Evaluating Treatment Options for Patients With Infective Endocarditis

CHF: Congestive heart failure; CI: Contraindication; DM: Diabetes mellitus; ICU: Intensive care unit; IE: Infective endocarditis; iv.: Intravenous; LV: Left ventricle; NS: Not significant; PVE: Prosthetic valve endocarditis. Adapted with permission from [32].

^†Emergency: surgery within 24 h, urgent: surgery within a few days, elective: after at least 1 or 2 weeks of antibiotic therapy.
^‡Class of recommendation.
^§Level of evidence.
^¶Surgery maybe preferred if procedure preserving valve is feasible.
Data taken with permission from [5].

Table 3.  Management of neurological complications.

	Class†	Level‡
After a silent cerebral embolism or transient ischemic attack, surgery is recommended without delay if an indication remains	I	B
Following intracranial hemorrhage, surgery must be postponed for at least 1 month	I	C
Neurosurgery or endovascular therapy are indicated for very large, enlarging or ruptured intracranial aneurysm	I	C
After a stroke, surgery indicated for heart failure, uncontrolled infection, abscess or persistent high embolic risk should not be delayed. Surgery should be considered as long as coma is absent and cerebral hemorrhage has been excluded by cranial CT	IIa	B
Intracranial aneurysm should be looked for in any patient with IE and neurological symptoms – CT or MR angiography should be considered for diagnosis	IIa	B
Conventional angiography should be considered when noninvasive techniques are negative and suspicion of intracranial aneurysms remains	IIa	B

^†Class of recommendation.
^‡Level of evidence.
CT: Computed tomography; MR: Magnetic resonance.
Data taken with permission from [5].

Authors and Disclosures

Aneil Malhotra*¹ & Bernard D Prendergast<sup>1

1</sup>Department of Cardiology, The John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK

Financial & competing interests disclosure
BD Prendergast was a member of the European Society of Cardiology Infective Endocarditis Guidelines working group (2009). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

*Author for correspondence
Tel.: +44 1865 228 927 Fax: +44 1865 228 989 aneil.malhotra@ouh.nhs.uk

Sidebar

Executive Summary

Indications

• Congestive heart failure:

  • Congestive heart failure caused by severe aortic or mitral regurgitation or, more rarely, by valve obstruction caused by vegetations.

  • Severe acute aortic or mitral regurgitation with echocardiographic signs of elevated left ventricular end diastolic pressure or significant pulmonary hypertension.

  • Congestive heart failure as a result of prosthetic dehiscence or obstruction.

• Systemic embolism:

  • Recurrent emboli despite appropriate antibiotic therapy.

  • Large vegetations (>10 mm) following one or more clinical or silent embolic events after initiation of antibiotic therapy.

  • Large vegetations and other predictors of a complicated course.

  • Very large vegetations (>15 mm) without embolic complications, especially if valve sparing surgery is likely (remains controversial).

  • In all cases, surgery for the prevention of embolism must be performed very early since embolic risk is highest during the first days of therapy.

  • Cerebrovascular complications:

    • Silent neurological complication or transient ischemic attack and other surgical indications.

    • Ischemic stroke and other surgical indications, provided that cerebral hemorrhage has been excluded and neurological complications are not severe (e.g., coma).

    • Surgery is contraindicated for at least 1 month after intracranial hemorrhage unless neurosurgical or endovascular intervention can be performed to reduce bleeding risk.

• Uncontrolled infection:

  • Persistent sepsis, fever or positive blood cultures persisting for >5–7 days despite an appropriate antibiotic regime, assuming that vegetations or other lesions requiring surgery persist and that extracardiac sources of sepsis have been excluded.

  • Relapsing infective endocarditis (IE), especially when caused by organisms other than sensitive streptococci or in patients with prosthetic valves.

  • Most patients with abscess, fistulous tract or pseudoaneurysm formation.

• Resistant pathogens:

  • Staphylococcus aureus IE involving a prosthetic valve and most cases involving a left sided native valve.

  • IE caused by other aggressive organisms ( Brucella, Staphyloccus lugdunensis).

  • IE caused by multiresistant organisms (e.g., methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci) and rare infections caused by Gram-negative bacteria or fungal infections.

  • Pseudomonas aeruginosa IE.

• Prosthetic valve endocarditis:

  • Most cases of early prosthetic valve endocarditis.

  • Most cases of prosthetic valve endocarditis caused by S. aureus .

  • Late prosthetic valve endocarditis with heart failure caused by prosthetic dehiscence or obstruction, or other indications for surgery.

• Surgery should be performed immediately, irrespective of antibiotic therapy, in patients with persistent pulmonary edema or cardiogenic shock. If congestive heart failure disappears with medical therapy and there are no other surgical indications, intervention can be postponed to allow a period of days or weeks antibiotic treatment under careful clinical and echocardiographic observation. In patients with well-tolerated severe valvular insufficiency or prosthetic dehiscence and no other reasons for surgery, conservative therapy under careful clinical and echocardiographic observation is recommended with consideration of deferred surgery after resolution of the infection, depending upon tolerance of the valve lesion.

The Timing of Surgery

• Emergency surgery (within 24 h):

  • Native (aortic or mitral) or prosthetic valve endocarditis and severe congestive heart failure or cardiogenic shock caused by:

    • Acute valvular regurgitation.

    • Severe prosthetic dysfunction (dehiscence or obstruction).

    • Fistula into a cardiac chamber or the pericardial space.

• Urgent surgery (within days):

  • Native valve endocarditis with persisting congestive heart failure, signs of poor hemodynamic tolerance or abscess.

  • Prosthetic valve endocarditis with persisting congestive heart failure, signs of poor hemodynamic tolerance or abscess.

  • Prosthetic valve endocarditis caused by staphylococci or Gram-negative organisms

  • Large vegetation (>10 mm) with an embolic event.

  • Large vegetation (>10 mm) with other predictors of a complicated course.

  • Very large vegetation (>15 mm) especially if conservative surgery is feasible.

  • Large abscess and/or periannular involvement with uncontrolled infection.

• Early elective surgery (during the in-hospital stay usually after 1 or 2 weeks of antibiotics):

  • Severe aortic or mitral regurgitation with congestive heart failure and good response to medical therapy.

  • Prosthetic valve endocarditis with valvular dehiscence or congestive heart failure and good response to medical therapy.

  • Presence of abscess or periannular extension.

  • Persisting infection when extracardiac focus has been excluded.

  • Fungal or other infections resistant to medical cure.