New ESC Guidelines on Infective Endocarditis

September 10, 2009

September 10, 2009 (Barcelona, Spain) — As widely expected, the European Society of Cardiology (ESC) has revised its guidelines on the prevention, diagnosis, and treatment of infective endocarditis (IE) [1]. Key among the recommendations is the advice to reserve antibiotic prophylaxis only for those at the highest risk of IE undergoing the highest-risk dental procedures.

This change is in line with those made in the US--a focused update on antibiotic prophylaxis against infective endocarditis in patients with valvular heart disease was issued by the ACC/AHA last year, as reported by heartwire.

Dr Gilbert Habib (La Timone Hospital, Marseille, France) described the new ESC guidelines on IE during a press conference at the European Society of Cardiology 2009 Congress last week. Habib said there were "no important differences" between the US and European guidelines, with the exception that the Americans still recommend prophylaxis for IE in transplant patients, "and we don't recommend it because we don't think it's significant and useful."

Dr Sid Smith (University of North Carolina, Chapel Hill) said: "This has been a topic of great interest across the Atlantic, and there's strong agreement; we have similar recommendations for prophylaxis and treatment."

Focus on Reduced Prophylaxis, Major Role of Echocardiography

Habib began by explaining that the epidemiology of IE is changing, with new predisposing factors identified, such as intravenous drug abuse, old age, and nosocomial disease. The latter--often known as healthcare-associated IE--represents up to 30% of cases and reinforces the need to adopt aseptic measures during any invasive procedure, he stressed.

The new ESC guidelines-- the first update since 2004--recommend reserving antibiotic prophylaxis for IE during dental procedures to those at highest risk, defined as those with prosthetic heart valves, people with congenital heart disease, and those who have previously had IE.

Prophylaxis is no longer recommended for those at moderate risk, such as people with acquired valve dysfunction or hypertrophic cardiomyopathy, or those deemed at low risk, such as those with pacemakers and/or defibrillators or who have had previous CABG surgery.

These changes have been made because "there is no real scientific proof of the efficacy of antibiotic prophylaxis for IE," said Habib, and it is potentially dangerous and carries the risk of antibiotic resistance developing. The onus is now on prevention rather than prophylaxis, he said, with good oral hygiene and regular dental review being more important than antibiotic prophylaxis to reduce the risk of IE.

The new guidelines also stress the "major role" that echocardiography has to play, it being key to diagnosis, prognosis, and management of patients with endocarditis, said Habib.

For the First Time, Recommendations on Optimal Timing of Surgery for IE

One key issue that is covered for the first time in the new ESC guidance, and that was developed in collaboration with cardiac surgeons, "is a systematic recommendation on the optimal timing of surgery for IE, which is a much-discussed subject in clinical practice," said Habib.

The ESC guidelines are now recommending earlier and more conservative surgery following studies showing this to be beneficial, Habib noted.

Smith said he did not believe this subject was covered in as much detail in the US guidelines.