations for Diagnosis of IE Referenced studies that support the recommendations are summarized in Online Data Supplement 42. COR LOE Recommendations

1 B-NR 1.  In patients at risk of IE (eg, those with congenital or acquired VHD, previous IE, prosthetic heart valves, certain congenital or heritable heart malformations, immunodeficiency states, or injection drug use) who have unexplained fever blood, culture samples should be obtained.1

1 B-NR 2.  In patients with the recent onset of left-sided valve regurgitation, at least 2 sets of blood culture samples should be obtained.1–12

1 B-NR 3.  In patients with suspected IE, the Modified Duke Criteria should be used for diagnosis (Tables 24 and 25).2–10

1 B-NR 4.  Patients with IE should be evaluated and managed with consultation with a multispecialty Heart Valve Team, which includes an infectious disease specialist, cardiologist, and cardiac surgeon; a cardiac anesthesiologist for surgically managed patients11; and a neurologist for patients with neurological events.11–13

1 B-NR 5.  In patients with suspected IE, TTE is recommended to identify vegetations, characterize the hemodynamic severity of valvular lesions, assess ventricular function and pulmonary pressures, and detect complications.14–23

1 B-NR 6.  In all patients with known or suspected IE and nondiagnostic TTE results, when complications have developed or are clinically suspected or when intracardiac device leads are present, TEE is recommended.21,23–40

1 B-NR 7.  In patients with IE who have a change in clinical signs or symptoms (eg, new murmur, embolism, persistent fever, HF, abscess, or atrioventricular heart block) and in patients at high risk of complications (eg, extensive infected tissue, large vegetation on initial echocardiogram, or staphylococcal, enterococcal, or fungal infections), TTE and/or TEE are recommended for reevaluation.24,31,41–46 1 B-NR 8.  In patients undergoing valve surgery for IE, intraoperative TEE is recommended.47–50

1 B-NR 9.  In patients being considered for an early change to oral antibiotic therapy for the treatment of stable IE, a baseline TEE before switching to oral therapy and a repeat TEE 1 to 3 days before completion of the oral antibiotic regimen should be performed.51 2a B-NR 10.  In patients with Staphylococcus aureus bacteremia without a known source, TEE is reasonable to diagnose possible IE.11,36,52–56

2a B-NR 11.  In patients with a prosthetic valve in the presence of persistent fever without bacteremia or a new murmur, a TEE is reasonable to aid in the diagnosis of IE.57–60

2a B-NR 12.  In patients in whom the anatomy cannot be clearly delineated by echocardiography in the setting of suspected paravalvular infections, CT imaging is reasonable.37,61–68

2a B-NR 13.  In patients classified by Modified Duke Criteria as having “possible IE,”

18F-fluorodeoxyglucose PET/CT is reasonable as adjunct diagnostic imaging.69–71

2b B-NR 14.  In patients with nosocomial S. aureus bacteremia with a known portal of entry from an extracardiac source, TEE might be considered to detect concomitant staphylococcal IE.22,53,54,72–74

Synopsis In patients with suspected endocarditis, the Modified Duke Criteria (Tables 24 and 25) are the current standard for diagnosis and incorporate clinical, imaging, and bacteriological criteria. These criteria have been well validated by comparison with surgical or autopsy findings and in the clinical outcomes of numerous studies involving a wide spectrum of patients, including children, the elderly, prosthetic valve recipients, injection drug users, and non–drug users, as well as patients in both primary- and tertiary-care settings. For patients with VHD and known or suspected IE, obtain blood culture results before initiation of antibiotic therapy. For diagnosis and management of patients with IE, additional members of the Heart Valve MDT include infectious disease experts, who can provide advanced approaches to microbiological diagnosis. Cardiac imaging with TTE, TEE, and now CT and CT/ PET imaging is critical for diagnosis of IE.4,6–10

Recommendation-Specific Supportive Text

1.	 Blood culture results are positive in 90% of patients with IE provided that ≥2 blood culture samples are obtained at different times, ideally >6 hours apart if clinical status allows, at peripheral sites before initiation of antimicrobial therapy. More important than the time interval of the collection of culture samples is observing strict aseptic technique, avoiding sampling from intravascular lines, and ensuring an adequate volume of blood for the culture sample. Routine incubation of blood culture samples for >7 days is no longer necessary in the era of continuous-monitoring blood culture

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