Management of Infective Endocarditis
Diagnostic Approach
- The European Society of Cardiology recommends transthoracic echocardiography (TTE) as the first-line imaging modality in all cases of suspected infective endocarditis 1
- The European Society of Cardiology recommends transesophageal echocardiography (TOE) when clinical suspicion remains high despite negative or non-diagnostic TTE, and is mandatory when a prosthetic heart valve or intracardiac device is present 1, 2
- Repeat echocardiography (TTE and/or TOE) should be performed within 5-7 days if initial examination is negative but clinical suspicion remains high, as recommended by the European Society of Cardiology 1
- Immediate repeat imaging is necessary when complications are suspected (new murmur, embolism, persistent fever, heart failure, abscess, atrioventricular block), according to the European Society of Cardiology 1, 2
Multidisciplinary "Endocarditis Team" Approach
- Patients with infective endocarditis should be managed by a specialized "Endocarditis Team" including infectious disease specialists, microbiologists, cardiologists, imaging specialists, cardiac surgeons, and specialists in congenital heart disease when needed, as recommended by the European Society of Cardiology 3, 4
- Patients with complicated IE (heart failure, abscess, embolic or neurological complications) should be referred early to a reference center with immediate surgical capabilities, according to the European Society of Cardiology 3, 5
Surgical Management
- Urgent surgery is mandatory in cases of aortic or mitral valve endocarditis with severe regurgitation or obstruction causing heart failure, as recommended by the European Society of Cardiology 1, 6
- Urgent surgery is also mandatory in cases of locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation), according to the European Society of Cardiology 1, 6
- Infection caused by fungi or multiresistant organisms requires urgent surgery, as recommended by the European Society of Cardiology 1, 6
- Persistent vegetations >10 mm after ≥1 embolic episodes despite appropriate antibiotic therapy require urgent surgery, according to the European Society of Cardiology 1, 6
Management of Cardiac Device-Related Infective Endocarditis (CDRIE)
- Prolonged antibiotic therapy and complete hardware removal are recommended in definite CDRIE and in presumably isolated pocket infection, as recommended by the European Society of Cardiology 1, 7
- Percutaneous extraction is recommended in most patients with CDRIE, even those with vegetations >10 mm, according to the European Society of Cardiology 1, 7
Prevention
- Antibiotic prophylaxis should be considered for patients at highest risk for IE, including those with any prosthetic valve or prosthetic material used for cardiac valve repair, as recommended by the European Society of Cardiology 2
- Patients with previous episode of IE should receive antibiotic prophylaxis, according to the European Society of Cardiology 8
- Certain types of congenital heart disease require antibiotic prophylaxis, as recommended by the European Society of Cardiology 8, 2
Special Considerations
- In patients with neurological complications, management decisions should involve neurologists and neurosurgeons, as recommended by the European Society of Cardiology 5
- Neurosurgery or endovascular therapy is indicated for very large, enlarging, or ruptured intracranial infectious aneurysms, according to the European Society of Cardiology 1, 2
- For patients with S. bovis/S. gallolyticus IE, investigation for occult colorectal cancer is recommended, as suggested by the European Society of Cardiology 9
- Patients in the intensive care unit with IE should be managed according to protocolized international guidelines for severe sepsis or septic shock, as recommended by the European Society of Cardiology 7
Management of Infective Endocarditis
Diagnostic Approach
- The European Society of Cardiology recommends that three or more sets of blood cultures should be obtained before initiating antimicrobial therapy 10
Antimicrobial Therapy
- The European Society of Cardiology recommends empirical treatment for community-acquired native valve or late prosthetic valve endocarditis with ampicillin plus cloxacillin/oxacillin plus gentamicin, or vancomycin plus gentamicin for penicillin-allergic patients 11
- The European Society of Cardiology recommends empirical treatment for early prosthetic valve endocarditis or healthcare-associated endocarditis with vancomycin plus gentamicin plus rifampin 11
Surgical Management
- The European Society of Cardiology recommends emergency surgery for aortic or mitral endocarditis with severe acute regurgitation, obstruction or fistula causing refractory pulmonary edema or cardiogenic shock 12, 13
- The European Society of Cardiology recommends urgent surgery for aortic or mitral endocarditis with severe regurgitation or obstruction causing symptoms of heart failure 12, 13
- The European Society of Cardiology recommends urgent surgery for locally uncontrolled infection, such as abscess, false aneurysm, fistula, or enlarging vegetation 12, 13
- The European Society of Cardiology recommends urgent surgery for prevention of embolism in patients with aortic or mitral endocarditis and persistent vegetations >10 mm after one or more embolic episodes despite appropriate antibiotic therapy 12, 13
Cardiac Device-Related Infective Endocarditis
- The European Society of Cardiology recommends prolonged antibiotic therapy and complete hardware removal in definite cardiac device-related infective endocarditis 10
- The European Society of Cardiology recommends percutaneous extraction in most patients with cardiac device-related infective endocarditis, even those with vegetations >10 mm 10
Outpatient Parenteral Antibiotic Therapy
- The European Society of Cardiology recommends inpatient treatment during the critical phase (first 2 weeks) and considers outpatient parenteral antibiotic therapy after 2 weeks if the patient is medically stable 14
Special Considerations
- The European Society of Cardiology recommends managing patients with severe sepsis or septic shock according to protocolized international guidelines 15
- The European Society of Cardiology recommends decision-making for critically ill patients to involve the multidisciplinary Endocarditis Team 15
Prevention
- The European Society of Cardiology recommends routine antibiotic prophylaxis before cardiac device implantation 10
- The European Society of Cardiology recommends eliminating potential sources of sepsis ≥2 weeks before implantation of an intravascular/cardiac foreign material, except in urgent procedures 10