ICU · cardiovascular
Acute Infective Endocarditis — Comprehensive ICU Management
Also known as Infective endocarditis · IE · Bacterial endocarditis · Subacute bacterial endocarditis · SBE · Native valve endocarditis · Prosthetic valve endocarditis · Modified Duke criteria · Valve vegetation
Infective endocarditis — microbial infection of the endocardial surface causing valvular destruction, embolisation, and sepsis. Modified Duke criteria for definite IE; S. aureus dominant in ICU disease; cultures before antibiotics, TTE then TOE, bactericidal therapy counted from first effective therapy, and early surgery for heart failure, uncontrolled infection, and large mobile vegetations.
Checked against its sources on 14 Oct 2026
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Red flags
- S. aureus bacteraemia = ENDORCARDITIS until proven otherwise — ALL S. aureus bacteraemia patients should have echocardiography (TOE preferred — TTE misses 20-30% of vegetations)
- Acute severe valvular regurgitation from IE → acute heart failure → EARLY SURGERY (within 24-48h) — do NOT wait for antibiotic course to complete
- New heart block in a patient with aortic valve endocarditis = PERIANNULAR ABSCESS extending into the septum → surgical emergency
- Cerebral embolism (stroke) from IE vegetation = stop anticoagulation, assess for haemorrhagic transformation, consider early surgery (recent stroke is NOT an absolute contraindication to surgery if heart failure mandates it)
- TOE (transoesophageal echo) is SUPERIOR to TTE for IE — detects smaller vegetations (>3 mm vs >6 mm for TTE), visualises abscess/fistula, assesses prosthetic valves — ALWAYS do TOE if IE suspected
Meet the patient
An older man with weeks of low-grade fever and malaise, now arrives in septic shock with acute pulmonary oedema. A new early diastolic murmur at the left sternal edge, bibasal crackles, cool peripheries, raised lactate. Blood cultures (drawn before antibiotics) grow Staphylococcus aureus. The bedside echo shows a large aortic-valve vegetation with severe acute aortic regurgitation.[1][2]
The registrar wants to "stabilise him on antibiotics for a week, then operate." Stop. This man has heart failure from acute valvular regurgitation — the number-one surgical indication in IE, and the one you cannot wait on. The antibiotics cannot fix a destroyed valve, and the heart failure will kill him long before the course completes. The Endocarditis Team is called now, not next week.[1][4]
References32ShowHide
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