Approach Considerations

The hallmark of any type of IE is that of a continuous bacteremia.

Laboratory Studies

A continuous bacteremia is the hallmark of endovascular infections such as OUD-IE. This is defined as a minimum of three sets of blood cultures positive for the same organism that are drawn from different sites at least 15 minutes apart.^{[16, 17]}

Various molecular techniques, such as MALDI-TOF and 16SrDNA PCR PhenoTest BC Kit hold great promise in significantly reducing the turnaround time for the final identification of pathogens and antibiotic sensitivities from blood samples.^{[18, 19]}

Because CRP levels increase during acute and chronic inflammation, including deep-seated infections, sepsis, autoimmune conditions, COVID-19 infection, and IE, serial CRP measurements are a convenient method of documenting therapeutic responsiveness of both diseases.

D-dimer is another marker used to determine the probability of a DVT or PE in a person with COVID-19 and IE given their pro-thrombotic state. Due to its high negative predictive value (NPV), a negative test provides reassurance that the probability of a DVT or a PE is low.

See Infective Endocarditis.

Imaging Studies

Some studies emphasize the importance of a full cardiac evaluation for COVID-19 positive OUD-IE. The purpose would be to rule out associated viral myocarditis as well as to detect valvular microthrombi that could increase the risk of a patient with OUD developing IE due to a variety of intravascular devices.^{[16, 17, 20, 21]} Guidelines from the American College of Cardiology/American Heart Association and the Infectious Diseases Society of America recommend that all patients with S aureus bacteremia undergo evaluation with a transthoracic echocardiogram (TTE). We recommend a transesophageal echocardiogram (TEE) to follow a TTE in all patients with OUD who have positive blood cultures. This was not feasible during the COVID-19 pandemic owing to concern for transmission to healthcare workers as well as limited access because of the surge of inpatients. During the pandemic, the number of TEEs declined by 50%. This increased the risk of failing to diagnose or document infection of small endocardial thrombi associated among patients with OUD-IE and COVID-19 infection.^{[16, 17, 22]} The amount of echocardiograms performed likely has been limited because of the high hospital census. Such has led to significant delays in diagnosis leading to increased morbidity and mortality.^{[23, 24]}

Alternative considerations such as cardiac magnetic resonance imaging and positron emission tomography scanning may be considered as they do not require close contact with personnel for extended periods of time while still documenting valve function and evidence of vegetations.^[25]These alternative imaging modalities may reduce the number of cases of occult thrombi that were identified after poor outcomes from acute onset PEs or DVTs.

Treatment & Management

Alizadeh K, Bucke D, Khan S. Complex case of COVID-19 and infective endocarditis. BMJ Case Rep. 2021 Aug 3. 14 (8):[QxMD MEDLINE Link].
Kumanayaka D, Mutyala M, Reddy DV, Slim J. Coronavirus Disease 2019 Infection as a Risk Factor for Infective Endocarditis. Cureus. 2021 May 3. 13 (5):e14813. [QxMD MEDLINE Link].
Alizadehasl A, Salehi P, Roudbari S, Peighambari MM. Infectious endocarditis of the prosthetic mitral valve after COVID-19 infection. Eur Heart J. 2020 Dec 21. 41 (48):4604. [QxMD MEDLINE Link].
Kraiem S, Amor HH. Bi-valvular endocarditis occurring 2 months after COVID-19 infection. Pan Afr Med J. 2021. 39:37. [QxMD MEDLINE Link].
Jolobe OMP. The complexity of multivalve infective endocarditis in intravenous drug users. QJM. 2021 Oct 1. [QxMD MEDLINE Link].
Balata D, Mellergård J, Ekqvist D, Baranowski J, Garcia IA, Volosyraki M, et al. Non-Bacterial Thrombotic Endocarditis: A Presentation of COVID-19. Eur J Case Rep Intern Med. 2020. 7 (8):001811. [QxMD MEDLINE Link].
Garcia-Vidal C, Moreno-García E, Hernández-Meneses M, Puerta-Alcalde P, Chumbita M, Garcia-Pouton N, et al. Personalized Therapy Approach for Hospitalized Patients with Coronavirus Disease 2019. Clin Infect Dis. 2022 Jan 7. 74 (1):127-132. [QxMD MEDLINE Link].
Oberhoffer M, Karzai W, Meier-Hellmann A, Bögel D, Fassbinder J, Reinhart K. Sensitivity and specificity of various markers of inflammation for the prediction of tumor necrosis factor-alpha and interleukin-6 in patients with sepsis. Crit Care Med. 1999 Sep. 27 (9):1814-8. [QxMD MEDLINE Link].
Kernan KF, Carcillo JA. Hyperferritinemia and inflammation. Int Immunol. 2017 Nov 1. 29 (9):401-409. [QxMD MEDLINE Link].
Shakoory B, Carcillo JA, Chatham WW, Amdur RL, Zhao H, Dinarello CA, et al. Interleukin-1 Receptor Blockade Is Associated With Reduced Mortality in Sepsis Patients With Features of Macrophage Activation Syndrome: Reanalysis of a Prior Phase III Trial. Crit Care Med. 2016 Feb. 44 (2):275-81. [QxMD MEDLINE Link].
Rossouw TM, Anderson R, Manga P, Feldman C. Emerging Role of Platelet-Endothelium Interactions in the Pathogenesis of Severe SARS-CoV-2 Infection-Associated Myocardial Injury. Front Immunol. 2022. 13:776861. [QxMD MEDLINE Link].
Talha KM, DeSimone DC, Sohail MR, Baddour LM. Pathogen influence on epidemiology, diagnostic evaluation and management of infective endocarditis. Heart. 2020 Dec. 106 (24):1878-1882. [QxMD MEDLINE Link].
Siddiqi K, Freeman PR, Fanucchi LC, Slavova S. Rural-urban differences in hospitalizations for opioid use-associated infective endocarditis in Kentucky, 2016-2019. J Rural Health. 2021 Jun 18. 39 (6):320-326. [QxMD MEDLINE Link].
Byon HD, Ahn S, Yan G, Crandall M, LeBaron V. Association of a Substance Use Disorder with Infectious Diseases among Adult Home Healthcare Patients with a Venous Access Device. Home Healthc Now. 2021 Nov-Dec 01. 39 (6):320-326. [QxMD MEDLINE Link].
Audétat MC, Sader J, Coen M. Clinical reasoning and COVID 19 pandemic: current influencing factors Let us take a step back!. Intern Emerg Med. 2021 Jun. 16 (4):1109-1111. [QxMD MEDLINE Link].
Pecoraro AJK, Pienaar C, Herbst PG, Poerstamper S, Joubert L, Taljaard J, et al. Causes of infective endocarditis in the Western Cape, South Africa: a prospective cohort study using a set protocol for organism detection and central decision making by an endocarditis team. BMJ Open. 2021 Dec 6. 11 (12):e053169. [QxMD MEDLINE Link].
Amir M, Djaharuddin I, Sudharsono A, Ramadany S. COVID-19 concomitant with infective endocarditis: A case report and review of management. Int J Infect Dis. 2020 Sep. 98:109-112. [QxMD MEDLINE Link].
Cosyns B, Motoc A, Arregle F, Habib G. A Plea Not to Forget Infective Endocarditis in COVID-19 Era. JACC Cardiovasc Imaging. 2020 Nov. 13 (11):2470-2471. [QxMD MEDLINE Link].
Anton-Vazquez V, Dworakowski R, Cannata A, Amin-Youssef G, Gunning M, Papachristidis A, et al. 16S rDNA PCR for the aetiological diagnosis of culture-negative infective endocarditis. Infection. 2022 Feb. 50 (1):243-249. [QxMD MEDLINE Link].
Bhalodi AA, MacVane SH, Ford B, Ince D, Kinn PM, Percival KM, et al. Real-World Impact of the Accelerate PhenoTest ® BC Kit on patients with bloodstream infections in IOAS (Improving Outcomes and Antimicrobial Stewardship): A Quasi-Experimental Multicenter Study. Clin Infect Dis. 2021 Oct 27. 41 (45):4365. [QxMD MEDLINE Link].
Albloshi AMK, Alqumber MAA. Infective endocarditis: Role of molecular techniques in early diagnosis. Saudi J Biol Sci. 2021 Dec. 28 (12):6844-6852. [QxMD MEDLINE Link].
Dias CN, Brasil Gadelha Farias LA, Moreira Barreto Cavalcante FJ. Septic Embolism in a Patient with Infective Endocarditis and COVID-19. Am J Trop Med Hyg. 2020 Dec. 103 (6):2160-2161. [QxMD MEDLINE Link].
Toth E, Dancy L, Amin-Youssef G, Papachristidis A, Dworakowski R. Collateral implications of the COVID-19 pandemic: belated presentation of infective endocarditis in a young patient. Eur Heart J. 2020 Dec 1. 41 (45):4365. [QxMD MEDLINE Link].
Mouzakitis I, Kleinaki Z, Petropoulou T, Alexiou E, Stefanidis A. Staphylococcus lugdunensis Native Valve Endocarditis in a Patient With Confirmed COVID-19: A Cautionary Tale of an Old Disease Not to Be Forgotten in the Pandemic Era. Cureus. 2021 Sep. 13 (9):e17724. [QxMD MEDLINE Link].
Livesay J, Coombes T, Spoons J, Dolacky S, Shorman M. Comparing Echocardiographic Modalities in Native-Valve Infective Endocarditis Due to Methicillin-Resistant Staphylococcus Aureus in People Who Inject Drugs. Cureus. 2021 Nov. 13 (11):e19372. [QxMD MEDLINE Link].
Spinoni EG, Degiovanni A, Della Corte F, Patti G. Infective endocarditis complicating COVID-19 pneumonia: a case report. Eur Heart J Case Rep. 2020 Dec. 4 (6):1-5. [QxMD MEDLINE Link].
Bor DH, Woolhandler S, Nardin R, Brusch J, Himmelstein DU. Infective endocarditis in the U.S., 1998-2009: a nationwide study. PLoS One. 2013. 8 (3):e60033. [QxMD MEDLINE Link].
El-Dalati S, Cronin D, Riddell J 4th, Shea M, Weinberg RL, Stoneman E, et al. A step-by-step guide to implementing a multidisciplinary endocarditis team. Ther Adv Infect Dis. 2021 Jan-Dec. 8:20499361211065596. [QxMD MEDLINE Link].
Paras ML, Wolfe SB, Bearnot B, Sundt TM, Marinacci L, Dudzinski DM, et al. Multidisciplinary team approach to confront the challenge of drug use-associated infective endocarditis. J Thorac Cardiovasc Surg. 2021 Nov 5. 49 (11):1441-1442. [QxMD MEDLINE Link].
Bhargava A, Riederer K, Sharma M, Fukushima EA, Johnson L, Saravolatz L. High rate of Multidrug-Resistant Organisms (MDROs) among COVID-19 patients presenting with bacteremia upon hospital admission. Am J Infect Control. 2021 Nov. 49 (11):1441-1442. [QxMD MEDLINE Link].
Saini V, Jain C, Singh NP, Alsulimani A, Gupta C, Dar SA, et al. Paradigm Shift in Antimicrobial Resistance Pattern of Bacterial Isolates during the COVID-19 Pandemic. Antibiotics (Basel). 2021 Aug 7. 10 (8):686-91. [QxMD MEDLINE Link].
Rosenthal VD, Maki DG, Jamulitrat S, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009. Am J Infect Control. 2010 Mar. 38 (2):95-104.e2. [QxMD MEDLINE Link].
Wisplinghoff H, Seifert H, Tallent SM, Bischoff T, Wenzel RP, Edmond MB. Nosocomial bloodstream infections in pediatric patients in United States hospitals: epidemiology, clinical features and susceptibilities. Pediatr Infect Dis J. 2003 Aug. 22 (8):686-91. [QxMD MEDLINE Link].
Raymond J, Aujard Y. Nosocomial infections in pediatric patients: a European, multicenter prospective study. European Study Group. Infect Control Hosp Epidemiol. 2000 Apr. 21 (4):260-3. [QxMD MEDLINE Link].
Hughes S, Troise O, Donaldson H, Mughal N, Moore LSP. Bacterial and fungal coinfection among hospitalized patients with COVID-19: a retrospective cohort study in a UK secondary-care setting. Clin Microbiol Infect. 2020 Oct. 26 (10):1395-1399. [QxMD MEDLINE Link].
He Y, Li W, Wang Z, Chen H, Tian L, Liu D. Nosocomial infection among patients with COVID-19: A retrospective data analysis of 918 cases from a single center in Wuhan, China. Infect Control Hosp Epidemiol. 2020 Aug. 41 (8):982-983. [QxMD MEDLINE Link].
Sanaiha Y, Lyons R, Benharash P. Infective endocarditis in intravenous drug users. Trends Cardiovasc Med. 2020 Nov. 30 (8):491-497. [QxMD MEDLINE Link].
Vaughn VM, Gandhi TN, Petty LA, Patel PK, Prescott HC, Malani AN, et al. Empiric Antibacterial Therapy and Community-onset Bacterial Coinfection in Patients Hospitalized With Coronavirus Disease 2019 (COVID-19): A Multi-hospital Cohort Study. Clin Infect Dis. 2021 May 18. 72 (10):e533-e541. [QxMD MEDLINE Link].
Gatti M, Andreoni M, Pea F, Viale P. Real-World Use of Dalbavancin in the Era of Empowerment of Outpatient Antimicrobial Treatment: A Careful Appraisal Beyond Approved Indications Focusing on Unmet Clinical Needs. Drug Des Devel Ther. 2021. 15:3349-3378. [QxMD MEDLINE Link].
Andreoni M, Bassetti M, Corrao S, De Rosa FG, Esposito V, Falcone M, et al. The role of dalbavancin for Gram positive infections in the COVID-19 era: state of the art and future perspectives. Expert Rev Anti Infect Ther. 2021 Sep. 19 (9):1125-1134. [QxMD MEDLINE Link].
Iversen K, Ihlemann N, Gill SU, Madsen T, Elming H, Jensen KT, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. N Engl J Med. 2019 Jan 31. 380 (5):415-424. [QxMD MEDLINE Link].
Lewis S, Liang SY, Schwarz ES, Liss DB, Winograd RP, Nolan NS, et al. Patients With Serious Injection Drug Use-Related Infections who Experience Patient-Directed Discharges on Oral Antibiotics Have High Rates of Antibiotic Adherence but Require Multidisciplinary Outpatient Support for Retention in Care. Open Forum Infect Dis. 2022 Feb. 9 (2):ofab633. [QxMD MEDLINE Link].
Atroshchenko GV, Munoz DE, Jahanyar J, Khoury GE, de Kerchove L. Complex valve reconstruction in isolated tricuspid valve endocarditis. JTCVS Tech. 2021 Dec. 10:293-295. [QxMD MEDLINE Link].
Akinosoglou K, Apostolakis E, Koutsogiannis N, Leivaditis V, Gogos CA. Right-sided infective endocarditis: surgical management. Eur J Cardiothorac Surg. 2012 Sep. 42 (3):470-9. [QxMD MEDLINE Link].
Duval X, Iung B, Klein I, Brochet E, Thabut G, Arnoult F, et al. Effect of early cerebral magnetic resonance imaging on clinical decisions in infective endocarditis: a prospective study. Ann Intern Med. 2010 Apr 20. 152 (8):497-504, W175. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

of 0

Table 1: Clinical Complication Patterns of COVID-19 Infection

Major Pathological Mechanisms	Definitions	Targeted Pathogenic Pathway	Onset of Symptoms (Days)
Coinfection	Bacterial, fungal, viral co-infection	Interaction of viral specific proteins with host receptors leading to endothelial activation and dysfunction^[7]	6-12
Inflammatory		Endothelitis due to platelet activation^[7]
Type A	↑ CRP ↓ ferritin	IL-6	8-13
Type B	↑ CRP ↑ ferritin	IL-1, IL-6	10-13
Type C	↓ CRP ↑ ferritin	IL- 1	11-16
Thrombotic	DVT, PE	Hypercoagulable state induced by COVID-19 infection^[7]	10-18