Endocarditis: Diagnosis and Management

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Prevention 3. Diagnosis 5. Prognostic assessment at admission 7. Antimicrobial therapy: principles and methods 7. Main complications of left-sided valve infective endocarditis and their management 8. Other complications of infective endocarditis 9. Surgical therapy: principles and methods Outcome after discharge: follow-up and long-term prognosis Management of specific situations To do and not to do messages from the guidelines Appendix All rights reserved.

Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more. Sign in to My ESC. ESC sub specialties communities. Associations Working Groups Councils. Because of their rarity and severity, these conditions should be discussed by the Endocarditis Team or with an ID specialist. Antibiotic treatment of blood culture-negative infective endocarditis adapted from Brouqui et al.

The presented durations are based on selected case reports. In the case of central nervous system involvement, sulfadiazine 1. Trimethoprim is not active against T. Treatment of IE should be started promptly.

Three sets of blood cultures should be drawn at min intervals before initiation of antibiotics. Whether the infection affects a native valve or a prosthesis [and if so, when surgery was performed early vs. The place of the infection community, nosocomial, or non-nosocomial healthcare-associated IE and knowledge of the local epidemiology, especially for antibiotic resistance and specific genuine culture-negative pathogens Table Proposed antibiotic regimens for initial empirical treatment of infective endocarditis in acute severely ill patients before pathogen identification a.

Outpatient parenteral antibiotic therapy OPAT is used to consolidate antimicrobial therapy once critical infection-related complications are under control e. Criteria that determine suitability of outpatient parenteral antibiotic therapy for infective endocarditis adapted from Andrews et al. Surgical treatment is required in approximately half of the patients with IE because of severe complications. Surgery is justified in patients with high-risk features that make the possibility of cure with antibiotic treatment unlikely and who do not have co-morbid conditions or complications that make the prospect of recovery remote.

Age per se is not a contraindication to surgery. Early consultation with a cardiac surgeon is recommended in order to determine the best therapeutic approach.

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Each case must be individualized and all factors associated with increased risk identified at the time of diagnosis. Frequently the need for surgery will be determined by a combination of several high-risk features. In other cases, surgery can be postponed to allow 1 or 2 weeks of antibiotic treatment under careful clinical and echocardiographic observation before an elective surgical procedure is performed. Indications and timing of surgery in left-sided valve infective endocarditis native valve endocarditis and prosthetic valve endocarditis.

HF is the most frequent complication of IE and represents the most common indication for surgery in IE. Valvular regurgitation in native IE may occur as a result of mitral chordal rupture, leaflet rupture flail leaflet , leaflet perforation or interference of the vegetation mass with leaflet closure. A particular situation is infection of the anterior mitral leaflet secondary to an infected regurgitant jet of a primary aortic IE.

Clinical presentation of HF may include dyspnoea, pulmonary oedema and cardiogenic shock. Identification of surgical candidates and timing of surgery decisions should preferably be made by the Endocarditis Team. Surgery is also indicated in patients with severe acute aortic or mitral regurgitation without clinical HF but with echocardiographic signs of elevated left ventricular end-diastolic pressure e.

Surgery must be performed on an emergency basis, irrespective of the status of infection, when patients are in persistent pulmonary oedema or cardiogenic shock despite medical therapy. Urgent surgery should also be performed in patients with severe aortic or mitral insufficiency with large vegetations, even without HF. In patients with well-tolerated New York Heart Association class I or II severe valvular regurgitation and no other reasons for surgery, medical management with antibiotics under strict clinical and echocardiographic observation is a good option, although early surgery may be an option in selected patients at low risk for surgery.

Elective surgery should be considered depending on the tolerance of the valve lesion and according to the recommendations of the ESC Guidelines on the management of valvular heart disease. Uncontrolled infection is one of the most feared complications of IE and is the second most frequent cause for surgery. Infection due to resistant or very virulent organisms often results in uncontrolled infection.

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The definition of persisting infection is arbitrary and consists of fever and persisting positive cultures after 7—10 days of antibiotic treatment. Persisting fever is a frequent problem observed during treatment of IE.

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Infective Endocarditis (Guidelines on Prevention, Diagnosis and Treatment of)

Usually, temperature normalizes within 7—10 days under specific antibiotic therapy. Persisting fever may be related to several factors, including inadequate antibiotic therapy, resistant organisms, infected lines, locally uncontrolled infection, embolic complications or extracardiac site of infection and adverse reaction to antibiotics. Perivalvular extension of IE is the most frequent cause of uncontrolled infection and is associated with a poor prognosis and high likelihood of the need for surgery. Perivalvular complications include abscess formation, pseudoaneurysms and fistulae defined in Table Pseudoaneurysms and fistulae are severe complications of IE and are frequently associated with very severe valvular and perivalvular damage.

Perivalvular extension should be suspected in cases with persistent unexplained fever or new atrio-ventricular block. Therefore an electrocardiogram should be performed frequently during continuing treatment, particularly in aortic IE.

Infective Endocarditis: Symptoms, Diagnosis, and Treatment

Indeed, perivalvular extension is frequently discovered on a systematic TOE. However, small abscesses can be missed, even using TOE, particularly those in a mitral location when there is co-existent annular calcification. The results of surgery when the reason for the procedure is uncontrolled infection are worse than when surgery is performed for other reasons.

In some cases of IE, antibiotics alone are insufficient to eradicate the infection. Surgery has been indicated when fever and positive blood cultures persist for several days 7—10 days despite an appropriate antibiotic regimen and when extracardiac abscesses splenic, vertebral, cerebral or renal and other causes of fever have been excluded.

However, the best timing for surgery in this difficult situation is unclear. Recently it has been demonstrated that persistent blood cultures 48—72 h after initiation of antibiotics are an independent risk factor for hospital mortality. Signs of locally uncontrolled infection include increasing vegetation size, abscess formation, false aneurysms, and the creation of fistulae. Rarely when there are no other reasons for surgery and fever is easily controlled with antibiotics, small abscesses or false aneurysms can be treated conservatively under close clinical and echocardiographic follow-up.

Surgery is indicated in fungal IE, , in cases of multiresistant organisms e. MRSA or vancomycin-resistant enterococci or in the rare infections caused by Gram-negative bacteria. In NVE caused by S. Finally, surgery should be performed in patients with PVE and S. Unless severe co-morbidity exists, the presence of locally uncontrolled infection is an indication for early surgery in patients with IE. Embolic events are a frequent and life-threatening complication of IE related to the migration of cardiac vegetations.

The brain and spleen are the most frequent sites of embolism in left-sided IE, while pulmonary embolism is frequent in native right-sided and pacemaker lead IE.

Stroke is a severe complication and is associated with increased morbidity and mortality. However, contrast media should be used with caution in patients with renal impairment or haemodynamic instability because of the risk of worsening renal impairment in combination with antibiotic nephrotoxicity. Echocardiography plays a key role in predicting embolic events, 72 , , — although prediction remains difficult in the individual patient. Several factors are associated with increased risk of embolism, including the size and mobility of vegetations, 72 , , — the location of the vegetation on the mitral valve, 72 , — the increasing or decreasing size of the vegetation under antibiotic therapy, 72 , particular microorganisms S.

Several factors should be taken into account when assessing embolic risk. In a recent study of patients with IE, the 6-month incidence of new embolism was 8. Whatever the risk factors observed in an individual patient, it must be re-emphasized that the risk of new embolism is highest during the first days following initiation of antibiotic therapy and rapidly decreases thereafter, particularly beyond 2 weeks, 58 , 72 , , although some risk persists indefinitely while vegetations remain present, particularly for very large vegetations.

Avoiding embolic events is difficult since the majority occur before admission. The exact role of early surgery in preventing embolic events remains controversial. The value of early surgery in an isolated large vegetation is controversial. A recent randomized trial demonstrated that early surgery in patients with large vegetations significantly reduced the risk of death and embolic events compared with conventional therapy.

Finally, the decision to operate early for prevention of embolism must take into account the presence of previous embolic events, other complications of IE, the size and mobility of the vegetation, the likelihood of conservative surgery and the duration of antibiotic therapy. The main indications and timing of surgery to prevent embolism are given in Table Surgery undertaken for the prevention of embolism must be performed very early, during the first few days following initiation of antibiotic therapy urgent surgery , as the risk of embolism is highest at this time.

The risk of embolism is highest during the first 2 weeks of antibiotic therapy and is clearly related to the size and mobility of the vegetation, although other risk factors exist. The decision to operate early to prevent embolism is always difficult and specific for the individual patient. Governing factors include the size and mobility of the vegetation, previous embolism, type of microorganism and duration of antibiotic therapy.

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Clinical presentation is variable and may include multiple symptoms or signs in the same patient, but focal signs predominate and ischaemic strokes are most commonly diagnosed. Vegetation length and mobility also correlate with embolic tendency.