What are the guidelines for infective endocarditis (IE) management?

From the Guidelines

The 2015 ESC guidelines for the management of infective endocarditis are the most comprehensive and widely accepted resource for managing this condition, as they provide a detailed approach to diagnosis, treatment, and management of complications 1. The management of infective endocarditis requires a multidisciplinary approach, involving cardiologists, cardiac surgeons, and infectious disease specialists.

• The guidelines recommend empiric antibiotic therapy with vancomycin and ceftriaxone for native valve endocarditis, and vancomycin, cefepime, and rifampin for prosthetic valve endocarditis, while awaiting culture results.
• Blood cultures should be obtained before initiating antibiotics, with at least three sets from different venipuncture sites.
• Transesophageal echocardiography is preferred over transthoracic for diagnosis in adults with suspected endocarditis.
• Early surgical consultation is essential for cases involving prosthetic valves, heart failure, persistent bacteremia, or large vegetations.
• Patients with complicated infective endocarditis, such as those with heart failure, abscess, or embolic complications, should be referred to a reference center with immediate surgical facilities 1. The guidelines also emphasize the importance of individualized treatment plans, taking into account the patient's specific condition, comorbidities, and risk factors.
• The decision to refer a patient to an "Endocarditis Team" in a reference center should be based on the complexity of the case and the need for specialized care 1. Overall, the 2015 ESC guidelines provide a comprehensive framework for the management of infective endocarditis, and should be considered the gold standard for guiding clinical practice in this area 1.

From the Research

Infective Endocarditis Guidelines

The best infective endocarditis guideline is not explicitly stated in the provided studies, but the following information can be gathered:

• The use of aminoglycosides for the treatment of endocarditis has been dramatically reduced over the last 20 years, and should be administered once daily, and no longer than 2 weeks 2.
• For staphylococcal endocarditis, recent data reinforced the role of anti-staphylococcal penicillins, for methicillin-susceptible isolates (alternative, cefazolin), and vancomycin for methicillin-resistant isolates (alternative, daptomycin) 2.
• The optimal duration of antibacterial treatment is 4 weeks for most native valve endocarditis, and 6 weeks for prosthetic-valve endocarditis 2.
• Patients with penicillin-sensitive viridans or nonenterococcal group D streptococcal endocarditis may be treated successfully with aqueous penicillin G alone for four weeks or with combined penicillin and streptomycin for two weeks 3.
• Enterococcal endocarditis should be treated for four to six weeks with a combination of aqueous penicillin G together with either streptomycin or gentamicin 3.
• Patients with endocarditis caused by Staphylococcus aureus should receive antimicrobial therapy for four to six weeks with a semisynthetic penicillin (nafcillin or oxacillin) or a cephalosporin such as cephalothin or cefazolin 3.

Comparison of Antibiotic Regimens

Several studies compared different antibiotic regimens for the treatment of infective endocarditis, including:

• Quinolone (levofloxacin) plus standard treatment versus standard treatment alone 4, 5.
• Daptomycin versus low-dose gentamicin plus an anti-staphylococcal penicillin or vancomycin 4, 5.
• Cloxacillin plus gentamicin versus a glycopeptide (vancomycin or teicoplanin) plus gentamicin 4, 5.
• Ceftriaxone plus gentamicin versus ceftriaxone alone 4, 5.
• Fosfomycin plus imipenem versus vancomycin 5.
• Partial oral treatment versus conventional intravenous treatment 5.

Quality of Evidence

The quality of evidence for the comparison of different antibiotic regimens is generally low or very low due to the high risk of bias and small sample size of the included studies 4, 5. Therefore, current evidence does not support or reject any regimen of antibiotic therapy for the treatment of infective endocarditis 4, 5.