16.3 Infective Endocarditis, Device Infections & Other Focal Cardiovascular Infections
Key Takeaways
Early surgery is indicated in infective endocarditis for heart failure from valve dysfunction, uncontrolled infection such as abscess or persistent bacteremia, and vegetations larger than 10 mm with embolism (or very large vegetations).
In the 2012 EASE trial, surgery within 48 hours for large vegetations reduced embolic events (3% vs 23%) without changing mortality.
Anticoagulation is generally avoided or interrupted after embolic stroke in endocarditis because of hemorrhagic transformation risk, especially with Staphylococcus aureus.
Cardiac implantable device infection requires complete hardware extraction; antibiotics alone fail, and transesophageal echocardiography assesses lead vegetations.
Purulent pericarditis is a surgical drainage problem; pericardiocentesis alone often fails because the exudate is loculated and thick.
Infective Endocarditis: Diagnosis
The 2023 Duke-ISCVID criteria updated the classic Duke framework. The essential logic remains:
Major microbiologic criteria:
- Typical organisms in at least two separate blood cultures: viridans streptococci, Streptococcus gallolyticus (formerly bovis), HACEK organisms, S. aureus, Enterococcus faecalis.
- Persistent bacteremia with organisms that are less typical.
- Positive serology or PCR for Coxiella burnetii, Bartonella, and Tropheryma whipplei.
Major imaging criteria:
- Echocardiographic vegetation, abscess, pseudoaneurysm, intracardiac fistula, valve perforation, or new prosthetic dehiscence.
- 18F-FDG PET/CT abnormal activity around a prosthetic valve or device (now a major criterion), and CT evidence of paravalvular involvement.
Minor criteria include predisposing heart disease or injection drug use, fever, vascular phenomena (septic emboli, mycotic aneurysm, intracranial hemorrhage, Janeway lesions), immunologic phenomena (glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor), and microbiologic findings that do not meet major criteria.
Practical approach:
- Draw at least three sets of blood cultures from separate sites before antibiotics.
- Transthoracic echocardiography first, then transesophageal echocardiography when the transthoracic study is negative or inadequate, when a prosthesis or device is present, or when complications are suspected.
- Add cardiac CT for paravalvular extension, brain MRI for silent emboli, and PET/CT for prosthetic material.
- S. gallolyticus bacteremia mandates colonoscopy (association with colonic neoplasia).
- S. aureus bacteremia always deserves an echocardiogram and a careful search for metastatic foci.
Treatment and the Surgical Decision
Empiric therapy in a critically ill patient covers S. aureus (including MRSA), streptococci, and enterococci: vancomycin plus ceftriaxone, or vancomycin plus gentamicin for prosthetic valves with rifampin added once the organism is known. Definitive therapy is organism-directed for 4 to 6 weeks, usually intravenous, with cardiology, cardiac surgery, and infectious diseases co-managing.
Indications for early surgery:
- Heart failure from valve regurgitation or obstruction (the strongest indication).
- Uncontrolled infection: abscess, fistula, pseudoaneurysm, heart block, or persistent bacteremia and fever beyond 5 to 7 days despite appropriate antibiotics.
- Prevention of embolism: a vegetation larger than 10 mm with a prior embolic event, or very large vegetations (above about 15 mm). In the EASE trial, early surgery (within 48 hours) for large vegetations reduced embolic events from 23% to 3% without changing mortality.
- Difficult organisms: fungal endocarditis, multidrug-resistant organisms, S. aureus prosthetic valve endocarditis.
- Prosthetic valve endocarditis with dehiscence, obstruction, or relapse.
Anticoagulation: endocarditis itself is not an indication. In a patient already anticoagulated (for example, a mechanical valve), the risk of hemorrhagic transformation after a septic embolic stroke, particularly with S. aureus, usually leads to interrupting anticoagulation for about 2 weeks after a significant embolic stroke, with individualized multidisciplinary decisions. Avoid aspirin as adjunctive therapy, which did not reduce embolism and increased bleeding.
Neurologic complications: ischemic stroke is common, and mycotic aneurysms can rupture. Image the brain vessels when there is hemorrhage, focal headache, or unexplained deterioration. Thrombolysis is contraindicated in stroke caused by endocarditis; mechanical thrombectomy can be considered.
Right-Sided Endocarditis
- Usually S. aureus in people who inject drugs, or device- and catheter-related.
- Presents with fever, bacteremia, and septic pulmonary emboli (multiple peripheral cavitating nodules) rather than systemic emboli.
- Many cases respond to antibiotics alone; surgical indications include right heart failure, persistent bacteremia, very large vegetations, and recurrent pulmonary emboli. Tricuspid valve repair is preferred to replacement when possible.
- Treat the substance use disorder as part of the plan; relapse drives recurrent endocarditis.
Cardiac Implantable Electronic Device Infection
- Pocket infection: erythema, swelling, erosion, or discharge over the generator. Do not aspirate the pocket.
- Lead endocarditis or device-related bacteremia: S. aureus or coagulase-negative staphylococci.
- Management: complete removal of the generator and all leads, culture of the hardware, 2 to 6 weeks of antibiotics depending on bacteremia and vegetations, and reimplantation on the contralateral side after clearance. Antibiotics without extraction relapse in most cases.
- S. aureus bacteremia in a device carrier mandates transesophageal echocardiography even without local signs.
Purulent Pericarditis and Myocardial Abscess
- Purulent pericarditis arises from contiguous pneumonia or empyema, bacteremia, thoracic surgery, or trauma, typically with S. aureus, S. pneumoniae, or gram-negative organisms. Patients present with sepsis and often tamponade.
- Pericardial fluid shows a very high white cell count with low glucose and high LDH.
- Treatment requires drainage, usually surgical (pericardiotomy or pericardiectomy) because the purulent exudate loculates and thickens; needle pericardiocentesis alone frequently fails. Give prolonged intravenous antibiotics, and consider intrapericardial fibrinolysis to prevent constriction.
- Tuberculous pericarditis presents subacutely; adjunctive corticosteroids are used selectively, and constrictive physiology may follow.
Head, Neck and Orbital Infections With Critical Care Implications
| Infection | Features | Management |
|---|---|---|
| Septic cavernous sinus thrombosis | Spread from sinusitis or facial or dental infection: proptosis, chemosis, periorbital edema, cranial nerves III, IV, V1, V2, and VI palsies, often bilateral | MRI or CT venography; prolonged high-dose antibiotics covering S. aureus and anaerobes; drainage of the source; anticoagulation is often used despite limited evidence; steroids for cranial neuropathy are debated |
| Orbital cellulitis and abscess | Proptosis, pain with eye movement, reduced vision | Imaging, antibiotics, surgical drainage; distinguish from preseptal cellulitis |
| Ludwig angina | Submandibular space infection with tongue elevation and airway compromise | Early airway control, broad-spectrum antibiotics, surgical drainage |
| Lemierre syndrome | Internal jugular septic thrombophlebitis after pharyngitis, usually Fusobacterium necrophorum, with septic pulmonary emboli | Beta-lactam-beta-lactamase inhibitor or carbapenem, or metronidazole plus a cephalosporin; anticoagulation individualized |
| Epiglottitis | Rapidly progressive sore throat, drooling, muffled voice, stridor in adults | Airway control in a controlled setting with surgical backup, ceftriaxone plus anti-staphylococcal coverage |
| Invasive fungal sinusitis | Diabetes with ketoacidosis or neutropenia; black necrotic turbinates, facial numbness | Emergent surgical debridement plus liposomal amphotericin B |
| Deep neck space abscess | Trismus, neck swelling, dysphagia; retropharyngeal extension to the mediastinum | CT with contrast, drainage, broad-spectrum antibiotics; watch for descending necrotizing mediastinitis |
Bone and joint infections also reach the ICU: septic arthritis needs joint aspiration before antibiotics and urgent drainage (arthroscopic or open), and large-joint involvement with S. aureus bacteremia often signals endocarditis or another deep focus. Vertebral osteomyelitis presents with back pain and bacteremia and frequently accompanies epidural abscess.
A 52-year-old man with Staphylococcus aureus bacteremia has a 16 mm mitral valve vegetation, severe mitral regurgitation, and pulmonary edema requiring noninvasive ventilation on day 3 of appropriate antibiotics. Which factor most strongly indicates early surgery?
The duration of bacteremia being less than 1 week
Heart failure caused by severe valve regurgitation
The organism being methicillin-sensitive rather than resistant
The presence of Janeway lesions on examination
A 74-year-old woman with a dual-chamber pacemaker implanted 3 years ago presents with 2 weeks of fever and Staphylococcus aureus bacteremia. The pocket looks normal, and transesophageal echocardiography shows a 9 mm vegetation on the ventricular lead. What is the most appropriate management?
Six weeks of intravenous antibiotics with the device left in place and repeat imaging at the end of therapy
Generator removal with retention of the chronically implanted leads plus 4 weeks of antibiotics
Complete extraction of the generator and all leads plus antibiotic therapy, with reimplantation on the contralateral side after clearance
Chronic oral suppressive antibiotic therapy without any hardware intervention
A 45-year-old man with pneumococcal pneumonia develops hypotension, muffled heart sounds, and a large pericardial effusion. Pericardiocentesis yields 60 mL of thick purulent fluid with 92,000 white cells/µL, but the effusion reaccumulates within hours and the catheter stops draining. What is the most appropriate next step?
Surgical pericardial drainage, such as pericardiotomy, with continued intravenous antibiotics
Repeat needle pericardiocentesis daily until the fluid clears
Intravenous antibiotics alone, because the fluid is a reactive sympathetic effusion
Colchicine plus high-dose NSAID therapy for inflammatory pericarditis
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