After endocarditis:
follow-up, recurrence prevention and daily life

Article written and reviewed by Dr Luca Moretti

The end of antibiotic treatment does not coincide with the end of follow-up. After infective endocarditis, it is necessary to verify that the infection has been eradicated, monitor valve and cardiac function and reduce the risk of a new episode. Anyone who has already had endocarditis remains at high risk for life.
The main warning sign not to underestimate is a new fever or low-grade fever without a clear cause, particularly if accompanied by chills, sweating, marked fatigue or other signs of infection. In this situation, the physician should be contacted promptly and, when the clinical picture allows, blood cultures should be obtained before starting empirical antibiotics.

After discharge, the following are particularly important:

• attend scheduled cardiology and infectious disease follow-up visits;
• promptly report fever, chills or new symptoms compatible with infection;
• maintain good oral hygiene and regular dental check-ups;
• inform physicians and dentists that you have had endocarditis;
• know when dental antibiotic prophylaxis is indicated;
• promptly treat skin, dental and other possible infections;
• resume physical activity gradually according to residual cardiac damage and any procedures performed.

Infective endocarditis can leave very different consequences from one person to another. Some patients recover without important valvular sequelae, while others need continued follow-up for valvular regurgitation, prosthetic valves, heart failure or complications of the acute episode. For this reason, life after endocarditis does not follow the same schedule for everyone.

Which follow-up checks are needed after discharge

Follow-up is tailored according to the valve involved, the microorganism, any surgical procedure, the presence of prosthetic material and complications during hospitalization. Guidelines recommend close clinical surveillance, especially during the early period after treatment, because recurrence, worsening valve function or signs of heart failure may occur.
At the end of antimicrobial therapy, a clinical and cardiology assessment is generally performed, often with echocardiography, to establish a new reference point after the acute phase. The 2023 ESC guidelines also indicate blood cultures after completion of antibiotics.

At subsequent follow-up visits, echocardiography and blood tests may be repeated when the clinical situation requires them. Frequency should not be turned into a rigid schedule: a person with significant residual valvular regurgitation or a prosthetic valve needs a different pathway from someone who has recovered without significant structural damage.
Follow-up also serves to assess possible anemia, kidney function, medication tolerance, nutritional status and physical recovery. After cardiac surgery, specific follow-up relating to the procedure and the repaired or replaced valve is added.

Recurrence: when a new fever should raise suspicion of endocarditis again

Endocarditis can recur. A distinction is generally made between relapse, meaning recurrence caused by the same microorganism and therefore potentially related to persistence of the original focus, and reinfection, caused by a new microorganism. In contemporary series, recurrence affects a minority of survivors, but the risk is sufficiently important to justify attention to new symptoms.
In a large prospective cohort, approximately 5.7% of patients followed after discharge developed a second episode. This figure cannot predict individual risk, which depends on numerous factors, but it shows why previous endocarditis should not be considered a completely closed event once antibiotics have been completed.

A new fever, chills, night sweats, marked weakness or other signs of infection require prompt assessment. This does not mean that every febrile episode is a new endocarditis: influenza, urinary and respiratory infections and many other conditions remain much more common. A history of endocarditis does, however, change the threshold at which these symptoms should be assessed.
When the clinical situation allows, it is important to obtain blood cultures before antibiotics. Independently starting leftover antibiotics from previous treatment can reduce the likelihood of identifying the pathogen and complicate the diagnostic pathway.

Dental care, oral hygiene and antibiotic prophylaxis after endocarditis

Previous endocarditis places the patient among the high-risk groups for whom dental prevention is particularly important. The most useful everyday measure is not frequent antibiotic use, but keeping the gums and teeth healthy and undergoing regular dental check-ups. For people who have had endocarditis, and therefore fall within the high-risk category, the ESC recommends follow-up and professional dental cleaning at least twice a year. Caries, periodontitis and dental foci should be treated before they become chronic problems.
Daily oral hygiene reduces the frequency of gingival inflammation and bacteremia associated with ordinary activities such as chewing and toothbrushing. Guidelines therefore emphasize oral health as part of long-term prevention.

People who have already had endocarditis are also among those for whom antibiotic prophylaxis before certain invasive dental procedures is recommended, particularly procedures involving manipulation of gingival tissue or the periapical region of the tooth or perforation of the oral mucosa. This does not mean taking antibiotics before every visit, X-ray or dental treatment.
The distinction between procedures that do and do not require prophylaxis is explained in the dedicated guide to endocarditis prophylaxis at the dentist. It is useful always to inform the dentist about the previous episode and to bring updated cardiology documentation.

Skin, infections, tattoos and other precautions in daily life

Prevention also concerns the skin. Wounds, skin infections, abscesses and other possible foci should be managed correctly and not neglected. European recommendations emphasize the importance of good skin hygiene and advise avoiding procedures that unnecessarily increase the risk of bacteremia or infection, including tattoos and piercings.
There is no need to live while avoiding normal social contact: endocarditis is not a contagious disease transmitted by being close to another person. The problem is microorganisms entering the bloodstream in a predisposed person, not ordinary daily contact.

In the event of a respiratory, urinary, skin or dental infection, antibiotics should not be taken preventively simply because the person has had endocarditis. Antibiotics should be used when indicated for the specific infection and according to prescription, avoiding both unnecessary treatment and delays when a true infection requires therapy.
It is useful to inform healthcare professionals of the history of endocarditis before invasive procedures. This allows the risk to be assessed correctly in the context of the procedure and the other cardiac conditions present.

Physical activity, fatigue and returning to normal life

Recovery after endocarditis may take time. Weeks of infection, hospitalization, surgery, loss of muscle mass and reduced activity can leave fatigue and weakness even when the infection has been cured. Guidelines encourage appropriate mobilization and rehabilitation, adapted to cardiac status and any cardiac surgical procedure.
There is no number of weeks that applies to everyone before returning to sport or physically demanding work. Ventricular function, severity of any valvular regurgitation, presence of arrhythmias, the procedure performed, sternal healing and the degree of deconditioning all matter.

Return to activities should therefore be gradual. New dyspnea, leg swelling, persistent palpitations, chest pain, syncope or a marked decline in exercise capacity require reassessment rather than being automatically attributed to convalescence.
Medication may also change after the episode: anticoagulants, heart failure medications or other therapies depend on the type of valve, any prosthesis and residual conditions. They should not be stopped or modified simply because the infection has ended.

Frequently asked questions after endocarditis

Can endocarditis return?
Yes. It may be a relapse related to the same microorganism or a new infection caused by a different pathogen. The risk is not high in most patients, but it is greater than in people who have never had endocarditis.

Does fever mean that endocarditis has returned?
No. Fever has many causes. After endocarditis, however, persistent or unexplained fever should be assessed more promptly and may require blood cultures before antibiotics.

Do I need an antibiotic every time I go to the dentist?
No. Previous endocarditis is an indication for prophylaxis for specific invasive dental procedures, not for every dental visit or procedure.

Can I return to sport?
Often yes, but return should be gradual and depends on the cardiac consequences of the episode and any procedure performed. The cardiologist determines when activity can be resumed and with what limitations.

How long do I need follow-up?
Cardiology monitoring continues over time, especially if valvular disease, a prosthetic valve or other consequences remain. The intensity and frequency of follow-up are individualized.