From the Guidelines
Healthcare-associated infective endocarditis (HAIE) should be managed with a prolonged course of intravenous antibiotics, usually for 4-6 weeks, tailored to the specific causative organism, and surgical intervention may be necessary in certain cases. The most common pathogen in HAIE is Staphylococcus aureus, and combination therapy with nafcillin or oxacillin (2g IV every 4 hours) plus gentamicin (1mg/kg IV every 8 hours) for the first 3-5 days is often recommended, followed by nafcillin/oxacillin alone to complete the course 1. For methicillin-resistant S. aureus (MRSA), vancomycin (15-20mg/kg IV every 8-12 hours) or daptomycin (6-10mg/kg IV daily) is preferred 1. Some key points to consider in the management of HAIE include:
- Early diagnosis through blood cultures and echocardiography, followed by immediate appropriate antibiotic therapy, is crucial for improving outcomes in this condition, which carries a mortality rate of 20-40% despite optimal treatment 1.
- Prevention strategies include strict adherence to infection control practices during invasive procedures, appropriate antibiotic prophylaxis for high-risk patients undergoing dental or other invasive procedures, and prompt removal of unnecessary vascular catheters 1.
- The American Heart Association recommends that prophylaxis be given only to the high-risk group of patients prior to dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth or perforation of oral mucosa 1.
- High-risk patients are defined as those patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis, not necessarily those with an increased lifetime risk of acquisition of infective endocarditis 1. The current recommendations result in greater clarity for patients, health care providers, and consulting professionals, and emphasize the importance of maintaining optimal oral health and hygiene to reduce the incidence of bacteremia from daily activities 1.
From the Research
Definition and Epidemiology of Healthcare-Associated Infective Endocarditis
- Healthcare-associated infective endocarditis (HAIE) is a growing health problem associated with high mortality 2
- The epidemiology of infective endocarditis (IE) has shifted recently with an increase in healthcare-associated IE 3
- HAIE is responsible for a significant proportion of cases due to increasing numbers of cardiac devices 4
Risk Factors and Sources of Infection
- Vascular manipulation is the main cause of bacteraemia responsible for HAIE 2
- Peripheral vein catheter-associated bacteraemia accounted for 32.8% of the catheter-related bacteraemias 2
- Previous hospitalization, dialysis, and urologic procedures are common sources of infection in non-nosocomial HAIE 5
- Enterococcus spp. caused 23% of non-nosocomial HAIE, and more than half of them were associated with urologic or gastrointestinal procedures 5
Diagnosis and Treatment
- The modified Duke criteria algorithm is the standard of care in the clinical diagnosis of IE 4, 3
- Newer imaging technologies such as multi-slice computed tomography, photon-emission computed tomography, and magnetic resonance imaging might add value to conventional echocardiography in diagnosis and management of IE 4
- Treatment consists of long-term antibiotic therapy, infectiological source control and/or cardiac surgery 4, 3
- Intravenous antibiotics are first-line therapy with cardiac surgery being reserved for certain complications of IE and/or for clinical situations in which there is a high risk of complications 3
Mortality and Outcomes
- In-hospital mortality was higher in the HAIE group (44.9% vs. 24.2%) 2
- Septic shock and surgery not performed because of high surgical risk were independent predictors of mortality in HAIE 2
- Patients with two or more previous healthcare-related risk factors had higher in-hospital and one-year mortality 5