Top Things to Know: Infective Endocarditis: Diagnosis, Antibiotic Therapy, and Management

Updated: September 08, 2026

Prepared by Daniel C. DeSimone, MD, FAHA and Larry M. Baddour, MD, FAHA

  1. Since the 2015 American Heart Association Scientific Statement, the incidence of infective endocarditis (IE) has continued to rise with major shifts in epidemiology, including increasing injection drug use–associated IE related to the opioid epidemic, an aging population with complex comorbidities, and expanding use of cardiovascular implantable devices and prosthetic materials.
  2. Advances in laboratory diagnostics and imaging—including molecular pathogen detection, emerging radiopharmaceutical imaging, and artificial intelligence—are reshaping how IE is diagnosed and monitored, with the potential to enable earlier targeted therapy and more precise disease assessment.
  3. Treatment strategies have evolved beyond prolonged intravenous therapy and delayed surgery to include multidisciplinary Endocarditis Teams, early procedural interventions, and alternative antimicrobial strategies, aiming to improve outcomes in a disease still associated with substantial morbidity and nearly 40% one-year mortality.
  4. Since the 2015 American Heart Association Scientific Statement, the incidence of infective endocarditis (IE) has continued to rise with major shifts in epidemiology, including increasing injection drug use–associated IE related to the opioid epidemic, an aging population with complex comorbidities, and expanding use of cardiovascular implantable devices and prosthetic materials.
  5. The 2023 Duke/ISCVID criteria are used for the contemporary diagnosis of IE and incorporate molecular microbiologic techniques and advanced multimodality imaging findings, improving diagnostic sensitivity.
  6. Advances in laboratory diagnostics and imaging—including molecular pathogen detection, emerging radiopharmaceutical imaging, and artificial intelligence—are reshaping how IE is diagnosed and monitored, with the potential to enable earlier targeted therapy and more precise disease assessment.
  7. The Endocarditis Team is recommended for the management of IE and has been associated with improved patient outcomes.
  8. In patients with bloodstream infection without clinical evidence of valvular heart disease, the need for echocardiography depends on the causative organism and patient-specific risk factors for IE.
  9. Because both transthoracic and transesophageal echocardiography have reduced sensitivity in TAVR-associated IE, multimodality imaging—particularly ¹⁸F-FDG PET/CT—may be required to establish the diagnosis.
  10. Molecular diagnostic testing of blood or cardiac valve tissue can be useful when conventional cultures are negative or inconclusive.
  11. Treatment strategies have evolved beyond prolonged intravenous therapy and delayed surgery to include multidisciplinary Endocarditis Teams, early procedural interventions, and alternative antimicrobial strategies, aiming to improve outcomes in a disease still associated with substantial morbidity and nearly 40% one-year mortality.
  12. Partial oral antibiotic therapy after the acute treatment phase and the use of long-acting lipoglycopeptides (e.g., dalbavancin or oritavancin) may be appropriate antimicrobial strategies in carefully selected patients.
  13. Additional treatment considerations include avoiding gentamicin in staphylococcal prosthetic valve endocarditis because risks outweigh benefits, recognizing that positive cultures or molecular tests from resected valve tissue do not alter postoperative antibiotic duration, and considering percutaneous mechanical aspiration for select high-surgical-risk patients with right-sided IE who fail medical therapy.

View the summary for Infective Endocarditis: Diagnosis, Antibiotic Therapy, and Management

Advertisement

Citation

DeSimone DC, Marks L, Dayer MJ, Esquer Garrigos Z, Messika-Zeitoun D, O’Gara PT, Pettersson GB, Bucholz EM, Andrews LS, Fowler VG Jr, Miro JM, Baddour LM; on behalf of the American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Clinical Car¬diology; Council on Cardiovascular and Stroke Nursing; and the Council on Car¬diovascular Radiology and Intervention. Infective endocarditis: diagnosis, antibiotic therapy, and management: a scientific statement from the American Heart Asso¬ciation. Circulation. Published online September 8, 2026: doi: 10.1161/CIR.0000000000001466
Advertisement
Advertisement