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Infective endocarditis is an infection of the inner lining of the heart, most often affecting a heart valve. It happens when bacteria (or, less often, fungi) circulating in the bloodstream attach to a valve — usually one that is already abnormal, artificial, or previously damaged — and form a growth called a vegetation. It is a serious illness needing weeks of intravenous antibiotics and, in many cases, heart surgery to repair or replace the damaged valve. This page explains what infective endocarditis is, who is at risk, how it is treated, and the physiotherapy role in recovery.
Definition
Infective endocarditis (IE) is infection of the endocardium — the lining of the heart chambers and valves — most commonly affecting the aortic or mitral valve, a prosthetic valve, or, in people who inject drugs, the tricuspid valve. Bacteria adhering to the valve surface form a fibrin-platelet mass called a vegetation, which can destroy the valve and shed infected fragments into the bloodstream.1
Pathophysiology
IE typically requires two factors to coincide: a valve surface that is abnormal or damaged (from congenital or acquired valvular heart disease, a prosthetic valve, or prior rheumatic damage) and bacteraemia — bacteria circulating in the blood from dental procedures, skin infection, intravenous drug use, or an indwelling line.
Once attached, the vegetation grows within a fibrin matrix that shelters organisms from both antibiotics and immune cells — the reason treatment requires weeks of high-dose therapy rather than a standard course. From there the disease progresses along three fronts simultaneously: local destruction of the leaflet, annulus or septum, causing severe regurgitation, abscess or fistula; embolisation of infected fragments to the brain, spleen, kidneys or limbs; and a systemic immune-complex response affecting the kidneys and joints.1
Co-morbidities
Underlying valvular heart disease, a prosthetic heart valve, prior IE and congenital heart disease all predispose. Intravenous drug use, chronic dialysis, poor dental health, diabetes and immunosuppression raise risk further. Implanted cardiac electronic devices — pacemakers and defibrillators — are an increasingly important substrate, and device-lead infection is managed differently from native-valve disease, usually requiring complete system extraction.2 Stroke, heart failure and renal impairment are complications during the acute illness rather than pre-existing conditions.
Prevalence
IE is uncommon but serious, affecting a small number of people per 100,000 population each year, with rates rising in some countries linked to an ageing population with more prosthetic valves and devices, and to intravenous drug use. In-hospital mortality remains substantial even with modern treatment.1
Causes and risk factors
Staphylococcus aureus and viridans group streptococci are the most common causative organisms, with Enterococcus species and, in prosthetic-valve infection, coagulase-negative staphylococci also important. S. aureus is the most aggressive, capable of infecting a normal valve and destroying it quickly. Entry points include dental procedures and poor dental hygiene, skin and soft-tissue infection, intravenous drug use, and infected intravascular catheters or dialysis access.1
Symptoms
Typical presentation
Presentation is often subacute: persisting fever, night sweats, weight loss, fatigue and malaise over days to weeks. A new or changing heart murmur is a key clinical clue. Acute S. aureus endocarditis behaves differently, presenting over days with severe sepsis.
Embolic and immune features
Small tender nodules in the fingers or toes (Osler's nodes), painless red marks on the palms or soles (Janeway lesions) and splinter haemorrhages under the nails are classic but not common. Embolic events are — and in a proportion of patients a stroke is the presenting event, before fever is recognised as significant.3
Recognising deterioration
New breathlessness or orthopnoea suggests valve destruction with acute regurgitation; new neurological symptoms suggest embolism; persisting fever after several days of appropriate antibiotics suggests uncontrolled infection or abscess. Each is a reason for immediate escalation rather than observation.
Diagnosis
Why diagnosis matters
IE is frequently diagnosed late because its early features — fever, fatigue, weight loss — are non-specific and common. Any unexplained fever in a person with a prosthetic valve, prior IE, congenital heart disease or an implanted cardiac device should prompt blood cultures before antibiotics are given. Starting antibiotics first is the single commonest avoidable error, because it can render cultures negative for weeks and remove the information the whole treatment plan depends on.1
How is it diagnosed?
Diagnosis combines clinical, microbiological and imaging findings using the Duke criteria, updated in 2023 to incorporate modern imaging and a wider range of organisms, and to classify the diagnosis as definite, possible or rejected.4
Blood cultures
At least three sets from separate sites, taken before antibiotics, identify the organism and drive the entire antibiotic strategy. Culture-negative endocarditis — usually because of prior antibiotics, or a fastidious organism — needs specialist microbiology input and serology.4
Echocardiography
Transthoracic echocardiography is performed first; transoesophageal echocardiography follows when suspicion remains high, images are inadequate, or prosthetic-valve or device infection is possible, since it visualises vegetations, abscesses and leaflet perforation far more sensitively. A normal transthoracic study does not exclude IE.1
Other imaging
Cardiac CT defines perivalvular abscess and pseudoaneurysm; 18F-FDG PET/CT has become important in prosthetic-valve and device infection, where echocardiography is least reliable; and cerebral imaging identifies clinically silent emboli and mycotic aneurysms that change surgical timing.1
Investigations for related conditions
Renal function, inflammatory markers, and a search for the portal of entry — dental review, skin, line sites, and colonoscopy where Streptococcus gallolyticus is isolated, given its association with colonic neoplasia — are all part of the workup.3
Management
Management and goals
The goals are to eradicate infection, to preserve or restore valve function, to prevent embolism, and to remove the source. Care is coordinated by a specialist endocarditis team spanning cardiology, cardiac surgery, infectious diseases and microbiology — an approach associated with lower mortality than fragmented care.1
Antibiotic therapy
Treatment requires a prolonged course of targeted antibiotics, typically four to six weeks, chosen by organism and susceptibility. Traditionally entirely intravenous, this has changed: in stabilised left-sided endocarditis, switching to oral therapy after an initial intravenous period was non-inferior to continued intravenous treatment, and partial oral therapy is now an accepted option in selected patients.5 This matters for rehabilitation, because it can bring discharge and mobilisation forward by weeks.
Surgery
Surgery to repair or replace the affected valve is needed in roughly half of cases. Indications are heart failure from valve destruction, uncontrolled infection despite antibiotics, and a high embolic risk from large mobile vegetations. In severe left-sided disease with large vegetations, early surgery reduced embolic events compared with conventional treatment.6 Timing after a stroke is a specialist judgement balancing further embolism against haemorrhagic transformation.
Identifying deterioration
Persisting fever beyond about a week of appropriate therapy, new conduction abnormality on ECG (suggesting an aortic root abscess), new regurgitant murmur, or new focal neurology all indicate that the situation has changed.
Action plan
- Complete the full antibiotic course, including any outpatient or oral continuation — stopping early is the main cause of relapse.
- Report new fever, breathlessness, weakness or confusion immediately, during treatment and for months afterwards.
- Protect the intravenous line: keep the site clean and dry, and report redness, pain or leakage.
- Attend dental review once safe to do so, and maintain daily dental hygiene thereafter.
- Tell every future clinician and dentist about the episode — prior IE is itself a major risk factor.
Medications
Antibiotics
Organism-directed, high-dose and prolonged, with regimens set by the endocarditis team. Course length is counted from the first day of effective therapy, or from surgery where the valve is found to be infected. Aminoglycoside- and glycopeptide-containing regimens require monitoring of renal function and hearing.5
Anticoagulation
IE does not itself require anticoagulation, and starting it does not prevent embolism. Existing anticoagulation — for a mechanical valve, for example — is a specialist balance, particularly after cerebral embolism, where the risk of haemorrhagic transformation is significant.3
Prophylaxis after an episode
Prior IE places a person in the highest-risk group, for whom antibiotic prophylaxis before defined dental procedures is recommended alongside meticulous dental hygiene.1
Multi-system manifestations
Brain
Cerebral embolism affects a substantial minority and is the complication with the greatest impact on mortality and long-term function.3 Mycotic aneurysms, meningitis and cerebral abscess also occur. Neurological rehabilitation frequently runs alongside cardiac recovery.
Kidneys
Renal impairment is common and multifactorial — immune-complex glomerulonephritis, septic emboli, reduced perfusion, and nephrotoxicity from antibiotics and contrast. It constrains drug dosing and complicates fluid management.
Spleen and peripheral emboli
Splenic infarction and abscess, renal infarcts, and limb or mesenteric emboli all occur. A persistent fever with left upper quadrant pain suggests splenic abscess and may require drainage before valve surgery.
Musculoskeletal
Back pain in IE is not a mechanical problem until proven otherwise: vertebral osteomyelitis and discitis are well-recognised complications, particularly with S. aureus and streptococcal infection, and new spinal pain warrants imaging rather than manual therapy.
Heart
Beyond the valve itself, perivalvular abscess, fistula, conduction block and heart failure are the local complications that most often drive the decision to operate.
Living with infective endocarditis
Recovery and deconditioning
Recovery after a prolonged admission and, often, valve surgery is gradual, and fatigue persists well after the infection is cleared. Even short periods of bed rest cause measurable loss of muscle mass and strength in older adults, and weeks of it produce profound deconditioning that is frequently mistaken for ongoing illness.7
Outpatient antibiotics and lines
Many people complete treatment at home with a long line in place. Activity is usually unrestricted within line-care precautions, and staying mobile during this period substantially shortens later rehabilitation.5
Dental care and preventing recurrence
Good dental hygiene and prompt treatment of skin infections reduce the risk of a further episode, and prior IE warrants lifelong attention to both.1
What to report
Recurring fever, night sweats, unexplained weight loss or new breathlessness after treatment must be reported promptly — relapse and reinfection both occur, and both are easier to treat early.
Prognosis
IE remains a serious illness with in-hospital mortality in the double digits as a percentage, reflecting heart failure, embolic stroke and overwhelming sepsis. Neurological complications are among the strongest determinants of both mortality and functional outcome.3 Outcomes are better with prompt diagnosis, organism-directed therapy and timely surgery where indicated. Long-term survivors need ongoing valve surveillance and carry a raised lifetime risk of a further episode.
Role of the physiotherapist
Physiotherapy runs through the whole admission rather than starting at discharge:
- During the acute illness — early mobilisation and structured activity counter the deconditioning caused by systemic infection and prolonged bed rest, and early physical therapy in critically ill patients improves return to independent function.8
- After embolic stroke — targeted neurological rehabilitation delivered alongside cardiac recovery, with the two programmes coordinated rather than sequential.
- After valve surgery — sternal management, chest care and progressive mobilisation, following the same pathway as other cardiac surgery.
- Cardiac rehabilitation — exercise-based rehabilitation after heart valve surgery improves exercise capacity9 and is delivered once cleared by cardiology, with realistic expectations set for a group that starts from a low base.10
Physiotherapists are also well placed to reinforce dental-hygiene, line-care and wound-care education relevant to preventing a further episode, and to flag the red flags above — new fever, new breathlessness, new neurology, new back pain — which they may be the first to see.
Warning signs
Part 1 · References
- Delgado V, Ajmone Marsan N, de Waha S, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J 2023;44(39):3948–4042.
- Sandoe JAT, Barlow G, Chambers JB, et al. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection and long-term outcomes after endocarditis. J Antimicrob Chemother 2015;70(2):325–359.
- Thúny F, Avierinos JF, Tribouilloy C, et al. Impact of cerebrovascular complications on mortality and neurologic outcome during infective endocarditis: a prospective multicentre study. Eur Heart J 2007;28(9):1155–1161.
- Fowler VG Jr, Durack DT, Selton-Suty C, et al. The 2023 Duke–International Society for Cardiovascular Infectious Diseases criteria for infective endocarditis. Clin Infect Dis 2023;77(4):518–526.
- Iversen K, Ihlemann N, Gill SU, et al. Partial oral versus intravenous antibiotic treatment of endocarditis (POET). N Engl J Med 2019;380(5):415–424.
- Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med 2012;366(26):2466–2473.
- Kortebein P, Ferrando A, Lombeida J, Wolfe R, Evans WJ. Effect of 10 days of bed rest on skeletal muscle in healthy older adults. JAMA 2007;297(16):1772–1774.
- Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373(9678):1874–1882.
- Sibilitz KL, Berg SK, Tang LH, et al. Exercise-based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database Syst Rev 2016;(3):CD010876.
- Pollmann AGE, Frederiksen M, Prescott E. Cardiac rehabilitation after heart valve surgery: improvement in exercise capacity and morbidity. J Cardiopulm Rehabil Prev 2017;37(3):191–198.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Supervised exercise, breathing technique and self-management education are the mainstay of cardiorespiratory physiotherapy for this condition.
Clinical evidence
Part 1 covers the same condition without the technical detail. What follows is the evidence base behind it, written for clinicians — the literature, the reasoning and the gaps.
For clinicians: this summary supports clinical reasoning and is not a protocol. Check current guidelines and local policy before applying it, and read it alongside the key references and guidelines directory.
Framing. Infective endocarditis is diagnosed and managed by an endocarditis team — cardiology, cardiac surgery, infectious diseases and imaging — because the decisions that determine outcome are microbiological and surgical.1 The physiotherapy relevance is almost entirely indirect but substantial: these patients embolise, they stroke, they develop heart failure from valve destruction, they spend weeks on intravenous antibiotics, and they arrive at rehabilitation profoundly deconditioned and often after valve surgery.
Contemporary management
- Early surgery in left-sided endocarditis with large vegetations and severe valve disease reduced the composite of death and embolic events, principally by preventing systemic embolism.2
- Partial oral antibiotic therapy was non-inferior to full-course intravenous treatment in stabilised left-sided endocarditis (POET), which is progressively shortening inpatient stay and shifting rehabilitation into the community.3
- Outpatient parenteral antibiotic therapy is now standard for selected stable patients, meaning physiotherapists commonly see patients mid-treatment with a long line in situ.1
- Embolic and neurological complications occur in a substantial minority, with cerebral events the most common; silent cerebral embolism is frequent on imaging.1,4
- Prophylaxis is now narrow: antibiotic prophylaxis before dental procedures is reserved for the highest-risk group (prosthetic valve, prior endocarditis, certain congenital lesions), with oral hygiene emphasised for everyone.1
Rehabilitation evidence
- Exercise-based cardiac rehabilitation after heart valve surgery improves exercise capacity in randomised trials, with uncertain effect on mortality and a small evidence base — but referral is recommended and frequently omitted.5,6
- Early mobilisation of the critically ill reduces ICU-acquired weakness and improves functional outcomes, and applies directly to the patient managed in intensive care for septic or cardiogenic complications.7
- Prolonged bed rest is itself harmful: weeks of intravenous therapy without structured activity produces measurable loss of muscle mass and function that is avoidable.7,8
- Chest physiotherapy has no role in treating the infection — airway clearance is indicated only where there is a coexisting respiratory problem such as pneumonia, aspiration or post-operative sputum retention.9
Physiotherapy implications
- Screen neurologically before every session in the acute phase. New focal weakness, dysarthria, visual loss or severe headache may be embolic stroke or a mycotic aneurysm and is an emergency, not a rehabilitation finding.4
- Know the valve and the haemodynamics: new or worsening heart failure from acute regurgitation changes exercise tolerance rapidly, and a patient awaiting urgent surgery is not a rehabilitation candidate beyond gentle mobility.2
- Mobilise within the medical plan rather than waiting for the end of antibiotics — graded walking, sit-to-stand and light resistance work preserve function through a six-week course.7,8
- Protect the line: avoid heavy or repetitive loading of the limb with a PICC, check dressings before upper-limb work, and report redness, swelling or pain along the vein.
- After valve surgery, apply the local sternal management protocol, progress upper-limb loading gradually, and refer to cardiac rehabilitation as the default.5
- With anticoagulation (mechanical valve or atrial fibrillation), avoid contact and high-fall-risk activity and reassess falls risk in older patients.
- Escalate new or recurrent fever, new murmur-related symptoms, breathlessness at rest, embolic phenomena in the skin, or any sudden loss of function.
Clinical reasoning
- Fever with a prosthetic valve, prior endocarditis, indwelling line or injecting drug use is a diagnostic emergency — hold treatment and refer, do not attribute it to a chest infection.1
- Sudden functional deterioration during admission is usually embolic, haemodynamic or septic, not deconditioning.
- Distinguish the patient stabilised for outpatient therapy (train them) from the patient awaiting urgent surgery (protect them); the medical team defines which.
- Long-stay patients in this group are commonly socially isolated, in pain and low in mood; adherence depends on addressing those as much as the exercise prescription.
Evidence gaps
- No trial has tested any physiotherapy or rehabilitation intervention specifically in infective endocarditis; practice is extrapolated from valve surgery, sepsis and critical-care populations.5,7
- Safe exercise thresholds in the presence of a large mobile vegetation are unknown and rest on physiological caution.
- Optimal timing and structure of rehabilitation during prolonged antibiotic therapy is undefined.
- Long-term functional and quality-of-life outcomes after endocarditis, particularly following embolic stroke, are poorly described.10
References for the clinical evidence summary
- Delgado V, Ajmone Marsan N, de Waha S, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J 2023;44(39):3948–4042.
- Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med 2012;366(26):2466–2473.
- Iversen K, Ihlemann N, Gill SU, et al. Partial oral versus intravenous antibiotic treatment of endocarditis (POET). N Engl J Med 2019;380(5):415–424.
- Thúny F, Avierinos JF, Tribouilloy C, et al. Impact of cerebrovascular complications on mortality and neurologic outcome during infective endocarditis: a prospective multicentre study. Eur Heart J 2007;28(9):1155–1161.
- Sibilitz KL, Berg SK, Tang LH, et al. Exercise-based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database Syst Rev 2016;(3):CD010876.
- Pollmann AGE, Frederiksen M, Prescott E. Cardiac rehabilitation after heart valve surgery: improvement in exercise capacity and morbidity. J Cardiopulm Rehabil Prev 2017;37(3):191–198.
- Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373(9678):1874–1882.
- Kortebein P, Ferrando A, Lombeida J, Wolfe R, Evans WJ. Effect of 10 days of bed rest on skeletal muscle in healthy older adults. JAMA 2007;297(16):1772–1774.
- Yang M, Yan Y, Yin X, et al. Chest physiotherapy for pneumonia in adults. Cochrane Database Syst Rev 2013;(2):CD006338.
- Sandoe JAT, Barlow G, Chambers JB, et al. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection and long-term outcomes after endocarditis. J Antimicrob Chemother 2015;70(2):325–359.
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