What is the recommended management approach for endocarditis?

Management of Infective Endocarditis

The management of infective endocarditis requires a multidisciplinary team approach in a reference center with immediate surgical facilities and specialized expertise to optimize patient outcomes and reduce mortality.1

Diagnostic Approach

• Transthoracic echocardiography (TTE) is recommended as the first-line imaging modality in all cases of suspected infective endocarditis 1
• Transesophageal echocardiography (TOE) is recommended when clinical suspicion remains high despite negative or non-diagnostic TTE, and is mandatory when a prosthetic heart valve or intracardiac device is present 1
• Repeat echocardiography (TTE and/or TOE) should be performed within 5-7 days if initial examination is negative but clinical suspicion remains high 1
• Immediate repeat imaging is necessary when complications are suspected (new murmur, embolism, persistent fever, heart failure, abscess, atrioventricular block) 1

Multidisciplinary "Endocarditis Team" Approach

• Patients with infective endocarditis should be managed by a specialized "Endocarditis Team" including infectious disease specialists, microbiologists, cardiologists, imaging specialists, cardiac surgeons, and specialists in congenital heart disease when needed 1
• Patients with complicated IE (heart failure, abscess, embolic or neurological complications) should be referred early to a reference center with immediate surgical capabilities 1
• Even patients with uncomplicated IE managed in non-reference centers should maintain regular communication with a reference center 1

Antibiotic Therapy

• Bactericidal therapy with appropriate antibiotics is essential for sterilizing vegetations 2
• For staphylococcal endocarditis, treatment should include a semisynthetic penicillin (nafcillin or oxacillin) or cephalosporin for 4-6 weeks 3
• For penicillin-sensitive viridans or nonenterococcal group D streptococcal endocarditis, aqueous penicillin G alone for 4 weeks or combined with streptomycin for 2 weeks is effective 3
• Enterococcal endocarditis requires 4-6 weeks of penicillin G combined with either streptomycin or gentamicin 3
• Vancomycin is indicated for endocarditis caused by methicillin-resistant staphylococci, and has been reported effective alone or in combination with an aminoglycoside for endocarditis caused by S. viridans or S. bovis 4
• For enterococcal endocarditis, vancomycin is effective only in combination with an aminoglycoside 4

Surgical Management

• Urgent surgery is mandatory in the following situations:

  • Aortic or mitral valve endocarditis with severe regurgitation or obstruction causing heart failure 1
  • Locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation) 1
  • Infection caused by fungi or multiresistant organisms 1
  • Persistent vegetations >10 mm after ≥1 embolic episodes despite appropriate antibiotic therapy 1

• After silent embolism or transient ischemic attack, cardiac surgery (if indicated) should be performed without delay 1

• Following intracranial hemorrhage, surgery should generally be postponed for ≥1 month 1

• Complete debridement of infected tissue with a safety margin is crucial for successful surgical outcomes 5

Management of Cardiac Device-Related Infective Endocarditis (CDRIE)

• Prolonged antibiotic therapy and complete hardware removal are recommended in definite CDRIE and in presumably isolated pocket infection 1
• Percutaneous extraction is recommended in most patients with CDRIE, even those with vegetations >10 mm 1
• After device extraction, reassessment of the need for reimplantation is necessary 1
• Routine antibiotic prophylaxis is recommended before device implantation 1

Prevention

• Antibiotic prophylaxis should be considered for patients at highest risk for IE, including those with:
  • Any prosthetic valve or prosthetic material used for cardiac valve repair
  • Previous episode of IE
  • Certain types of congenital heart disease 1
• Prophylaxis should only be considered for dental procedures requiring manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa 1
• Antibiotic prophylaxis is not recommended for respiratory, gastrointestinal, genitourinary procedures, or skin and soft tissue procedures 1

Special Considerations

• In patients with neurological complications, management decisions should involve neurologists and neurosurgeons 1
• Neurosurgery or endovascular therapy is indicated for very large, enlarging, or ruptured intracranial infectious aneurysms 1
• For patients with S. bovis/S. gallolyticus IE, investigation for occult colorectal cancer is recommended 1
• Patients in the intensive care unit with IE should be managed according to protocolized international guidelines for severe sepsis or septic shock 1