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REVIEW

C URRENT
OPINION Endocarditis in the intensive care unit: an update
Ines Lakbar a, Louis Delamarre a, Sharon Einav b and Marc Leone a

Purpose of review
The incidence of infective endocarditis (IE) is increasing worldwide, resulting in a higher number of patients
with IE being admitted to intensive care units (ICU). Nearly half of patients with IE develop a complication
during their clinical course. However, few well conducted studies or reviews are devoted to critically ill IE
patients. This review discusses the contemporary perioperative and intensive care literature.
Recent findings
IE epidemiology is changing towards elderly and frail patients. ICU patients are at risk of risk of
developing IE because they are often in a pro-inflammatory state and many also have several indwelling
catheters, which favors infection. Increased performance and recent advances in cardiac imaging allow for
easier diagnosis of EI, but the applicability of these techniques to ICU patients is still relatively limited. New
developments in antibiotic treatment and adjunctive therapies are explored further in this review.
Summary
The lack of evidence on ICU patients with IE highlights the critical importance of multidisciplinary decision-
making and the need for further research.
Keywords
critically ill patient, infective endocarditis, intensive care unit, outcomes

INTRODUCTION Epidemiology and pathophysiology

Infective endocarditis (IE) is a disease with an inci-
dence of 3–5 per 100 000 individuals per year
according to European population-based studies
[1]. Despite recent improvements in treatment, IE
remains associated with high morbidity and mortal-
ity rates due to a change in the profiles of IE patients.
Compared to previous cohorts, patients with IE
today are older, more likely to have a prosthetic
valve or device-related infections and more likely
&
to develop healthcare associated infections [1,2 ]. In
a US population based-study, complications associ-
ated with increased mortality rates were reported in
&
nearly 40% of patients [3 ]. Likewise, in a large
European study, the outcome of IE patients with
septic shock was poor, with a 1-year mortality rate
&
approximating two-thirds [4 ]. Despite these data,
few well conducted studies or reviews are dedicated
to critically ill IE patients. In addition, nearly half of
&&
IE patients undergo a surgical intervention [5 ],
hence the perioperative management of these
patients is of particular interest. This review will
discuss the contemporary literature and will provide
an overview of the current state of knowledge
regarding the perioperative and intensive care of
critically ill IE patients.
A large meta-analysis pooling data from nationwide
population-based registries in Europe reported a
doubling of the incidence of IE from 2000 to 2018
&
[2 ]. This trend was also found among intensive care
unit (ICU) patients [6]. Such an increase may be
explained by increased performance rates of inva-
sive procedures in the cardiac patient. Indeed, a
large prospective cohort reporting data from 40
countries showed an increase in the incidence of
prosthetic and device-related IE from 2016 to 2018,
representing up to 40% of all the diagnosed IE [1].
Aortic valve replacement rates have also doubled in
a
Department of Anesthesiology and Intensive Care Unit, Aix Marseille
University, Assistance Publique Hôpitaux Universitaires de Marseille,
Nord Hospital, Marseille, France and bGeneral Intensive Care Unit of the
Shaare Zedek Medical Centre and the Hebrew University Faculty of
Medicine, Jerusalem, Israel
Correspondence to Ines Lakbar, Department of Anesthesiology and
Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpi-
taux Universitaires de Marseille, Nord Hospital, 15 chemin des Bourrely,
13015 Marseille, France. Tel: +33 4 91 96 86 55;
e-mail: ines.lakbar@ap-hm.fr
Curr Opin Crit Care 2022, 26:000–000
DOI:10.1097/MCC.0000000000000973

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Severe infections
KEY POINTS
 The incidence of infective endocarditis increases
worldwide, including in intensive care unit (ICU), with
an increase in patients’ age, frailty and history of
cardiac devices and prosthetic valves.
 Nearly half of infective endocarditis (IE) patients
develop complication(s), which are associated with
mortality and ICU admission.
 The diagnosis of IE benefits from the advances in
cardiac imaging (computed tomography and nuclear
medicine), but the applicability of those techniques to
ICU patients is poorly reported.
 Innovative treatments are described, such as hyperbaric
oxygen, antiplatelets and anticoagulation medications,
but none has been thoroughly explored in clinical trials.
the last decade with a major increase of transcath-
eter valve replacement procedures [7,8]. These endo-
vascular procedures have the same risk of IE as do
surgical procedures [9]. Both result in some degree of
valvular structural alteration and subsequent endo-
thelial injury. Structural valve alterations provide a
breeding ground for circulating micro-organisms as
they expose sub-endothelial molecules (collagen
and von Willebrandt factor) which allow bacterial
adhesion and also modify the shear stress of the
blood flow [10,11]. These predisposing conditions
have been reported in degenerative heart valve dis-
ease. However, a new animal model revealed that
generalized inflammation, as it occurs in sepsis,
results in valve inflammation, which, in combina-
tion with bacteremia, leads to IE [12] (Fig. 1).
This animal model was developed using Staph-
ylococcus aureus, as its main virulence factors allow it
to manipulate the host’s innate and adaptive immun-
ity and coagulation cascades and thus thwart the
defense mechanisms of the host [10,13]. These semi-
nal studies are consistent with clinical findings, as S.
aureus is the most common pathogen in patients with
IE, followed by Streptococcus and Enterococcus species
&
[2 ]. Furthermore, in a cohort of ICU patients with
IE-related septic shock, S. aureus was the main agent
&
responsible for the infection [4 ]. A significant
increase in Enterococcus-associated IE has been
reported consistently over the past decade, likely
related to the increased frequency of transcatheter
procedures in the elderly, as the femoral microbiota of
the elderly has been documented as displaying a
higher incidence of enterococcal colonization
&
[1,2 ,14]. The same microbiological profile was found
in a cohort of ICU patients [6]. The main etiologies of
IE according to valve location are depicted in Fig. 2.
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In a nutshell, the incidence of IE has increased in
the last two decades in the overall population and
therefore in the ICU population. Furthermore, ICU
patients are at risk of developing IE because they are
often in a pro-inflammatory state and many also have
several indwelling catheters, which favors infection.
Finally, the indications for transcatheter procedures
extend to include the elderly and frail and these
patients are at greater risk of complications with
increased mortality rates than prior cohorts.
Risk factors for a poor outcome
&
In patients with IE, acute respiratory failure [4 ],
& & &
acute kidney injury [3 ,4 ,15,16], sepsis [3 ,17,18],
& &
acute heart failure [3 ,4 ,18], acute neurological fail-
&
ure [3 ,16,19], multiorgan failure (as illustrated by
high sequential organ failure assessment [SOFA]
&
scores) [19–21], preexisting comorbidities [4 ,15]
and disseminated intravascular coagulopathy are
all common causes of ICU admission. All of these
&
are also associated with high rates of mortality [3 ].
Increasing age, which is a trend also observed in
patients admitted to the ICU for IE, seems associated
with mortality as well [16,17,19,21]. Additional fac-
tors which have been associated with complications
of IE, are congenital heart disease, congestive heart
failure, a heavy burden of comorbidities and specific
&
causative pathogens, that is S. aureus and fungi [3 ].
A multicenter prospective observational study
which included 246 ICU patients admitted for com-
plicated IE, noted that SOFA scores
5 and C-reactive
protein (CRP) levels
17.6 mg/l were associated with
higher in-hospital mortality with an receiver operat-
ing characteristic (ROC) area under the curve (AUC)
of 0.87 (95% confidence interval [CI] 0.83–0.91),
while SOFA score, but not CRP, was also associated
with mortality at 12–36 months [19]. In a meta-anal-
ysis gathering data from nine studies and 627 non-
ICU patients, an increased serum troponin level was
associated with increased in-hospital mortality (odds
ratio [OR] 5.7, 95% CI 3.5–10.3) and 1-year mortality
(OR 2.67, 95% CI 1.42–5.02) [22]. Increased D-dimer
levels were also associated with in-hospital mortality
and 6-month mortality in an observational study of
613 non-ICU patients [23]. In a single center retro-
spective study in non-ICU patients, elevated serum
procalcitonin concentrations both at admission and
at 48–72 h were associated with in-hospital mortality
[16]. Conversely, cardiac surgery is often reported as
&
a protective factor regarding mortality [4 ,18,19].
Diagnosis
The diagnosis of IE is challenging in the ICU patient
[24]. Fever is common in ICU patients and is
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Endocarditis in the intensive care unit: an update Lakbar et al.

FIGURE 1. Mechanisms of valve infection.

therefore not specific to IE. Murmur is a classical
symptom, but auscultation can be difficult in ICU
patients, particularly in those requiring mechanical
ventilation or with tachycardia. Atypical clinical
presentations are therefore frequent in ICU patients.
Late diagnosis of IE, based on the occurrence of
complications, is common. Furthermore, in many
cases, these complications are often the indication
&
for ICU admission in the first place [3 ]. These
complications may be cardiovascular (22.6%), neu-
&
rological (16.7%), renal (6.4%) or hematologic [3 ].
About 1 in 10 patients with IE will also develop
septic shock. Moreover, infection occurs in up to
7.4% of prosthetic valves and 9% of implanted
cardiac devices, but such infections often have mis-
leading clinical and ultrasound presentations [25].
Finally, the diagnosis of other diseases, sharing
those nonspecific symptoms, can be falsely priori-
tized, as it has been the case during the coronavirus
disease 2019 (COVID-19) [26–29]. Furthermore,
delayed consultation and testing during the pan-
demic [30] have been shown to affect the diagnosis
and management of IE, as well as other pathologies
[30–36]. Hence physicians should maintain a high
rate of suspicion in ICU patients regarding the pos-
sibility of IE [30].
The cornerstone of diagnosis of IE remains visual-
ization of the cardiac valves. Transthoracic echocar-
diography (TTE) is only moderately sensitive for
detection of vegetations in both native (sensitivity:
60–70%) and prosthetic (sensitivity: 50%) valves [37].
However, in most ICUs, this technique is immedi-
ately available and repeatable at the bedside by the
intensivist. Transesophageal echocardiography (TEE)
exhibits a much better performance for detection of
vegetations, with a sensitivity of 90–100% and 90%
in native and prosthetic valves, respectively [37].
The diagnostic criteria of IE have been modified
in 2015, through the introduction of the modified
Duke criteria in the North American guidelines [38]

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Severe infections
FIGURE 2. The common etiologies of infectious endocarditis according to the location of the involved valve [79].
and the European Society of Cardiology (ESC) cri-
teria in the European guidelines [24].
The 2015 ESC diagnostic criteria added three
elements to the modified Duke criteria [39]. Two of
those three, suggested as major criteria, involved the
use of advanced cardiac imaging techniques to detect
cardiac lesions attributable to IE, whereas the detec-
tion of recent silent embolic events or infectious
aneurysms by imaging is proposed as a new minor
criterion. The new major criteria based on cardiac
imaging techniques are the detection of paravalvular
lesions by cardiac multislice computed tomography
(CT) and the detection of abnormal activity on pros-
thetic valve by 18F-flurodeoxyglucose (FDG) positron
emission tomography/computed tomography (PET/
CT) or radiolabelled leucocyte single-photo emission
computed tomography (SPECT/CT).
Cardiac multislice CT is a high-resolution
(<1 mm) imaging technique of the heart after ECG-
&
gated retrospective reconstruction [40 ,41]. Cardiac
CT has a performance almost similar to TEE for diag-
& &
nosing IE [40 ,42 ]. However, cardiac CT better
detects paravalvular abscesses and pseudo-aneur-
ysms, whereas TEE seems to better detect vegetations
sized <10 mm and valvular perforations [41]. In
patients with prosthetic valves, the sensitivity of
CT and TEE seem similar, with a trend towards better
performance of cardiac CT for paravalvular abscesses,
vegetations and inflammatory infiltrations, whereas
& &
TEE better detects paravalvular leakage [40 ,42 ,43 ].
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Some authors therefore propose to combine both
techniques when prosthetic valve endocarditis is sus-
pected. The pharmacological reduction of heart rate
that is recommended to ensure good-quality images
&
may limit the use of cardiac CT in ICU patients [40 ].
This imaging tool should therefore probably be
chosen only when performing TEE is not feasible.
The comparative performances of TEE and cardiac
CT are presented in Table 1 and Fig. 3.
The second imaging technique recommended in
the ESC guidelines, 18F-FDG PET/CT, relies on 18F-
FDG uptake by white blood cells after an injection 1-h
prior to imaging. 18F-FDG PET/CT has a sensitivity of
67–80%, specificity of 75%, positive predictive value
of 90% and negative predictive value of 40% for
&
the diagnosis of prosthetic valve endocarditis [44 –
46], and a sensitivity and specificity of 85% for the
diagnosis of infection in implanted cardiac devices
[47]. In native valve IE, known for inducing a smaller
white blood cell traffic [48], 18F-FDG PET/CT alone
showed a sensitivity within the range of 20–57% and
&
a specificity approximating 100% [49 ,50].
The application of ESC criteria, including
those observed in 18F-FDG PET/CT, increased the
sensitivity of modified Duke criteria for native valve
endocarditis from 63.5% to 70% without affecting its
specificity [49 ]. However, imaging with 18F-FDG
&
PET/CT requires fasting for 24 h, hemodynamic
stability and sometimes heparin (50 UI/kg)
& &
to enhance glucose/FDG uptake [48,51,52 ].
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Table 1. Summary of the morphological diagnosis tools in infective endocarditis, with considerations pertaining to their use in ICU
Performance in Availability/
Performance in prosthetic feasibility
Technique Indication native valves valves in ICU Contraindications Limitations in ICU References

TTE Suspected IE Se: 60--70% Se: 50% High None -Lower quality images in Pelletier-Galarneau [37]
ventilated patients
-Operator-dependent ac
curacy
TEE -Suspected IE Se: 90--100% Se: 90% High Esophageal surgery, -Requires sedation Pelletier-Galarneau
&
-Confirmed IE mediastinum - Requires fasting [37], Sifaoui [42 ],
&
-Assessment of radiotherapy, unstable - Requires experienced Koo [40 ],
&
valve damage cervical spine fracture, operator (cardiologist Michalowska [43 ]
and heart upper airway mass or intensivist)
function -More difficult to visualize
-Preoperative prosthetic valves due to
assessment metal artifacts
Heart rate 75 bpm
&
Cardiac multislice -Suspected IE Accuracy: 92.6% Se: 92%, Sp: 86% Scarce data Not specific Koo [40 ], Khalique

MCC 280501
&
computerized -Confirmed IE available facilitates ECG-gated [41], Sifaoui [42 ],
&
tomography (CT) -Assessment of analysis Michalowska [43 ]
valve damage Can be difficult or poorly
and heart tolerated in ICU

Endocarditis in the intensive care unit: an update Lakbar et al.

function patients
-Preoperative
assessment
18
F-FGD PET/CT -Suspected IE Se: 20--57% Se: 67--77% Low, scarce Not specific Requires 24 h fasting, Mahmood [46], Venet
Sp: 100% Sp: 75% data available hemodynamic stability, [45], Abikhzer [50],
&
PPV: 91% avoidance of Philip [44 ], Philip
&
NPV: 42% corticosteroids and [49 ], van Hulst
&
hyperglycemia. [52 ], Schenone [83]
Heparin may enhance
image quality, but
potentially deleterious
in ICU patients
www.co-criticalcare.com

Radiolabelled -Complementary NA NA Low to very low Not specific Similar to 18F-FGD PET/ NA
leucocyte after 18F-FGD CT limitations
SPECT/CT PET/CT Requires
radiopharmaceutical
preparation of
autologous leucocytes.
Time-consuming image
acquisition

18
F-FGD PET/CT, F18-flurodeoxyglucose positron emission tomography and computed tomography; CT, computerized tomography; Se, sensitivity; Sp, specificity; SPECT/CT, single-photo emission computerized
tomography; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.
5

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Severe infections
FIGURE 3. Comparison of the performance of transesophageal echocardiography and multislice cardiac computed
tomography for the diagnosis of infective endocarditis. CT, computerized tomography; Se, sensitivity; Sp, specificity; TEE,
transesophageal echocardiography.
Concurrent administration of corticosteroids and the
presence of hyperglycemia have been associated with
&
false negative results [52 ]. Despite these limitations
of 18F-FDG PET/CT in ICU patients, the use of this tool
in such patients has been described by a few teams,
with successful diagnosis of IE in several cases
&
[52 ,53]. Unfortunately, there is still very little data
on the performance and feasibility of nuclear imaging
in ICU patients and no data on the performance of
nuclear imaging specifically for diagnosis of IE in ICU
&
patients [52 ].
Radiolabelled leucocyte SPECT/CT requires a
radiolabeling of autologous leucocytes that, once
re-injected, will accumulate in damaged heart tissue
in a time-dependent fashion [24]. The data regard-
ing its use in critically ill IE patients is insufficient to
draw any assessment of its pertinence and feasibility
at the time of this writing. The characteristics and
performance of those diagnosis tools are presented
in Table 1. Finally, the 2015 ESC criteria have been
shown to be more sensitive but not more specific
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than modified Duke criteria for the diagnosis of
&
prosthetic valve endocarditis [44 ]. The performance
of those criteria in the ICU setting in not described.
An increasing proportion of ICU physicians
have expertise in point of care ultrasound practice.
The question whether the availability of ultrasonog-
raphy-trained physicians in the ICU facilitates the
diagnosis of IE remains unresolved in the existing
literature. Lau et al. [54] reported similar perform-
ance of intensivist-led vs. cardiologists-led TEE in
ICU patients if the intensivists were board certified
for ultrasound. The 2016 guidelines for the training
standards in ultrasound in the ICU graded the skills
of endocarditis diagnosis as a basic skill, whereas TEE
and prosthetic valve endocarditis diagnosis were
graded as advanced skills [25].
Microbiological innovations
Microorganism detection and identification have
dramatically improved over the last years, especially
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Endocarditis in the intensive care unit: an update Lakbar et al.

due to the improvements in 16S-ARN PCR and Next-
Generation Sequencing (NGS). The impact of these
techniques has been mostly described in cases of
suspected IE with negative blood cultures, where
NGS or 16S-RNA sequencing were performed post-
operatively on valvular tissue [55–59], without spe-
cific application in the ICU setting.
MANAGEMENT
Antibiotic treatment
Randomized controlled trials assessing antibiotic
treatment are rare in the general IE population
[60], and none is available in the ICU patients.
International guidelines provide recommendations
based mainly on low quality evidence from exper-
imental and observational data [24,38]. A summary
of empirical treatment as recommended by interna-
tional guidelines is provided in Table 2. Microbio-
logical samples should be taken before antibiotic
treatment is started. In case of non-nosocomial IE
in native valves, treatment should ensure coverage
for methicillin-susceptible S. aureus, b-hemolytic
streptococci according to European experts whereas
American experts stated that antibiotic treatment
should be tailored to the clinical case [24]. Indeed,
American guidelines highlight that initiation of
antibiotic treatment is rarely urgent in cases of IE
[38]. In patients with septic shock, urgent introduc-
tion of empirical antibiotics is recommended, and
this recommendation should therefore also apply to
patients with known or suspected IE and septic
&&
shock [61 ]. Of note, preliminary observational
data suggested that ceftaroline and ceftobiprole
could be used when staphylococci and enterococci
are the causative agents of IE [62,63], in contrast to
linezolid which may be associated with higher mor-
tality rates in this setting [64].
Once the causative microorganism has been
identified, antibiotic treatment should be adapted
to antimicrobial susceptibility, appropriate drug
coverage must be chosen with the ‘‘Endocarditis
Team’’, a multidisciplinary group of clinicians, fol-
lowing the principles of antimicrobial stewardship
[65] (Table 2). The choice of treatment should take
into account the individual characteristics of the
ICU patient: kidney function (from augmented
renal clearance to acute kidney injury), capillary
leakage, hypoalbuminemia, and organ support
requirements, such as renal replacement therapy
(RRT) and extracorporeal membrane oxygenation
(ECMO) [66]. There is a growing body of evidence
supporting the monitoring of therapeutic drug

Table 2. The antibiotic regimens suggested in International guidelines (adapted from reference [60])
American Heart Association European Society of Cardiology (ESC)
(AHA) guidelines, 2015 [38] guidelines, 2015 [24]

Empirical treatment in the ICU To be adjusted based on clinical If community-acquired

course and risk factors
Staphylococcal endocarditis, Methicillin-susceptible
native valve(s) Antistaphylococcal penicillin
Methicillin-resistant
Vancomycin or daptomycin
Staphylococcal endocarditis, Methicillin-susceptible
prosthetic valve(s) Antistaphylococcal penicillin þ
gentamicin þ rifampicin
Methicillin-resistant
Vancomycin or daptomycin þ
gentamicin þ rifampin
Streptococcal endocarditis, susceptible Four-week course
strains (MIC penicillin < 0.25 mg/l) Penicillin G or ceftriaxone
Enterococcal endocarditis, Ampicillin þ ceftriaxone
penicillin-susceptible strains 6 weeks
6 weeks
Ampicillin þ (cl)oxacillin þ gentamicin
If nosocomial
Vancomycin þ gentamicin þ rifampicina
Methicillin-susceptible
Antistaphylococcal penicillin
Methicillin-resistant
Vancomycin or daptomycin
Methicillin-susceptible
Antistaphylococcal penicillin þ gentamicin þ rifampicin
Methicillin-resistant
Vancomycin or daptomycin þ gentamicin þ rifampin
Four-week course
Penicillin G or ceftriaxone or amoxicillin
Ampicillin þ ceftriaxone

Antibiotic treatment should be selected by consensus within the ‘‘Endocarditis Team’’, a team of experts including infectious diseases specialists, microbiologists,
cardiologists and intensivists.
Long-term gentamicin, listed as an option in the guidelines, has been deliberately omitted from this table because the authors believe that long-term
aminoglycosides should be reserved for difficult-to-treat multidrug-resistant infections owing to the high risk of acute kidney injury and muscle weakness in critically
ill patients [80]. This consideration is backed by expert opinion that aminoglycosides could be avoided in 90% of cases [81].
a
Rifampicin is only indicated for prosthetic valve endocarditis and should only be introduced 5--7 days after the start of the pivotal antiinfective regime [60].

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Severe infections
antibiotic levels in critically ill patients [67,68],
which can be applied to the context of IE [69].
Oral treatment should be regarded as a step-
down treatment and should be reserved only for
patients who have cleared their bacteremia [70].
Complications
Septic shock and sepsis should be managed as recom-
mended in the Surviving Sepsis Campaign guidelines,
with early optimal management combining fluid
resuscitation, antibiotic treatment and surgical con-
&&
trol of the source of infection if necessary [61 ]. Car-
diac output should be closely monitored as it may be
impaired indirectly by the septic cardiomyopathy
associated with septic shock or directly by valvular
insufficiency. Cardiovascular complications, includ-
ing cardiac arrest, cardiogenic shock, acute myocardial
infarction, acute heart failure and heart block were
reported in almost a quarter of patients with IE, regard-
less of their location of treatment in hospital (i.e.
&
general ward or ICU) [3 ]. In the ICU, acute heart
failure (from septic or cardiogenic shock) was reported
in more than half of the patients with IE [6].
The indications for urgent surgery in both Amer-
ican and European international guidelines are
heart failure, along with uncontrolled infection
(ongoing bacteriemia, local abscesses and fistulae)
and emboli prevention (in cases of recurrent emboli
or large vegetations) (Table 3). However, there are
discrepancies between American and European
experts regarding the timing of surgery. American
experts recommend early surgery, while European
experts highlight the need to weigh the benefits of
antibiotic completion before surgery against the risk
of an uncontrolled source of infection. This lack of
agreement in the guidelines highlights the paucity
of evidence in the literature and has led anesthesi-
ologists to advocate for multidisciplinary decisions,
Table 3. Indications for surgery in infective endocarditis
[24,38]
Indication for surgery Symptoms
Heart failure Severe valve obstruction
Severe valve regurgitation
Uncontrolled Persistent positive blood cultures despite
infection antibiotic treatment
Local complications: abscesses, false
aneurysms, fistulas
multidrug resistant bacteria or fungi
Prevention of Large vegetation with embolic events
embolic events
Enlarging vegetation despite antibiotic
treatment
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including surgical, anesthetic and ICU teams in a
&&
recent comprehensive review [5 ].
Specifically, after cerebral embolism, delaying
surgery has been recommended due to the risk of
infarct extension, hemorrhagic transformation of
an ischemic infarct and expansion of an intracranial
hemorrhage. Such practice has also not been associ-
ated with higher mortality rates [71]. However recent
data have also shown that early and late surgery have
the same outcomes in terms of mortality [71,72],
which raises ongoing questions regarding the optimal
delay for surgery. As for the treatment of the acute
ischemic stroke itself, thrombectomy has been
reported but its safety is yet to be proven [73,74].
Future
As shown in experimental studies, a complex inter-
action between bacteria, coagulation and innate
immunity is mandatory for valve infection. There-
fore, experimental and clinical studies have thus far
aimed to target platelets and coagulation factors in
order to inhibit vegetation growth and embolic
events, using aspirin as prophylactic or adjunctive
treatment. Clinical findings have already yielded
conflicting results regarding the use of aspirin as
prophylactic treatment for IE, in patients receiving
&
aspirin for long-term treatment [75 ]. In a mouse
model of bacteremia, the use of ticagrelor enhanced
platelet killing of S. aureus [76,77]. It has therefore
been advocated that further studies should evaluate
ticagrelor for prophylactic treatment of IE in patients
&
with prosthetic valves or indwelling devices [75 ].
Experimental studies also reported improved out-
comes in terms of vegetation size, bacterial load
and inflammation reduction with the use of dabiga-
&
tran, a direct thrombin inhibitor [78 ]. However, such
treatments in are challenging in ICU patients, as they
&
were associated with a major risk of bleeding [75 ].
Hyperbaric oxygen therapy could also be an
adjunctive treatment worth exploring in patients
with IE. In experimental models of IE, hyperbaric
oxygen therapy has been shown to enhance the
&
bactericidal effect of antibiotics [78 ].
CONCLUSION
IE remains a rare and complex disease, and although
recent research has opened up new avenues for
better management of IE and new treatment
options, the available evidence is still weak, prompt-
ing the recommendation for decisions on patient
management to be made within a multidisciplinary
team, particularly with regard to antibiotic treat-
ment and timing of surgery. We therefore advocate
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Endocarditis in the intensive care unit: an update Lakbar et al.
for the active involvement of intensivists in the
Endocarditis team.
Acknowledgements
All the figures were created with BioRender.com.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
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Volume 26  Number 00  Month 2022