Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Clinical manifestations and evaluation of adults with suspected native valve endocarditis

Daniel J Sexton, MD
Vivian H Chu, MD, MHS
Section Editor
Catherine M Otto, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Infective endocarditis (IE) refers to infection of the endocardial surface of the heart; it usually refers to infection of one or more heart valves or infection of an intracardiac device.

The clinical manifestations and evaluation of adults with suspected native valve IE will be reviewed here. Issues related to risk factors, complications, antimicrobial therapy, surgery, and outcome of native valve IE are discussed separately:

(See "Epidemiology, risk factors, and microbiology of infective endocarditis".)

(See "Complications and outcome of infective endocarditis".)

(See "Antimicrobial therapy of native valve endocarditis".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 28, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075.
  2. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435.
  3. Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med 2009; 169:463.
  4. Cahill TJ, Prendergast BD. Infective endocarditis. Lancet 2016; 387:882.
  5. Loughrey PB, Armstrong D, Lockhart CJ. Classical eye signs in bacterial endocarditis. QJM 2015; 108:909.
  6. Meine TJ, Nettles RE, Anderson DJ, et al. Cardiac conduction abnormalities in endocarditis defined by the Duke criteria. Am Heart J 2001; 142:280.
  7. Lindner JR, Case RA, Dent JM, et al. Diagnostic value of echocardiography in suspected endocarditis. An evaluation based on the pretest probability of disease. Circulation 1996; 93:730.
  8. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  9. Holland TL, Arnold C, Fowler VG Jr. Clinical management of Staphylococcus aureus bacteremia: a review. JAMA 2014; 312:1330.
  10. Colen TW, Gunn M, Cook E, Dubinsky T. Radiologic manifestations of extra-cardiac complications of infective endocarditis. Eur Radiol 2008; 18:2433.
  11. Duval X, Iung B, Klein I, et al. Effect of early cerebral magnetic resonance imaging on clinical decisions in infective endocarditis: a prospective study. Ann Intern Med 2010; 152:497.
  12. Meshaal MS, Kassem HH, Samir A, et al. Impact of routine cerebral CT angiography on treatment decisions in infective endocarditis. PLoS One 2015; 10:e0118616.
  13. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 1994; 96:200.
  14. Prendergast BD. Diagnostic criteria and problems in infective endocarditis. Heart 2004; 90:611.
  15. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30:633.
  16. Bayer AS, Ward JI, Ginzton LE, Shapiro SM. Evaluation of new clinical criteria for the diagnosis of infective endocarditis. Am J Med 1994; 96:211.
  17. Hoen B, Selton-Suty C, Danchin N, et al. Evaluation of the Duke criteria versus the Beth Israel criteria for the diagnosis of infective endocarditis. Clin Infect Dis 1995; 21:905.
  18. Sandre RM, Shafran SD. Infective endocarditis: review of 135 cases over 9 years. Clin Infect Dis 1996; 22:276.
  19. Nettles RE, McCarty DE, Corey GR, et al. An evaluation of the Duke criteria in 25 pathologically confirmed cases of prosthetic valve endocarditis. Clin Infect Dis 1997; 25:1401.
  20. 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.
  21. Cockerill FR 3rd, Wilson JW, Vetter EA, et al. Optimal testing parameters for blood cultures. Clin Infect Dis 2004; 38:1724.
  23. Werner AS, Cobbs CG, Kaye D, Hook EW. Studies on the bacteremia of bacterial endocarditis. JAMA 1967; 202:199.
  24. Woo PC, Tse H, Chan KM, et al. "Streptococcus milleri" endocarditis caused by Streptococcus anginosus. Diagn Microbiol Infect Dis 2004; 48:81.
  25. Parker MT, Ball LC. Streptococci and aerococci associated with systemic infection in man. J Med Microbiol 1976; 9:275.
  26. Anderson DJ, Murdoch DR, Sexton DJ, et al. Risk factors for infective endocarditis in patients with enterococcal bacteremia: a case-control study. Infection 2004; 32:72.
  27. Muñoz P, Bouza E, Marín M, et al. Heart valves should not be routinely cultured. J Clin Microbiol 2008; 46:2897.
  28. Gould FK, Denning DW, Elliott TS, et al. Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2012; 67:269.
  29. Habib G, Badano L, Tribouilloy C, et al. Recommendations for the practice of echocardiography in infective endocarditis. Eur J Echocardiogr 2010; 11:202.
  30. Bai AD, Steinberg M, Showler A, et al. Diagnostic Accuracy of Transthoracic Echocardiography for Infective Endocarditis Findings Using Transesophageal Echocardiography as the Reference Standard: A Meta-Analysis. J Am Soc Echocardiogr 2017; 30:639.
  31. Irani WN, Grayburn PA, Afridi I. A negative transthoracic echocardiogram obviates the need for transesophageal echocardiography in patients with suspected native valve active infective endocarditis. Am J Cardiol 1996; 78:101.
  32. De Castro S, Cartoni D, d'Amati G, et al. Diagnostic accuracy of transthoracic and multiplane transesophageal echocardiography for valvular perforation in acute infective endocarditis: correlation with anatomic findings. Clin Infect Dis 2000; 30:825.
  33. Daniel WG, Mügge A, Martin RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991; 324:795.
  34. Rasmussen RV, Høst U, Arpi M, et al. Prevalence of infective endocarditis in patients with Staphylococcus aureus bacteraemia: the value of screening with echocardiography. Eur J Echocardiogr 2011; 12:414.
  35. Incani A, Hair C, Purnell P, et al. Staphylococcus aureus bacteraemia: evaluation of the role of transoesophageal echocardiography in identifying clinically unsuspected endocarditis. Eur J Clin Microbiol Infect Dis 2013; 32:1003.
  36. Vieira ML, Grinberg M, Pomerantzeff PM, et al. Repeated echocardiographic examinations of patients with suspected infective endocarditis. Heart 2004; 90:1020.
  37. Bruun NE, Habib G, Thuny F, Sogaard P. Cardiac imaging in infectious endocarditis. Eur Heart J 2014; 35:624.
  38. Lang RM, Tsang W, Weinert L, et al. Valvular heart disease. The value of 3-dimensional echocardiography. J Am Coll Cardiol 2011; 58:1933.
  39. Dursun M, Yılmaz S, Yılmaz E, et al. The utility of cardiac MRI in diagnosis of infective endocarditis: preliminary results. Diagn Interv Radiol 2015; 21:28.
  40. Fagman E, Perrotta S, Bech-Hanssen O, et al. ECG-gated computed tomography: a new role for patients with suspected aortic prosthetic valve endocarditis. Eur Radiol 2012; 22:2407.
  41. Feuchtner GM, Stolzmann P, Dichtl W, et al. Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings. J Am Coll Cardiol 2009; 53:436.
  42. Gahide G, Bommart S, Demaria R, et al. Preoperative evaluation in aortic endocarditis: findings on cardiac CT. AJR Am J Roentgenol 2010; 194:574.
  43. Thuny F, Gaubert JY, Jacquier A, et al. Imaging investigations in infective endocarditis: current approach and perspectives. Arch Cardiovasc Dis 2013; 106:52.
  44. Kouijzer IJ, Vos FJ, Janssen MJ, et al. The value of 18F-FDG PET/CT in diagnosing infectious endocarditis. Eur J Nucl Med Mol Imaging 2013; 40:1102.
  45. Yeh CL, Liou JY, Chen SW, Chen YK. Infective endocarditis detected by ¹⁸F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in a patient with occult infection. Kaohsiung J Med Sci 2011; 27:528.
  46. Orvin K, Goldberg E, Bernstine H, et al. The role of FDG-PET/CT imaging in early detection of extra-cardiac complications of infective endocarditis. Clin Microbiol Infect 2015; 21:69.