Endocarditis overview: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
No edit summary
 
(117 intermediate revisions by 11 users not shown)
Line 1: Line 1:
{{SI}}
<div style="-webkit-user-select: none;">
{|class="infobox" style="position: fixed; top: 65%; right: 10px; margin: 0 0 0 0; border: 0; float: right;
|-
| {{#ev:youtube|https://https://www.youtube.com/watch?v=kW-85yk0ErQ|350}}
|-
|}
__NOTOC__
{{Endocarditis}}


{{CMG}}
{{CMG}}; '''Associate Editor-in-Chief:''' {{Maliha}} {{CZ}} [[Kosar Doraghi, M.D.]][mailto:k.doraghi@yahoo.com]


'''Associate Editor-in-Chief:''' {{CZ}}
==Overview==
Endocarditis is an [[inflammation]] of the inner layer of the [[heart]], the [[endocardium]]. It usually involves the [[heart valve]]s. While [[acute bacterial endocarditis]] is caused by an [[infection]] with a [[virulent]] [[organism]] such as [[Staphylococcus aureus]], group A or other [[beta-hemolytic streptococci]], [[subacute bacterial endocarditis]] is an indolent infection with less virulent organisms such as [[streptococcus viridans]].  Patients with unexplained [[fever]] for more than 48 hours and who are at high risk for [[infective endocarditis]] and patients among whom [[valvular disease|valve regurgitation]] is newly diagnosed should undergo a diagnostic workup to rule out [[endocarditis]].  The diagnosis of [[endocarditis]] depends on a thorough history and physical exam as well as on the results of the blood cultures and the findings on [[TTE|transthoracic echocardiogram]] or [[TEE|transesophageal echocardiogram]].  The [[modified Duke criteria]] is used to establish the diagnosis of [[endocarditis]]. [[Endocarditis]] is initially treated with [[Empiric therapy|empiric]] antibiotic therapy until the causative agent is identified.


{{EJ}}
==Historical Perspective==
[[Endocarditis]] was first described in 1554. The [[Inflammation|inflammatory]] process associated with [[endocarditis]] was discovered in 1799. [[Vegetation (pathology)|Vegetations]] were first discovered to be associated with [[endocarditis]] in 1806.


==Overview of Endocarditis==
==Classification==
'''Endocarditis''' is an [[inflammation]] of the inner layer of the [[heart]], the [[endocardium]]. The most common structures involved are the [[heart valve]]s.
[[Endocarditis]] may be classified based on the underlying [[pathophysiology]] of the process ([[Infective endocarditis|infective]] vs. [[Non-infective endocarditis|non-infective]]), the onset of the disease (acute vs. subacute or short incubation vs. long incubation), results of the cultures (culture-positive vs. [[Culture-negative endocarditis|culture]]-negative), the nature of the valve (native vs. [[prosthetic]]) and the valve affected ([[aortic]], [[mitral]], or [[tricuspid valve]]).


[[Endocarditis]] can be classified by etiology as either ''non-infective'' or ''infective'', depending on whether a [[microorganism]] is the source of the problem.
==Pathophysiology==
The [[pathogenesis]] of [[infective endocarditis]] includes valvular damage, altered and turbulent flow, [[bacteremia]], and lack of blood supply to the [[valve]]s. Damaged [[endothelium]] becomes a site for attachment of infectious agents in infectious [[endocarditis]].  [[Nonbacterial thrombotic endocarditis]] is related to [[Hypercoagulable state|hypercoagulable]] states such as [[pregnancy]] or systemic [[bacterial]] [[infection]]. The characteristic lesion of [[endocarditis]] is [[Vegetation (pathology)|vegetation]]. Vegetations are composed of [[fibrin]], [[inflammatory]] cells, [[platelets]], and [[microorganisms]].


Traditionally, infective endocarditis has been clinically divided into ''acute'' and ''subacute'' (because the patients tend to live longer in subacute as opposed to acute) endocarditis.  This classifies both the rate of progression and severity of disease. Thus subacute bacterial endocarditis (SBE) is often due to [[streptococci]] of low virulence and mild to moderate illness which progresses slowly over weeks and months, while acute bacterial endocarditis (ABE) is a fulminant illness over days to weeks, and is more likely due to ''[[Staphylococcus aureus]]'' which has much greater virulence, or disease-producing capacity.
==Causes==
The majority of cases of [[infective endocarditis]] are due to [[bacteria]]. Common causes of [[infective endocarditis]] include ''[[Streptococcus viridans]]'', ''[[Staphylococcus aureus|Staphylococci]]'', and ''[[Enterococcus]]''.


This terminology is now discouraged.  The terms ''short incubation'' (meaning less than about six weeks), and ''long incubation'' (greater than about six weeks) are preferred.  
==Differentiating Endocarditis From Other Diseases==
[[Endocarditis]] must be differentiated from other causes of a [[fever of unknown origin]] ([[FUO]]) such as [[pulmonary embolism]], [[deep vein thrombosis]], [[lymphoma]], [[drug fever]], [[cotton fever]], and [[Disseminated disease|disseminated]] [[granulomatosis]].


Infective endocarditis may also be classified as ''culture-positive'' or ''culture-negative''. Culture-negative endocarditis is due to micro-organisms that require a longer period of time to be identified in the laboratory. Such organisms are said to be '[[Growth medium|fastidious]]' because they have demanding growth requirements. Some pathogens responsible for culture-negative endocarditis include ''[[Aspergillus]] species'', ''[[Brucella]] species'', ''[[Coxiella burnetii]]'', ''[[Chlamydia]] species'', and [[HACEK organism|HACEK bacteria]].
==Risk Factors==
Common risk factors for [[endocarditis]] include [[prosthetic heart valves]], [[valvular heart disease]], [[congenital heart disease]], [[intravenous]] drug use, age-related [[Degenerative disease|degenerative]] [[valvular]] lesions, [[immunosuppression]], and [[colon cancer]].


Finally, the distinction between ''native-valve endocarditis'' and ''prosthetic-valve endocarditis'' is clinically important. Prosthetic-valve endocarditis constitutes 10-20% of cases of endocarditis. The greatest risk is during the first 6 months after valve surgery. [[Staphylococcus epidermidis]] is the most common cause. The infection often extends into the anulus and cardiac tissues.
==Epidemiology and Demographics==
The [[incidence]] of native valve infective [[endocarditis]] is approximately 1.7-6.2 cases per 100,000 individuals per year in the United States and Europe. The [[prevalence]] of [[infective endocarditis]] among [[Intravenous drug use|IV drug]] users ranges from 10 to 15%. The [[incidence]] of [[endocarditis]] increases with age; the median age of patients is 47 to 69 years. There is an increased [[incidence]] of infective [[endocarditis]] in persons 65 years of age and older. Males are more commonly affected with [[endocarditis]] than females. The male to female ratio is approximately 1.7:1.


Patients who inject [[narcotics]] intravenously may introduce infection which will travel to the right side of the heart. In other patients without a history of intravenous exposure, [[endocarditis]] is more frequently left-sided.
==Natural History, Complications, and Prognosis==
If left untreated, patients with [[endocarditis]] may progress to develop [[congestive heart failure]]. [[Endocarditis complications|Complications of endocarditis]] can occur as a result of the locally destructive effects of the infection. These [[complications]] include [[perforation]] of valve leaflets causing [[congestive heart failure]], [[abscesses]], and disruption of the heart's [[Conduction System|conduction]] system. [[Endocarditis]] may also cause [[embolization]] to the brain (causing a [[stroke]]), to the [[coronary artery]] (causing a [[heart attack]]), to the [[lung]] (causing [[pulmonary embolism]]), to the [[spleen]] (causing a splenic infarct), and to the [[kidney]] (causing a [[renal infarct]]).  [[Prognosis]] of [[endocarditis]] is generally poor and the overall mortality rate for both native and [[prosthetic valve]] [[endocarditis]] ranges from 20-25%. The mortality rate for right-sided [[endocarditis]] in injection drug users is approximately 10%. The 5 year survival rate for [[endocarditis|native valve endocarditis]] is 70-80% and 50-80%  for [[endocarditis|prosthetic valve endocarditis]].


=== Non-infective endocarditis ===
==Diagnosis==
Non-infective or marantic endocarditis is [[rare disease|rare]]. A form of sterile [[endocarditis]] is termed [[Libman-Sacks endocarditis]]; this form occurs more often in patients with [[lupus erythematosus]] and the [[antiphospholipid syndrome]]. Non-infective endocarditis may also occur in patients with [[cancer]], particularly mucinous [[adenocarcinoma]].
===Diagnostic Criteria===
The [[Duke criteria]] can be used to establish the diagnosis of [[endocarditis]]. The Duke clinical criteria for [[infective endocarditis]] require either: Two major criteria, or one major and three minor criteria, or five minor criteria.


=== Infective endocarditis ===
===History and Symptoms===
Given the poor vascular supply of the heart valves, entrance of infection fighting components of the bloodstream (such as [[white blood cell]]s) are reduced. So if an organism (such as [[bacterium|bacteria]]) establishes a foothold in the valves, the bodies ability to fight the infection inside the valve structures is reduced.
Common symptoms of [[endocarditis]] include [[fever]], [[chills]], new onset of [[murmur]], [[anorexia]], [[malaise]], [[weight loss]], and [[back pain]].


Normally, blood flows smoothly through these valves. If they have been damaged (for instance in [[rheumatic fever]]) the trauma of non-laminar flow can increase the risk of infection.
===Physical Examination===
Common signs on physical examination of [[endocarditis]] include [[fever]], [[rigors]], [[osler's nodes]], [[janeway lesions]] and evidence of [[embolization]]. [[Aortic insufficiency]] with a [[wide pulse pressure]], [[mitral regurgitation]] or [[tricuspid regurgitation]] may be present depending upon the valve that is infected.
 
===Laboratory Tests===
Two [[blood culture]]s should be ordered when [[infective endocarditis]] is suspected. Laboratory findings consistent with the diagnosis of endocarditis include elevated [[white blood cell count]], [[erythrocyte sedimentation rate]], [[rheumatoid factor]], and elevated [[BUN]] and [[creatinine]] if [[glomerulonephritis]] is present.
 
===Chest x-ray===
On chest [[X-rays|x-ray]], right sided [[endocarditis]] is characterized by [[pleural effusion]]s, multiple round densities, and cavitary multilobar infiltrates.
 
===Electrocardiography===
On [[EKG]], endocarditis may be characterized by conduction abnormalities, low [[QRS]] voltage, [[ST elevation]], [[heart block]], [[ventricular tachycardia]], and [[supraventricular tachycardia]]. The [[EKG]] may show [[ST elevation]] in the presence of [[embolization]] of a [[Vegetation (pathology)|vegetation]] or clot down the [[Coronary artery|coronary artery.]]
 
===Cardiac MRI===
Findings on cardiac [[Magnetic resonance imaging|MRI]] suggestive of infective [[endocarditis]] include valvular vegetations, valvular and perivalvular damage, and vascular [[Endothelium|endothelial]] involvement.
 
===CT Scan===
[[Computed tomography|CT scans]] may be helpful in the diagnosis of [[endocarditis]]. CT scan findings suggestive of [[endocarditis]] include vegetations, paravalvular [[abscesses]], and [[pseudoaneurysm]]s.
 
===Echocardiography===
[[Echocardiography]] may be diagnostic of [[endocarditis]]. [[Echocardiography]] allows detection of microbial [[Vegetation (pathology)|vegetations]] and the degree of valvular dysfunction. Findings on [[Transthoracic echocardiography|transthoracic]] and [[Transesophageal echo cardiography|transesophageal]] echocardiogram diagnostic of [[endocarditis]] include vegetations, valvular [[regurgitation]], [[pseudoaneurysm]]s, paravalvular [[abscess]], and [[fistula]]s.
 
==Treatment==
===Medical Therapy===
[[Antimicrobial]] therapy is the mainstay of therapy for [[endocarditis]]. [[Empiric therapy|Empiric]] antimicrobial therapy depends on the nature of the [[valve]] (native vs. [[Prosthesis|prosthetic]]) and the onset of [[endocarditis]] following valve implantation (less than 1 year vs. more than 1 year).  In patients with [[endocarditis]], [[Antithrombotic therapy|antithrombotic]] therapy may be administered when needed.  The [[prothrombin time]] must be carefully monitored as [[anticoagulant]]s may cause or worsen [[hemorrhage]] in patients with endocarditis.  [[Heparin]] administration should be avoided if possible.
 
==2023 ESC Guidelines for the management of endocarditis ESC Clinical Practice Guidelines (DO NOT EDIT)==
===New recommendations (DO NOT EDIT)<ref name="pmid37622656">{{cite journal| author=Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H | display-authors=etal| title=2023 ESC Guidelines for the management of endocarditis. | journal=Eur Heart J | year= 2023 | volume= 44 | issue= 39 | pages= 3948-4042 | pmid=37622656 | doi=10.1093/eurheartj/ehad193 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=37622656  }} </ref>===
===Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk of infective endocarditis (DO NOT EDIT)===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (General prevention measures are recommended in individuals at high and intermediate risk of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"<ref name="pmid31504413">{{cite journal| author=Habib G, Erba PA, Iung B, Donal E, Cosyns B, Laroche C | display-authors=etal| title=Clinical presentation, aetiology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study. | journal=Eur Heart J | year= 2019 | volume= 40 | issue= 39 | pages= 3222-3232 | pmid=31504413 | doi=10.1093/eurheartj/ehz620 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31504413  }} </ref>
|-
| bgcolor="LightGreen"|”'''2.'''  (Antibiotic prophylaxis is recommended in patients with ventricular assist devices) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"<ref name="pmid35756779">{{cite journal| author=Maeda K, Hirai Y, Nashi M, Yamamoto S, Taniike N, Takenobu T| title=Clinical features and antimicrobial susceptibility of oral bacteria isolated from the blood cultures of patients with infective endocarditis. | journal=J Dent Sci | year= 2022 | volume= 17 | issue= 2 | pages= 870-875 | pmid=35756779 | doi=10.1016/j.jds.2021.09.023 | pmc=9201522 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35756779  }} </ref>
|-
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:OrangeChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="OrangeChiffon"|"'''1.'''  (Antibiotic prophylaxis may be considered in recipients of heart transplant) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for infective endocarditis prevention in high-risk patients (DO NOT EDIT)===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Systemic antibiotic prophylaxis may be considered for
high-risk patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for infective endocarditis prevention in cardiac procedures (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for the role of echocardiography in infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (TOE is recommended when the patient is stable before switching from intravenous to oral antibiotic therapy) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
 
=== Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis (DO NOT EDIT)===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  ([18F]FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:OrangeChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="OrangeChiffon"|"'''1.'''  ([18F]FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Brain and whole-body imaging (CT, [18F]FDG-PET/CT, and/or MRI) are recommended in symptomatic patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
=== Recommendations for outpatient antibiotic treatment of infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Outpatient parenteral antibiotic treatment should be considered in patients with left-sided IE caused by Streptococcus spp., E. faecalis, S. aureus, or CoNS who were receiving appropriate i.v. antibiotic treatment for at least 10 days (or at least 7 days after cardiac surgery), are clinically stable, and who do not show signs of abscess formation or valve abnormalities requiring surgery on TOE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  A]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Outpatient parenteral antibiotic treatment is not recommended in patients with IE caused by highly difficult-to-treat microorganisms, liver cirrhosis (Child–Pugh B or C), severe cerebral nervous system emboli, untreated large extracardiac abscesses, heart valve complications, or other severe conditions requiring surgery, severe post-surgical complications, and in PWID-related IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
 
=== Recommendations for the treatment of neurological complications of infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (In embolic stroke, mechanical thrombectomy may be considered if the expertise is available in a timely manner) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Thrombolytic therapy is not recommended in embolic stroke due to IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for pacemaker implantation in patients with complete atrioventricular block and infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Immediate epicardial pacemaker implantation should be considered in patients undergoing surgery for valvular IE and complete AVB if one of the following predictors of persistent AVB is present: pre-operative conduction abnormality, S. aureus infection, aortic root abscess, tricuspid valve involvement, or previous valvular surgery) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for patients with musculoskeletal manifestations of infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (MRI or PET/CT is recommended in patients with suspected spondylodiscitis and vertebral osteomyelitis complicating IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (TTE/TOE is recommended to rule out IE in patients with spondylodiscitis and/or septic arthritis with positive blood cultures for typical IE microorganisms) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (More than 6-week antibiotic therapy should be considered in patients with osteoarticular IE-related lesions caused by difficult-to-treat microorganisms, such as S. aureus or Candida spp., and/or complicated with severe vertebral destruction or abscesses) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for pre-operative coronary anatomy assessment in patients requiring surgery for infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (In haemodynamically stable patients with aortic valve vegetations who require cardiac surgery and are high risk of CAD, a high-resolution multislice coronary CTA is recommended) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Invasive coronary angiography is recommended in patients requiring heart surgery who are high risk of CAD, in the absence of aortic valve vegetations.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (In emergency situations, valvular surgery without pre-operative coronary anatomy assessment regardless of CAD risk should be considered.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Invasive coronary angiography may be considered despite the presence of aortic valve vegetations in selected patients with known CAD or at high risk of significant obstructive CAD.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Indications and timing of cardiac surgery after neurological complications in active infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (In patients with intracranial haemorrhage and unstable clinical status due to HF, uncontrolled infection, or persistent high embolic risk, urgent or emergency surgery should be considered weighing the likelihood of a meaningful neurological outcome.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
 
=== Recommendations for post-discharge follow-up (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Patient education on the risk of recurrence and preventive measures, with emphasis on dental health, and based on the individual risk profile, is recommended during follow-up.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Addiction treatment for patients following PWID-related IE is recommended) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Cardiac rehabilitation including physical exercise training should be considered in clinically stable patients based on an individual assessment.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Psychosocial support may be considered to be integrated in follow-up care, including screening for anxiety and depression, and referral to relevant psychological treatment.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for prosthetic valve endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Surgery is recommended for early PVE (within 6 months of valve surgery) with new valve replacement and complete debridement) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
=== Recommendations for cardiovascular implanted electronic device-related infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Complete system extraction without delay is recommended in patients with definite CIED-related IE under initial empirical antibiotic therapy.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Extension of antibiotic treatment of CIED-related endocarditis to (4–)6 weeks following device extraction should be considered in the presence of septic emboli or prosthetic valves.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Use of an antibiotic envelope may be considered in select high-risk patients undergoing CIED reimplantation to reduce risk of infection) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|-
| bgcolor="LemonChiffon"|"'''1.'''  (In non-S. aureus CIED-related endocarditis without valve involvement or lead vegetations, and if follow-up blood cultures are negative without septic emboli, 2 weeks of antibiotic treatment may be considered following device extraction.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Removal of CIED after a single positive blood culture, with no other clinical evidence of infection, is not recommended) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for the surgical treatment of right-sided infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Tricuspid valve repair should be considered instead of valve replacement, when possible.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Surgery should be considered in patients with right-sided IE who are receiving appropriate antibiotic therapy and present persistent bacteraemia/sepsis after at least 1 week of appropriate antibiotic therapy.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|-
| bgcolor="LemonChiffon"|”'''3.'''  (Prophylactic placement of an epicardial pacing lead should be considered at the time of tricuspid valve surgical procedures) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Debulking of right intra-atrial septic masses by aspiration may be considered in select patients who are high risk of surgery.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
 
===2023  Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis (DO NOT EDIT)===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (General prevention measures are recommended in individuals at high and intermediate risk for IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Antibiotic prophylaxis is recommended in patients with previous IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Antibiotic prophylaxis is recommended in patients with surgically implanted prosthetic valves and with any material used for surgical cardiac valve repair.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Antibiotic prophylaxis is recommended in patients with transcatheter implanted aortic and pulmonary valvular prostheses.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|-
| bgcolor="LightGreen"|”'''2.'''  (Antibiotic prophylaxis is recommended in patients with untreated cyanotic CHD, and patients treated with surgery or transcatheter procedures with post-operative palliative shunts, conduits, or other prostheses. After surgical repair, in the absence of residual defects or valve prostheses, antibiotic prophylaxis is recommended only for the first 6 months after the procedure.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|-
| bgcolor="LightGreen"|”'''2.'''  (Antibiotic prophylaxis is recommended in patients with ventricular assist devices.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class Ila]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Antibiotic prophylaxis should be considered in patients with transcatheter mitral and tricuspid valve repair.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class Ilb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Antibiotic prophylaxis may be considered in recipients of heart transplant.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Antibiotic prophylaxis is not recommended in other patients at low risk for IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
|}
===2023 ESC Guidelines Recommendations for Prophylactic antibiotic regime for high-risk dental procedures===
[[Image:IMG 0918.jpeg|400px|left thumb|]]
 
===2023 ESC Guidelines Recommendations for Diagnostic Procedures of rare causes of blood culture-negative infective endocarditis ===
[[Image:IMG 1037.jpeg|400px|left thumb|]]
 
=== Recommendations for infective endocarditis prevention in high-risk patients (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| bgcolor="LightGreen"|"'''1.'''  (Antibiotic prophylaxis is recommended in dental extractions, oral surgery procedures, and procedures requiring manipulation of the gingival or periapical region of the teeth.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence: B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (Systemic antibiotic prophylaxis may be considered for high-riskc patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for infective endocarditis prevention in cardiac procedures (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Pre-operative screening for nasal carriage of S. aureus is recommended before elective cardiac surgery or transcatheter valve implantation to treat carriers.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  A]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (Peri-operative antibiotic prophylaxis is recommended before placement of a CIED.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  A]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Periprocedural antibiotic prophylaxis is recommended in patients undergoing surgical or transcatheter implantation of a prosthetic valve, intravascular prosthetic, or other foreign material.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Elimination of potential sources of sepsis (including of dental origin) should be considered ≥2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, except in urgent procedures.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|"'''1.'''  (Systematic skin or nasal decolonization without screening for S. aureus is not recommended.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Recommendations for the Endocarditis Team Recommendations (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Diagnosis and management of patients with complicated IE are recommended to be performed at an early stage in a Heart Valve Centre, with immediate surgical facilities and an Endocarditis Team’ to improve the outcomes.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (For patients with uncomplicated IE managed in a Referring Centre, early and regular communication between the local and the Heart Valve Centre endocarditis teams is recommended to improve the outcomes of the patients.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
===Recommendations for the role of echocardiography in infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (TTE is recommended as the first-line imaging modality in suspected IE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (TOE is recommended in all patients with clinical suspicion of IE and a negative or non-diagnostic TTE.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (TOE is recommended in patients with clinical suspicion of IE, when a prosthetic heart valve or an intracardiac device is present.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Repeating TTE and/or TOE within 5–7 days is recommended in cases of initially negative or inconclusive examination when clinical suspicion of IE remains high.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (TOE is recommended in patients with suspected IE, even in cases with positive TTE, except in isolated right-sided native valve IE with good quality TTE examination and unequivocal echocardiographic findings.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Performing an echocardiography should be considered in S. aureus, E. faecalis, and some Streptococcus spp. bacteraemia.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Repeating TTE and/or TOE is recommended as soon as a new complication of IE is suspected (new murmur, embolism, persisting fever and bacteraemia, HF, abscess, AVB) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (TOE is recommended when patient is stable before switching from intravenous to oral antibiotic therapy.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|”'''2.'''  (During follow-up of uncomplicated IE, repeat TTE and/ or TOE should be considered to detect new silent complications. The timing of repeat TTE and/or TOE depends on the initial findings, type of microorganism, and initial response to therapy.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Intra-operative echocardiography is recommended in all cases of IE requiring surgery) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (TTE and/or TOE are recommended at completion of antibiotic therapy for evaluation of cardiac and valve morphology and function in patients with IE who did not undergo heart valve surgery.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
 
===Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  ( 18F FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''3.'''  (Brain and whole-body imaging (CT, 18F FDG-PET/ CT, and/or MRI) are recommended in symptomaticc patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable.) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|"'''1.'''  (18F FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LemonChiffon"|”'''2.'''  (Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
==Definitions of the 2023 European Society of Cardiology modified diagnostic criteria of infective endocarditis (DO NOT EDIT)==
[[Image:IMG 1176.jpeg|400px]]
[[Image:IMG 1177.jpeg|400px]]
 
== Recommendations for antibiotic treatment of infective endocarditis due to oral streptococci and Streptococcus gallolyticus group (DO NOT EDIT)==
 
===Penicillin-susceptible oral streptococci and Streptococcus gallolyticus group (DO NOT EDIT)===
 
===Standard treatment: 4-week duration in NVE or 6-week duration in PVE (DO NOT EDIT)===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (In patients with IE due to oral streptococci and S. gallolyticus group, penicillin G, amoxicillin, or ceftriaxone are recommended for 4 (in NVE) or 6 weeks (in PVE), using the following doses: *Adult antibiotic dosage and route
Penicillin G 12–18 millionc U/day i.v. either in 4–6 doses or continuously
Amoxicillin 100–200 mg/kg/day i.v. in 4–6 doses
Ceftriaxone 2 g/day i.v. in 1 dose
*Paediatric antibiotic dosage and route
Penicillin G 200 000 U/kg/day i.v. in 4–6 divided doses
Amoxicillin 100–200c mg/kg/day i.v. in 4–6 doses
Ceftriaxone 100 mg/kg/day i.v. in 1 dose) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
===Standard treatment: 2-week duration (not applicable to PVE) (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (2-week treatment with penicillin G, amoxicillin, ceftriaxone combined with gentamicin is recommended only for the treatment of non-complicated NVE due to oral streptococci and S. gallolyticus in patients with normal renal function using the following doses: *Adult antibiotic dosage and route
Penicillin G 12–18 millionc U/day i.v. either in 4–6 doses or continuously, Amoxicillin 100–200 mg/kg/day i.v. in 4–6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose.
*Pediatric antibiotic dosage and route
Penicillin G 200 000 U/kg/day i.v. in 4–6 divided doses, Amoxicillin 100–200 mg/kg/dayc i.v. in 4–6 doses , Ceftriaxone 100 mg/kg i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose or 3 equally divided doses) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
===Allergy to beta-lactams (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (In patients allergic to beta-lactams and with IE due to oral streptococci and S. gallolyticus, vancomycin for 4 weeks in NVE or for 6 weeks in PVE is recommended using the following doses: *Adult antibiotic dosage and route
Vancomycine 30 mg/kg/day i.v. in 2 doses.
*Pediatric antibiotic dosage and route
Vancomycine 30 mg/kg/day i.v. in 2 or 3 equally divided doses) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
|}
=== Oral streptococci and Streptococcus gallolyticus group susceptible, increased exposure or resistant to penicillin (DO NOT EDIT)===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|"'''1.'''  (In patients with NVE due to oral streptococci and S. gallolyticus, penicillin G, amoxicillin, or ceftriaxone for 4 weeks in combination with gentamicin for 2 weeks is recommended using the following doses: *Adult antibiotic dosage and route
Penicillin G 24 million U/day i.v. either in 4–6 doses or continuously, Amoxicillin 12 g/day i.v. in 6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicin 3 mg/kg/day i.v. or i.m. in 1 dose) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|-
| bgcolor="LightGreen"|”'''2.'''  (In patients with PVE due to oral streptococci and S. gallolyticus, penicillin G, amoxicillin, or ceftriaxone for 6 weeks combined with gentamicin for 2 weeks is recommended using the following doses:
*Adult antibiotic dosage and route
Penicillin G 24 million U/day i.v. either in 4–6 doses or continuously, Amoxicillin 12 g/day i.v. in 6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
|}
==Sources==
* 2023 ESC Guidelines for the management of endocarditis
Developed by the task force on the management of endocarditis of the European Society of Cardiology (ESC)
Endorsed by the European Association for Cardio-Thoracic Surgery
(EACTS) and the European Association of Nuclear Medicine (EANM)
 
===Surgery===
 
Surgical removal of the [[valve]] is necessary for patients who fail to clear [[Microorganism|micro-organisms]] from their blood in response to [[antibiotic]] therapy, or in patients who develop [[cardiac failure]] resulting from destruction of a [[valve]] by [[infection]]. A removed valve is usually replaced with an artificial [[valve]] which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed [[Bioprosthetic valves|bioprosthetic]] valves. Surgical treatment of [[endocarditis]] involves excision of all infected [[valve]] tissue, drainage and debridement of [[abscess]] cavities, repair or replacement of damaged valves, and repair of any associated pathology such as [[fistula]]s or [[Septal defect|septal defects]].
 
==Prevention==
Prevention of [[infective endocarditis]] can be achieved through the administration of [[antibiotic]] [[prophylaxis]] to high risk subjects who are undergoing high risk procedures. The choice of [[antibiotic]] [[prophylaxis]] depends on whether the subject can tolerate oral intake or not, as well as on whether patient has allergy to [[penicillin]] or not.


==References==
==References==
{{reflist|2}}
{{reflist|2}}


[[Category:Cardioogy]]
[[Category:Cardiology]]
 
[[Category:Intensive care medicine]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]
[[Category:Cardiology board review]]
[[Category:Intensive care medicine]]
[[Category:Up-To-Date]]
 
{{WH}}
{{WH}}
{{WS}}
{{WS}}

Latest revision as of 23:17, 24 April 2024

https://https://www.youtube.com/watch?v=kW-85yk0ErQ%7C350}}

Endocarditis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Infective Endocarditis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications & Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

Diagnosis and Follow-up

Medical Therapy

Intervention

Case Studies

Case #1

Endocarditis overview On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Endocarditis overview

CDC onEndocarditis overview

Endocarditis overview in the news

Blogs on Endocarditis overview

to Hospitals Treating Endocarditis overview

Risk calculators and risk factors for Endocarditis overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Maliha Shakil, M.D. [2] Cafer Zorkun, M.D., Ph.D. [3] Kosar Doraghi, M.D.[4]

Overview

Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. While acute bacterial endocarditis is caused by an infection with a virulent organism such as Staphylococcus aureus, group A or other beta-hemolytic streptococci, subacute bacterial endocarditis is an indolent infection with less virulent organisms such as streptococcus viridans. Patients with unexplained fever for more than 48 hours and who are at high risk for infective endocarditis and patients among whom valve regurgitation is newly diagnosed should undergo a diagnostic workup to rule out endocarditis. The diagnosis of endocarditis depends on a thorough history and physical exam as well as on the results of the blood cultures and the findings on transthoracic echocardiogram or transesophageal echocardiogram. The modified Duke criteria is used to establish the diagnosis of endocarditis. Endocarditis is initially treated with empiric antibiotic therapy until the causative agent is identified.

Historical Perspective

Endocarditis was first described in 1554. The inflammatory process associated with endocarditis was discovered in 1799. Vegetations were first discovered to be associated with endocarditis in 1806.

Classification

Endocarditis may be classified based on the underlying pathophysiology of the process (infective vs. non-infective), the onset of the disease (acute vs. subacute or short incubation vs. long incubation), results of the cultures (culture-positive vs. culture-negative), the nature of the valve (native vs. prosthetic) and the valve affected (aortic, mitral, or tricuspid valve).

Pathophysiology

The pathogenesis of infective endocarditis includes valvular damage, altered and turbulent flow, bacteremia, and lack of blood supply to the valves. Damaged endothelium becomes a site for attachment of infectious agents in infectious endocarditis. Nonbacterial thrombotic endocarditis is related to hypercoagulable states such as pregnancy or systemic bacterial infection. The characteristic lesion of endocarditis is vegetation. Vegetations are composed of fibrin, inflammatory cells, platelets, and microorganisms.

Causes

The majority of cases of infective endocarditis are due to bacteria. Common causes of infective endocarditis include Streptococcus viridans, Staphylococci, and Enterococcus.

Differentiating Endocarditis From Other Diseases

Endocarditis must be differentiated from other causes of a fever of unknown origin (FUO) such as pulmonary embolism, deep vein thrombosis, lymphoma, drug fever, cotton fever, and disseminated granulomatosis.

Risk Factors

Common risk factors for endocarditis include prosthetic heart valves, valvular heart disease, congenital heart disease, intravenous drug use, age-related degenerative valvular lesions, immunosuppression, and colon cancer.

Epidemiology and Demographics

The incidence of native valve infective endocarditis is approximately 1.7-6.2 cases per 100,000 individuals per year in the United States and Europe. The prevalence of infective endocarditis among IV drug users ranges from 10 to 15%. The incidence of endocarditis increases with age; the median age of patients is 47 to 69 years. There is an increased incidence of infective endocarditis in persons 65 years of age and older. Males are more commonly affected with endocarditis than females. The male to female ratio is approximately 1.7:1.

Natural History, Complications, and Prognosis

If left untreated, patients with endocarditis may progress to develop congestive heart failure. Complications of endocarditis can occur as a result of the locally destructive effects of the infection. These complications include perforation of valve leaflets causing congestive heart failure, abscesses, and disruption of the heart's conduction system. Endocarditis may also cause embolization to the brain (causing a stroke), to the coronary artery (causing a heart attack), to the lung (causing pulmonary embolism), to the spleen (causing a splenic infarct), and to the kidney (causing a renal infarct). Prognosis of endocarditis is generally poor and the overall mortality rate for both native and prosthetic valve endocarditis ranges from 20-25%. The mortality rate for right-sided endocarditis in injection drug users is approximately 10%. The 5 year survival rate for native valve endocarditis is 70-80% and 50-80% for prosthetic valve endocarditis.

Diagnosis

Diagnostic Criteria

The Duke criteria can be used to establish the diagnosis of endocarditis. The Duke clinical criteria for infective endocarditis require either: Two major criteria, or one major and three minor criteria, or five minor criteria.

History and Symptoms

Common symptoms of endocarditis include fever, chills, new onset of murmur, anorexia, malaise, weight loss, and back pain.

Physical Examination

Common signs on physical examination of endocarditis include fever, rigors, osler's nodes, janeway lesions and evidence of embolization. Aortic insufficiency with a wide pulse pressure, mitral regurgitation or tricuspid regurgitation may be present depending upon the valve that is infected.

Laboratory Tests

Two blood cultures should be ordered when infective endocarditis is suspected. Laboratory findings consistent with the diagnosis of endocarditis include elevated white blood cell count, erythrocyte sedimentation rate, rheumatoid factor, and elevated BUN and creatinine if glomerulonephritis is present.

Chest x-ray

On chest x-ray, right sided endocarditis is characterized by pleural effusions, multiple round densities, and cavitary multilobar infiltrates.

Electrocardiography

On EKG, endocarditis may be characterized by conduction abnormalities, low QRS voltage, ST elevation, heart block, ventricular tachycardia, and supraventricular tachycardia. The EKG may show ST elevation in the presence of embolization of a vegetation or clot down the coronary artery.

Cardiac MRI

Findings on cardiac MRI suggestive of infective endocarditis include valvular vegetations, valvular and perivalvular damage, and vascular endothelial involvement.

CT Scan

CT scans may be helpful in the diagnosis of endocarditis. CT scan findings suggestive of endocarditis include vegetations, paravalvular abscesses, and pseudoaneurysms.

Echocardiography

Echocardiography may be diagnostic of endocarditis. Echocardiography allows detection of microbial vegetations and the degree of valvular dysfunction. Findings on transthoracic and transesophageal echocardiogram diagnostic of endocarditis include vegetations, valvular regurgitation, pseudoaneurysms, paravalvular abscess, and fistulas.

Treatment

Medical Therapy

Antimicrobial therapy is the mainstay of therapy for endocarditis. Empiric antimicrobial therapy depends on the nature of the valve (native vs. prosthetic) and the onset of endocarditis following valve implantation (less than 1 year vs. more than 1 year). In patients with endocarditis, antithrombotic therapy may be administered when needed. The prothrombin time must be carefully monitored as anticoagulants may cause or worsen hemorrhage in patients with endocarditis. Heparin administration should be avoided if possible.

2023 ESC Guidelines for the management of endocarditis ESC Clinical Practice Guidelines (DO NOT EDIT)

New recommendations (DO NOT EDIT)[1]

Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk of infective endocarditis (DO NOT EDIT)

Class I
"1. (General prevention measures are recommended in individuals at high and intermediate risk of IE) (Level of Evidence: C)"[2]
”2. (Antibiotic prophylaxis is recommended in patients with ventricular assist devices) (Level of Evidence: C)"[3]
Class IIb
"1. (Antibiotic prophylaxis may be considered in recipients of heart transplant) (Level of Evidence: C)"

Recommendations for infective endocarditis prevention in high-risk patients (DO NOT EDIT)

Class IIb
"1. (Systemic antibiotic prophylaxis may be considered for

high-risk patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems) (Level of Evidence: C)"

Recommendations for infective endocarditis prevention in cardiac procedures (DO NOT EDIT)

Class I
"1. (Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections.) (Level of Evidence: B)"
”2. (Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment) (Level of Evidence: C)"
Class II
"1. (Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures) (Level of Evidence: C)"

Recommendations for the role of echocardiography in infective endocarditis (DO NOT EDIT)

Class I
"1. (TOE is recommended when the patient is stable before switching from intravenous to oral antibiotic therapy) (Level of Evidence: B)"

Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis (DO NOT EDIT)

Class I
"1. (Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE) (Level of Evidence: B)"
”2. ([18F]FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE.) (Level of Evidence: B)"
Class IIb
"1. ([18F]FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE.) (Level of Evidence: B)"
Class I
"1. (Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive.) (Level of Evidence: B)"
”2. (Brain and whole-body imaging (CT, [18F]FDG-PET/CT, and/or MRI) are recommended in symptomatic patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria) (Level of Evidence: B)"
Class II
"1. (WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable) (Level of Evidence: C)"
Class IIb
"1. (Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients) (Level of Evidence: B)"

Recommendations for outpatient antibiotic treatment of infective endocarditis (DO NOT EDIT)

Class II
"1. (Outpatient parenteral antibiotic treatment should be considered in patients with left-sided IE caused by Streptococcus spp., E. faecalis, S. aureus, or CoNS who were receiving appropriate i.v. antibiotic treatment for at least 10 days (or at least 7 days after cardiac surgery), are clinically stable, and who do not show signs of abscess formation or valve abnormalities requiring surgery on TOE) (Level of Evidence: A)"
Class III
"1. (Outpatient parenteral antibiotic treatment is not recommended in patients with IE caused by highly difficult-to-treat microorganisms, liver cirrhosis (Child–Pugh B or C), severe cerebral nervous system emboli, untreated large extracardiac abscesses, heart valve complications, or other severe conditions requiring surgery, severe post-surgical complications, and in PWID-related IE.) (Level of Evidence: C)"

Recommendations for the treatment of neurological complications of infective endocarditis (DO NOT EDIT)

Class IIb
"1. (In embolic stroke, mechanical thrombectomy may be considered if the expertise is available in a timely manner) (Level of Evidence: C)"
Class III
"1. (Thrombolytic therapy is not recommended in embolic stroke due to IE) (Level of Evidence: C)"

Recommendations for pacemaker implantation in patients with complete atrioventricular block and infective endocarditis (DO NOT EDIT)

Class II
"1. (Immediate epicardial pacemaker implantation should be considered in patients undergoing surgery for valvular IE and complete AVB if one of the following predictors of persistent AVB is present: pre-operative conduction abnormality, S. aureus infection, aortic root abscess, tricuspid valve involvement, or previous valvular surgery) (Level of Evidence: C)"

Recommendations for patients with musculoskeletal manifestations of infective endocarditis (DO NOT EDIT)

Class I
"1. (MRI or PET/CT is recommended in patients with suspected spondylodiscitis and vertebral osteomyelitis complicating IE) (Level of Evidence: C)"
”2. (TTE/TOE is recommended to rule out IE in patients with spondylodiscitis and/or septic arthritis with positive blood cultures for typical IE microorganisms) (Level of Evidence: C)"
Class II
"1. (More than 6-week antibiotic therapy should be considered in patients with osteoarticular IE-related lesions caused by difficult-to-treat microorganisms, such as S. aureus or Candida spp., and/or complicated with severe vertebral destruction or abscesses) (Level of Evidence: C)"

Recommendations for pre-operative coronary anatomy assessment in patients requiring surgery for infective endocarditis (DO NOT EDIT)

Class I
"1. (In haemodynamically stable patients with aortic valve vegetations who require cardiac surgery and are high risk of CAD, a high-resolution multislice coronary CTA is recommended) (Level of Evidence: B)"
”2. (Invasive coronary angiography is recommended in patients requiring heart surgery who are high risk of CAD, in the absence of aortic valve vegetations.) (Level of Evidence: C)"
Class II
"1. (In emergency situations, valvular surgery without pre-operative coronary anatomy assessment regardless of CAD risk should be considered.) (Level of Evidence: C)"
Class IIb
"1. (Invasive coronary angiography may be considered despite the presence of aortic valve vegetations in selected patients with known CAD or at high risk of significant obstructive CAD.) (Level of Evidence: C)"

Indications and timing of cardiac surgery after neurological complications in active infective endocarditis (DO NOT EDIT)

Class II
"1. (In patients with intracranial haemorrhage and unstable clinical status due to HF, uncontrolled infection, or persistent high embolic risk, urgent or emergency surgery should be considered weighing the likelihood of a meaningful neurological outcome.) (Level of Evidence: C)"

Recommendations for post-discharge follow-up (DO NOT EDIT)

Class I
"1. (Patient education on the risk of recurrence and preventive measures, with emphasis on dental health, and based on the individual risk profile, is recommended during follow-up.) (Level of Evidence: C)"
”2. (Addiction treatment for patients following PWID-related IE is recommended) (Level of Evidence: C)"
Class II
"1. (Cardiac rehabilitation including physical exercise training should be considered in clinically stable patients based on an individual assessment.) (Level of Evidence: C)"
Class IIb
"1. (Psychosocial support may be considered to be integrated in follow-up care, including screening for anxiety and depression, and referral to relevant psychological treatment.) (Level of Evidence: C)"

Recommendations for prosthetic valve endocarditis (DO NOT EDIT)

Class I
"1. (Surgery is recommended for early PVE (within 6 months of valve surgery) with new valve replacement and complete debridement) (Level of Evidence: C)"

Recommendations for cardiovascular implanted electronic device-related infective endocarditis (DO NOT EDIT)

Class I
"1. (Complete system extraction without delay is recommended in patients with definite CIED-related IE under initial empirical antibiotic therapy.) (Level of Evidence: B)"
Class II
"1. (Extension of antibiotic treatment of CIED-related endocarditis to (4–)6 weeks following device extraction should be considered in the presence of septic emboli or prosthetic valves.) (Level of Evidence: C)"
Class IIb
"1. (Use of an antibiotic envelope may be considered in select high-risk patients undergoing CIED reimplantation to reduce risk of infection) (Level of Evidence: B)"
"1. (In non-S. aureus CIED-related endocarditis without valve involvement or lead vegetations, and if follow-up blood cultures are negative without septic emboli, 2 weeks of antibiotic treatment may be considered following device extraction.) (Level of Evidence: C)"
Class III
"1. (Removal of CIED after a single positive blood culture, with no other clinical evidence of infection, is not recommended) (Level of Evidence: C)"

Recommendations for the surgical treatment of right-sided infective endocarditis (DO NOT EDIT)

Class II
"1. (Tricuspid valve repair should be considered instead of valve replacement, when possible.) (Level of Evidence: B)"
”2. (Surgery should be considered in patients with right-sided IE who are receiving appropriate antibiotic therapy and present persistent bacteraemia/sepsis after at least 1 week of appropriate antibiotic therapy.) (Level of Evidence: C)"
”3. (Prophylactic placement of an epicardial pacing lead should be considered at the time of tricuspid valve surgical procedures) (Level of Evidence: C)"
Class II
"1. (Debulking of right intra-atrial septic masses by aspiration may be considered in select patients who are high risk of surgery.) (Level of Evidence: C)"

2023 Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis (DO NOT EDIT)

Class I
"1. (General prevention measures are recommended in individuals at high and intermediate risk for IE.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis is recommended in patients with previous IE.) (Level of Evidence: B)"
”3. (Antibiotic prophylaxis is recommended in patients with surgically implanted prosthetic valves and with any material used for surgical cardiac valve repair.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis is recommended in patients with transcatheter implanted aortic and pulmonary valvular prostheses.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis is recommended in patients with untreated cyanotic CHD, and patients treated with surgery or transcatheter procedures with post-operative palliative shunts, conduits, or other prostheses. After surgical repair, in the absence of residual defects or valve prostheses, antibiotic prophylaxis is recommended only for the first 6 months after the procedure.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis is recommended in patients with ventricular assist devices.) (Level of Evidence: C)"
Class Ila
"1. (Antibiotic prophylaxis should be considered in patients with transcatheter mitral and tricuspid valve repair.) (Level of Evidence: C)"
Class Ilb
"1. (Antibiotic prophylaxis may be considered in recipients of heart transplant.) (Level of Evidence: C)"
Class III
"1. (Antibiotic prophylaxis is not recommended in other patients at low risk for IE.) (Level of Evidence: C)"

2023 ESC Guidelines Recommendations for Prophylactic antibiotic regime for high-risk dental procedures

2023 ESC Guidelines Recommendations for Diagnostic Procedures of rare causes of blood culture-negative infective endocarditis

Recommendations for infective endocarditis prevention in high-risk patients (DO NOT EDIT)

Class I "1. (Antibiotic prophylaxis is recommended in dental extractions, oral surgery procedures, and procedures requiring manipulation of the gingival or periapical region of the teeth.) (Level of Evidence: B)"
Class IIb
"1. (Systemic antibiotic prophylaxis may be considered for high-riskc patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems.) (Level of Evidence: C)"

Recommendations for infective endocarditis prevention in cardiac procedures (DO NOT EDIT)

Class I
"1. (Pre-operative screening for nasal carriage of S. aureus is recommended before elective cardiac surgery or transcatheter valve implantation to treat carriers.) (Level of Evidence: A)"
”2. (Peri-operative antibiotic prophylaxis is recommended before placement of a CIED.) (Level of Evidence: A)"
”3. (Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections.) (Level of Evidence: B)"
”3. (Periprocedural antibiotic prophylaxis is recommended in patients undergoing surgical or transcatheter implantation of a prosthetic valve, intravascular prosthetic, or other foreign material.) (Level of Evidence: B)"
”3. (Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment.) (Level of Evidence: C)"
Class IIa
”2. (Elimination of potential sources of sepsis (including of dental origin) should be considered ≥2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, except in urgent procedures.) (Level of Evidence: C)"
”2. (Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures.) (Level of Evidence: C)"
Class III
"1. (Systematic skin or nasal decolonization without screening for S. aureus is not recommended.) (Level of Evidence: C)"

Recommendations for the Endocarditis Team Recommendations (DO NOT EDIT)

Class I
"1. (Diagnosis and management of patients with complicated IE are recommended to be performed at an early stage in a Heart Valve Centre, with immediate surgical facilities and an Endocarditis Team’ to improve the outcomes.) (Level of Evidence: B)"
”2. (For patients with uncomplicated IE managed in a Referring Centre, early and regular communication between the local and the Heart Valve Centre endocarditis teams is recommended to improve the outcomes of the patients.) (Level of Evidence: B)"

Recommendations for the role of echocardiography in infective endocarditis (DO NOT EDIT)

Class I
"1. (TTE is recommended as the first-line imaging modality in suspected IE.) (Level of Evidence: B)"
”2. (TOE is recommended in all patients with clinical suspicion of IE and a negative or non-diagnostic TTE.) (Level of Evidence: B)"
”3. (TOE is recommended in patients with clinical suspicion of IE, when a prosthetic heart valve or an intracardiac device is present.) (Level of Evidence: B)"
”3. (Repeating TTE and/or TOE within 5–7 days is recommended in cases of initially negative or inconclusive examination when clinical suspicion of IE remains high.) (Level of Evidence: C)"
”3. (TOE is recommended in patients with suspected IE, even in cases with positive TTE, except in isolated right-sided native valve IE with good quality TTE examination and unequivocal echocardiographic findings.) (Level of Evidence: C)"
Class IIa
”2. (Performing an echocardiography should be considered in S. aureus, E. faecalis, and some Streptococcus spp. bacteraemia.) (Level of Evidence: C)"
Class I
"1. (Repeating TTE and/or TOE is recommended as soon as a new complication of IE is suspected (new murmur, embolism, persisting fever and bacteraemia, HF, abscess, AVB) (Level of Evidence: B)"
”2. (TOE is recommended when patient is stable before switching from intravenous to oral antibiotic therapy.) (Level of Evidence: B)"
Class IIa
”2. (During follow-up of uncomplicated IE, repeat TTE and/ or TOE should be considered to detect new silent complications. The timing of repeat TTE and/or TOE depends on the initial findings, type of microorganism, and initial response to therapy.) (Level of Evidence: B)"
Class I
"1. (Intra-operative echocardiography is recommended in all cases of IE requiring surgery) (Level of Evidence: C)"
”2. (TTE and/or TOE are recommended at completion of antibiotic therapy for evaluation of cardiac and valve morphology and function in patients with IE who did not undergo heart valve surgery.) (Level of Evidence: C)"

Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis (DO NOT EDIT)

Class I
"1. (Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE) (Level of Evidence: B)"
”2. ( 18F FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE) (Level of Evidence: B)"
”3. (Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive.) (Level of Evidence: B)"
”3. (Brain and whole-body imaging (CT, 18F FDG-PET/ CT, and/or MRI) are recommended in symptomaticc patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria) (Level of Evidence: B)"
Class IIa
"1. (WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable.) (Level of Evidence: C)"
Class IIb
"1. (18F FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE) (Level of Evidence: B)"
”2. (Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients) (Level of Evidence: B)"

Definitions of the 2023 European Society of Cardiology modified diagnostic criteria of infective endocarditis (DO NOT EDIT)

Recommendations for antibiotic treatment of infective endocarditis due to oral streptococci and Streptococcus gallolyticus group (DO NOT EDIT)

Penicillin-susceptible oral streptococci and Streptococcus gallolyticus group (DO NOT EDIT)

Standard treatment: 4-week duration in NVE or 6-week duration in PVE (DO NOT EDIT)

Class I
"1. (In patients with IE due to oral streptococci and S. gallolyticus group, penicillin G, amoxicillin, or ceftriaxone are recommended for 4 (in NVE) or 6 weeks (in PVE), using the following doses: *Adult antibiotic dosage and route

Penicillin G 12–18 millionc U/day i.v. either in 4–6 doses or continuously Amoxicillin 100–200 mg/kg/day i.v. in 4–6 doses Ceftriaxone 2 g/day i.v. in 1 dose

  • Paediatric antibiotic dosage and route

Penicillin G 200 000 U/kg/day i.v. in 4–6 divided doses Amoxicillin 100–200c mg/kg/day i.v. in 4–6 doses Ceftriaxone 100 mg/kg/day i.v. in 1 dose) (Level of Evidence: B)"

Standard treatment: 2-week duration (not applicable to PVE) (DO NOT EDIT)

Class I
"1. (2-week treatment with penicillin G, amoxicillin, ceftriaxone combined with gentamicin is recommended only for the treatment of non-complicated NVE due to oral streptococci and S. gallolyticus in patients with normal renal function using the following doses: *Adult antibiotic dosage and route

Penicillin G 12–18 millionc U/day i.v. either in 4–6 doses or continuously, Amoxicillin 100–200 mg/kg/day i.v. in 4–6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose.

  • Pediatric antibiotic dosage and route

Penicillin G 200 000 U/kg/day i.v. in 4–6 divided doses, Amoxicillin 100–200 mg/kg/dayc i.v. in 4–6 doses , Ceftriaxone 100 mg/kg i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose or 3 equally divided doses) (Level of Evidence: B)"

Allergy to beta-lactams (DO NOT EDIT)

Class I
"1. (In patients allergic to beta-lactams and with IE due to oral streptococci and S. gallolyticus, vancomycin for 4 weeks in NVE or for 6 weeks in PVE is recommended using the following doses: *Adult antibiotic dosage and route

Vancomycine 30 mg/kg/day i.v. in 2 doses.

  • Pediatric antibiotic dosage and route

Vancomycine 30 mg/kg/day i.v. in 2 or 3 equally divided doses) (Level of Evidence: C)"

Oral streptococci and Streptococcus gallolyticus group susceptible, increased exposure or resistant to penicillin (DO NOT EDIT)

Class I
"1. (In patients with NVE due to oral streptococci and S. gallolyticus, penicillin G, amoxicillin, or ceftriaxone for 4 weeks in combination with gentamicin for 2 weeks is recommended using the following doses: *Adult antibiotic dosage and route

Penicillin G 24 million U/day i.v. either in 4–6 doses or continuously, Amoxicillin 12 g/day i.v. in 6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicin 3 mg/kg/day i.v. or i.m. in 1 dose) (Level of Evidence: B)"

”2. (In patients with PVE due to oral streptococci and S. gallolyticus, penicillin G, amoxicillin, or ceftriaxone for 6 weeks combined with gentamicin for 2 weeks is recommended using the following doses:
  • Adult antibiotic dosage and route

Penicillin G 24 million U/day i.v. either in 4–6 doses or continuously, Amoxicillin 12 g/day i.v. in 6 doses, Ceftriaxone 2 g/day i.v. in 1 dose, Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose) (Level of Evidence: B)"

Sources

  • 2023 ESC Guidelines for the management of endocarditis

Developed by the task force on the management of endocarditis of the European Society of Cardiology (ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Nuclear Medicine (EANM)

Surgery

Surgical removal of the valve is necessary for patients who fail to clear micro-organisms from their blood in response to antibiotic therapy, or in patients who develop cardiac failure resulting from destruction of a valve by infection. A removed valve is usually replaced with an artificial valve which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic valves. Surgical treatment of endocarditis involves excision of all infected valve tissue, drainage and debridement of abscess cavities, repair or replacement of damaged valves, and repair of any associated pathology such as fistulas or septal defects.

Prevention

Prevention of infective endocarditis can be achieved through the administration of antibiotic prophylaxis to high risk subjects who are undergoing high risk procedures. The choice of antibiotic prophylaxis depends on whether the subject can tolerate oral intake or not, as well as on whether patient has allergy to penicillin or not.

References

  1. ↑ Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H; et al. (2023). "2023 ESC Guidelines for the management of endocarditis". Eur Heart J. 44 (39): 3948–4042. doi:10.1093/eurheartj/ehad193. PMID 37622656 Check |pmid= value (help).
  2. ↑ Habib G, Erba PA, Iung B, Donal E, Cosyns B, Laroche C; et al. (2019). "Clinical presentation, aetiology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study". Eur Heart J. 40 (39): 3222–3232. doi:10.1093/eurheartj/ehz620. PMID 31504413.
  3. ↑ Maeda K, Hirai Y, Nashi M, Yamamoto S, Taniike N, Takenobu T (2022). "Clinical features and antimicrobial susceptibility of oral bacteria isolated from the blood cultures of patients with infective endocarditis". J Dent Sci. 17 (2): 870–875. doi:10.1016/j.jds.2021.09.023. PMC 9201522 Check |pmc= value (help). PMID 35756779 Check |pmid= value (help).

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Endocarditis_overview&oldid=1737522"