2015 ESC Guidelines for the Management of Infective Endocarditis
- Habib G, Lancellotti P, Antunes MJ, et al.
- 2015 ESC Guidelines for the Management of Infective Endocarditis. Eur Heart J 2015;Aug 29:[Epub ahead of print].
The following are key points to remember from this 2015 update from the European Society of Cardiology (ESC) on the management of infective endocarditis (IE):
- Prevention. Patients with the highest risk of IE include those with a prosthetic valve or prosthetic material used during valve repair, patients with previous IE, and patients with unrepaired cyanotic congenital heart disease. The ESC guidelines recommend counseling intermediate- and high-risk patients regarding the importance of dental and cutaneous hygiene, but reserve the use of antibiotic prophylaxis only for patients at the highest risk of IE.
- The ‘endocarditis’ team. IE is a disease that requires a collaborative approach. The ESC Task Force supports the management of patients with IE in reference centers by a specialized team.
- Diagnosis. The diagnosis of IE is based on the modified Duke criteria (including pathologic criteria and clinical criteria for IE), and can result in a diagnosis of definite IE, possible IE, or rejected IE. Among imaging modalities, echocardiography (both transthoracic and transesophageal) plays a key role in the management and monitoring of patients with IE.
- Prognostic assessment on admission. Predictors of poor outcome among patients with IE include patient characteristics (advanced age, prosthetic valve IE, diabetes, and comorbidities such as immunosuppression or frailty), clinical complications of IE (heart failure, renal failure, ischemic stroke, brain hemorrhage, septic shock), specific microorganisms (Staphylococcus aureus, fungi, non-HACEK gram-negative bacilli), and echocardiographic findings (periannular involvement, severe left-sided valve regurgitation, low left ventricular ejection fraction, pulmonary hypertension, large vegetations, severe prosthetic dysfunction).
- Antimicrobial therapy. The guidelines include specific recommendations for various organisms. Considerations in making recommendations included:
- Aminoglycosides are no longer recommended for native valve IE. When used, they should be administered in a single daily dose to reduce nephrotoxicity.
- Rifampin should be used only for foreign body IE, and after 3-5 days of effective antibiotic therapy (after bacteremia has cleared).
- Daptomycin and fosfomycin for treating staphylococcal IE and netilmicin for penicillin-susceptible oral and GI streptococci IE are considered to be alternative therapies because they are not available in all European countries.
- Only published antibiotic efficacy data from clinical trials and cohort studies in patients with IE were considered in the guideline recommendations.
- The optimal treatment of staphylococcal IE is still debated.
- Main complications of left-sided valve IE. The main complications of left-sided IE include heart failure, uncontrolled infection, and systemic embolization.
- Other complications of IE. Other complications of IE include neurological complications, infective aneurysms, splenic complications, myocarditis and pericarditis, heart rhythm and conduction disturbances, musculoskeletal manifestations, and acute renal failure.
- Surgical therapy. The two primary objectives of surgical intervention in IE are removal of infected tissue; and reconstruction of cardiac anatomy, including repair or replacement of infected valves.
- Specific situations. Specific conditions that require additional management considerations include prosthetic valve IE, IE complicating implanted electronic devices, right-sided IE, IE complicating congenital heart disease, IE during pregnancy, and antithrombotic therapy during IE.
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