Guidelines for the management of endocarditis

The 2023 ESC Guidelines for the management of endocarditis are an update of the previous version published in 2015. In the guidelines, antibiotic prophylaxis is recommended for high-risk patients before certain procedures.

Infective endocarditis is a rare condition but a major public health challenge; in 2019, the estimated incidence was 13.8 cases per 100,000 subjects per year, and it accounted for 66,300 deaths worldwide. The publication of important new data since the 2015 ESC Guidelines for the management of infective endocarditis, mandated an update of the recommendations [1–3]. There are 3 important factors in the pathophysiology of endocarditis:

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  • predisposing conditions of the patient;
  • the pathogen in the blood stream; and
  • the immune response of the host.

Prevention based on risk assessment and encouragement of hygiene

“Prevention is about defining patients with a predisposition for this disease,” explained Dr Stefano Caselli (HerzGefässZentrum im Park, Switzerland) [3].

Antibiotic prophylaxis is only recommended for high-risk patients; the highest risk is seen in patients who experienced previous infective endocarditis. In addition, patients with prosthetic valves, mitral and aortic bioprostheses, patients with congenital heart disease, and those with ventricular assist devices are at high risk. In the intermediate-risk category are patients with rheumatic heart disease, non-rheumatic valve disease, congenital valve defects, cardiovascular implanted electronic devices, and hypertrophic cardiomyopathy.

For patients at very high risk, antibiotic prophylaxis is indicated under certain circumstances, such as orodental procedures (class I). In contrast, only general preventive measures in terms of increased hygiene are recommended for medium-risk patients and should “ideally be extended to low-risk individuals.” These measures include good oral hygiene (twice-daily tooth cleaning and at least twice-yearly professional cleaning for high-risk patients, and yearly for others), strict cutaneous hygiene, and discouragement of piercings and tattoos.

Procedures at risk are not exclusively dental procedures, but also procedures such as dialysis, bone marrow puncture, lower and upper gastrointestinal endoscopy, and bronchoscopy. This led to a new recommendation for systemic antibiotic prophylaxis that may be considered for high-risk patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, or genitourinary tract, the skin, or the musculoskeletal system.

Moreover, there is a new recommendation for antibiotic prophylaxis before transcatheter aortic valve implantation (TAVI) and other transcatheter valvular procedures, covering common skin flora including Enterococcus spp. and S. aureus. “It is very important that we educate patients on the significance of hygiene,” Dr Caselli emphasised.

Diagnosis includes both transoesophageal and transthoracic ultrasound

“The diagnosis of infective endocarditis is based on clinical suspicion, consistent microbiological findings, and the detection of matching lesions on cardiac imaging,” said Prof. Nina Ajmone Marsan (Leiden University Medical Center, the Netherlands). Diagnosis begins with clinical classification, a blood culture, and transoesophageal and transthoracic ultrasound. It is emphasised that both methods should always be used (class I).

There are recommendations for other imaging methods, in particular for cardiac computed tomography angiography (CTA), which is recommended for patients with possible native valve endocarditis (NVE) to detect valvular lesions, or in NVE and prosthetic valve endocarditis (PVE) to diagnose paravalvular or periprosthetic complications, if echocardiography is inconclusive.

Echocardiography is the first imaging technique to diagnose infective endocarditis, although the use of other imaging techniques, either for the diagnosis of cardiac involvement or distant lesions, is highly encouraged.

The guideline also includes a specific diagnostic algorithm to support decision-making, especially for NVE, PVE, and infective endocarditis associated with cardiovascular-implanted electronic devices.

The diagnosis of endocarditis is made using a set of major and minor criteria. A definitive diagnosis can be made when 2 major criteria (e.g. blood cultures of typical micro-organisms consistent with infective endocarditis or imaging positive for infective endocarditis) or 1 major and 3 minor criteria (e.g. temperature >38 °C), or 5 minor criteria are met. Possible endocarditis is present if 1 major and 1 or 2 minor criteria or if 3–4 minor criteria are fulfilled.

Therapy: Preferably in a multidisciplinary team

Dr Emil Fosbøl (Rigshospitalet, Denmark) emphasised that the management of endocarditis can be demanding and should therefore be performed in a multidisciplinary endocarditis team [3]. Prophylactic, empirical, and targeted antibiotic therapy suggestions are similar to the 2015 ESC Guidelines.

Therapy is always started with intravenous administration of antibiotics. New in this guideline is an outpatient paradigm for antibiotic therapy (see Figure). As Dr Fosbøl explained, the new recommendation was given as a consequence of the POET study (NCT01375257), one of the few existing randomised-controlled trials in endocarditis [4]. This study has shown that this strategy is not only associated with a shorter hospital stay but also with better clinical outcomes.

Figure: Antibiotic treatment of infective endocarditis with a focus on outpatient care after stabilisation. Modified from [1]



OPAT, outpatient parenteral antibiotic treatment.

Oral treatment can be started by many patients after 10 days of intravenous therapy. Exceptions are infections with pathogens that are difficult to treat and patients with severe comorbidities, such as liver cirrhosis or a particularly problematic clinic. The guideline lists several criteria for stability (e.g. no fever over 2 days, an acceptable concentration of C-reactive protein). Stabilisation is key for the switch to oral therapy: there is a recommendation to perform transoesophageal ultrasound in every patient before switching to oral therapy (class I).

“We are not forced to keep patients in hospital for 6 weeks; indeed, it seems to harm them,” Dr Fosbøl said. But he also emphasised to only discharge patients early if they can be assumed to have excellent adherence. In addition, close monitoring is always indicated.

Surgical treatment is indicated in difficult cases (e.g. locally uncontrolled infections [abscess, fistula] or infections with fungi or multi-resistant germs). Specific indications are listed in the guideline [1].

1. 
   
   1. Delgado V, et al. Eur Heart J 2023; Aug 25. DOI: 10.1093/eurheartj/ehad193.
   2. Presentations in session: ‘2022 ESC Guidelines Overview,’ ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.
   3. Presentations in session: ‘2023 ESC Guidelines for the Management of Endocarditis,’ ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.
   4. Iversen K, et al. N Engl J Med 2019;380:415–424.

 

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Posted on 30 October 202330 October 2023