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Most patients with infective endocarditis respond to appropriate antibiotic treatment within 72 hours, with a definitive loss of fever and improvement in general well being. Patients who show such prompt improvement will usually do well, but those who remain febrile and septic despite optimal antibiotics usually need surgery.1Late recurrence of fever is frequently the result of antibiotic sensitivity or an infected central line, and is less often caused by the development of bacterial resistance, infection by multiple organisms or a second infection by fungus or staphylococcus. Lack of success in treating endocarditis frequently comes from failure to observe recognised guidelines,2 ,3 and from lack of a team approach involving both the clinical microbiologist and the cardiac surgeon from an early stage.
Persistent or recurrent fever
Microbiological issues
From the outset the clinical microbiologist needs to be involved closely. The treatment regimen needs to be matched to both the clinical and microbiological circumstances. When there is a continuing clinical problem, despite appropriate initial treatment, then the microbiologist must be consulted again.
Infection elsewhere
The possibility of infection occurring elsewhere—intracardiac or extracardiac—must be the first thought of the clinician faced with this situation.
Line infection
A common cause of recurrence of fever is the central line. This should be removed and the tip sent for culture. Often the culture is sterile but the fever resolves rapidly after removal of the line. Recolonisation of the infected valve by staphylococcus or fungus derived from the line is rare but can occur. It is usually caused by poor sterile technique and line care. Such additional infection is a serious problem. It needs appropriate antibiotic treatment and frequently requires urgent surgery.
Paravalvar/intracardiac abscess
The patient not doing well despite being infected by an antibiotic sensitive organism probably has a paravalvar abscess until proved otherwise. This must be sought vigorously and usually requires surgery to …