2015 ESC Guidelines for the management of infective endocarditis

THE TASK FORCE FOR THE MANAGEMENT OF INFECTIVE ENDOCARDITIS OF THE EUROPEAN SOCIETY OF CARDIOLOGY (ESC)

DR RISHI A BHARGAVA

INFECTIVE ENDOCARDITIS

Infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect.

Varieties of IE that were uncommon in the early antibiotic era have become prominent.

Cases of NIE, IVDA IE, and PVE have markedly increased. Valvular infections have entered the era of IE caused by

intravascular devices and procedures.

Definitions

Prophylaxis

Patients requiring antibiotic prophylaxis:-

Non specific prevention measures in high and intermediate risk patient

Procedure requiring antibiotics prophylaxis

Contd….

Recommended prophylaxis for high risk procedures in high risk patients

Recommendations for cardiac and vascular procedures

ECHOCARDI- OGRAPHY IN DIAGNOSIS

Use of TTE and TEE:-

Follow up during treatment

Intra op during cardiac surgery

After completion of therapy

Indication For Echocardiography In I.E.

CAUSATIVE ORGANISMS

The etiologic agents

•Streptococci: 60%-80% . •Viridans streptococci: 30%-40% . •Other streptococci: 15%-25%. •Enterococci: 5%-18% . •Coagulase-positive organisms: 10%-27%•Coagulase-negative organisms: 1 %-3%•Gram-negative aerobic bacilli: 1% -13% •Fungi: 2%-4% Staphylococci: 20%-35%

Also more commonly seen -Pseudomonas aeruginosa , esp in pentazocine addictCandida is commonly implicated in heroin addict

The most common etiologic agent of infective endocarditis - S. aureus

IV drug users

In patients with prosthetic valves, the microbiology is somewhat dependent on early (<12 months after valve replacement) versus late (>I2 months) endocarditis.

Staphylococci- 40% to 60% of the cases of early onset prosthetic valve endocarditis.

Coagulase-negative staphylococci - 30% to 35% of cases, S. Aureus - 20% to 25%.

Late onset PVE – organisms same as native valve disease.

• Fungal endocarditis -• IV drug users,• Recently undergonecardiovascular surgery,• Received prolonged IV antibiotic therapy.

HACEK organisms

HACEK is an acronym for a group of fastidious, slow-growing, gram-negative bacteria

Account for approximately 5% to 10% of cases of community-acquired endocarditis.

•H: Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus, .Haemophilus influenzae .•A : Actinobacillus actinomycetemcomitans .•C : Cardiobacterium hominis .•E : Eikenella corrodens •K: Kingella kingae, Kingella denitrificans

Investigation of rare causes of I.E.(blood culture -ve)

DIAGNOSTIC CRITERIA

Modified Duke’s criteria

Definition Of Different Criteria

ESC Algorithm For Diagnosis Of I.E.

PROGNOSTIC FACTORS

Predictors of poor outcome in patient with infective endocardiris

ANTIBIOTIC TREATMENT

Streptococcal bovis and oral streptococci

Penicillin susceptible – standard treatment – 2wk vs 4wk beta lactam allergicPenicillin aresistant Standard treatment Beta lactam allergic

Antibiotic treatment - oral streptococci and streptococci bovis- penicillin susceptible

Penicillin resistance :

Antibiotic treatment - staphylo-cocci

Native valve – Methicilin susceptible /methicillin resistant or pencilillin allergic Prosthetic valveMethicilin susceptible /methicillin resistant or pencilillin allergic

No role of gentamicin in native valve staph infection.Rifampicin is added 3-5 days after starting antibiotics in prosthetic valve endocarditis.

Antibiotic treatment - staphylo-cocci

Antibiotic treatment - staphylo-cocci – prosthetic valve

Antibiotic treatment - entero-cocci – prosthetic valve

Antibiotic treatment of blood culture negative infective endocarditis

Antibiotic treatment of blood culture negative infective endocarditis

Empirical treatment

Empirical treatment of acutely severe ill patient

Outpatient Parenteral Antibiotic Therapy(OPAT)

SURGICAL MANAGEMENT

Indication and timing of surgery in left sided valve infective endocarditis

Indication for surgical treatment of right sided infective endocarditis

Factors associated with increase rate of relapse

Cardiac device related infective endocarditis (CDRIE)

Diagnosis

Principles of Treatment

Mode of device removal

Re-implantation

Prophylaxis

I.E. In congenital heart diseases

Fewer systematic studies. Incidence is lower in children(o.o4% per year ) than in

adult(0.1%) CHD with multiple lesion is at higher risk than simple lesion. Mortality of 4-10 %. Prognosis is better than other forms. Surgical repair of CHD reduces the risk, provided there is no

residual shunt. Artificial valve substrate may increase the risk.

I.E. during pregnancy

Incidence – 0.006%. Higher inpatients with cardiac disease and further

more in pt with prosthetic valves. Maternal mortality is approximately 33% ,with most

death relating to HF or an embolic event. Foetal mortality is about 29%. Rapid detection and appropriate treatment is

important. Despite the high foetal mortality , urgent surgery

should be performed in pt who present with HF due to acute regurgitation.

“……..not to forget, they originated millions of years before us ; and how to survive, probably know better than us!! “