Clinicians who care for patients diagnosed with infective endocarditis (IE) are (un)fortunate to be able to refer to several guidelines about its diagnosis and treatment.1–3 The guidelines vary considerably, especially with regards to antibiotic prescribing recommendations, which generally reflect local practice and expert opinion in light of largely observational data. All guidelines recommend a multidisciplinary approach to the management of IE. The ‘team’ should include a cardiologist, a cardiac surgeon and an infection specialist. In the UK, antibiotic choices within this team are often determined by a consultant microbiologist, and treatment, as outlined by the British Society for Antimicrobial Chemotherapy (BSAC), may be followed in preference to guidelines produced by the European Society of Cardiology (ESC)1 or American Heart Association.3 The latest iteration from the BSAC was published early this year.2 Importantly, and for the first time, the working party included representation from the British Cardiac Society (BCS).

The reported incidence of IE is increasing steadily in England and Wales.4 This trend may be due to an ageing population with relatively greater prevalence of degenerative valve disease, prosthetic valves and intracardiac devices. Additionally, more patients are receiving haemodialysis, and periodontal disease remains common.5

Establishing the diagnosis of IE can be difficult and is often delayed. Oslerian signs of IE are now uncommon and their emphasis in undergraduate medical texts needs to change. A lack of ‘peripheral stigmata of endocarditis’ is often misinterpreted to mean that IE is unlikely. The revised BSAC guidelines point out that the Duke criteria were developed as a research tool and therefore have a high specificity but lower sensitivity. Failure to meet criteria for definite IE does not mean a patient does not have IE. The Duke criteria are limited when blood cultures are negative …