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Persistent/relapsing bacteraemia/fungaemia Gram-negative No vegetations and non-S. aureus Vegetations and/or S. aureus Septic emboli or prosthetic valve 2 weeks of antibiotics (Class IIb) 4 weeks of antibiotics (Class IIa) CIED reimplantationc (Class I) 6 weeks of antibiotics (Class IIa) CIED extraction Gram-positive or fungaemia Antibiotic therapy covering MRSA and Gram-negative bacteria (Class I) Suspicion of CIED-related IE 2023 ESC diagnostic criteria for IE Repeat diagnostic tests within 7 days Antimicrobial therapy Bacteraemia/fungaemia without other major criteria or source of infection Blood cultures TTE and TOE (or intracardiac echocardiography) [18F]FDG-PET/CT (or WBC SPECT)a (Class I) Possible IE Definite IE No IE Cured Probable isolated valve IEb Definite CIED involvement (Class IIb) (Class IIa) (Class I) Figure 13 Management of cardiovascular implanted electronic device-related infective endocarditis. [18F]FDG-PET/CT, 18F-fluorodeoxyglucose positron emission tomography/computed tomography; CIED, cardiovascular implanted electronic device; ESC, European Society of Cardiology; IE, infective endocarditis; MRSA, methicillin-resistant S. aureus; TOE, transoesophageal echocardiography; TTE, transthoracic echocardiography; WBC SPECT/CT, white blood cell single photon emission tomography/computed tomography. aIf no signs of pocket infection and negative TOE. bTaking into account the identified pathogen, procedural risk, and requirement for valve surgery. cAt a distant site and postponed as long as possible (until signs and symptoms of infection have resolved and blood cultures are negative for >72 h in the absence of vegetations and /or ‘ghosts’, or otherwise after >2 weeks of negative blood cultures). ESC Guidelines 4003 Downloaded from academic.oup.com/eurheartj/article/44/39/3948/7243107 by guest on 07 October 2026