Implementation of the 2015 European Society of Cardiology guidelines for the management of infective endocarditis in the Netherlands

Abstract

Because the occurrence of infective endocarditis (IE) continues to be associated with high mortality, a working group was created by the Dutch Society of Cardiology to examine how the most recent European Society of Cardiology (ESC) guidelines for IE management could be implemented most effectively in the Netherlands. In order to investigate current Dutch IE practices, the working group conducted a country-wide survey. Based on the results obtained, it was concluded that most ESC recommendations could be endorsed, albeit with some adjustments. For instance, the suggested pre-operative screening and treatment of nasal carriers of Staphylococcus aureus as formulated in the ESC guideline was found to be dissimilar to current Dutch practice, and was therefore made less restrictive. The recently adapted ESC diagnostic criteria for IE were endorsed, while the practical employment of the relevant diagnostic techniques was simplified in an adapted flowchart. In addition, the presence of a multidisciplinary, so-called 'endocarditis team' in tertiary centres was proposed as a quality indicator. An adapted flowchart specifically tailored to Dutch practice for microbiological diagnostic purposes was constructed. Lastly, the working group recommended the Stichting Werkgroep Antibioticabeleid (SWAB; Dutch Working Party on Antibiotic Policy) guidelines for IE treatment instead of the antibiotic regimens proposed by the ESC.

Keywords: Cardiac imaging; Disease management; Infection; Infective endocarditis; Microbiological diagnosis; Prosthetic heart valves.

Fig. 1

Flowchart of microbiological tests for infective endocarditis in The Netherlands. IE Infective endocarditis, BC blood cultures, SWAB Stichting Werkgroep Antibiotica Beleid (Dutch Working Party on Antibiotic Policy), PCR polymerase chain reaction. ^aIf the diagnostic test is not available, send the blood samples and/or blood cultures to a reference laboratory. ^bSo as not to miss Cutibacterium acnes and/or if blood cultures were drawn while receiving antimicrobial therapy. ^cBartonella spp. (IgM, IgG), Coxiella burnetii (including indirect immunofluorescent assay phase I IgG), Legionella spp. (IgM, IgG), Mycoplasma spp. (IgM, IgG). ^dSpecific PCRs: Bartonella spp., Coxiella burnetii, Legionella spp., Mycoplasma spp., Tropheryma whipplei

Fig. 2

Flowchart of diagnostic imaging for infective endocarditis in the Netherlands. IE infective endocarditis, TTE transthoracic echocardiogram, TEE transoesophageal echocardiogram, BC blood cultures, ¹⁸F‑FDG PET/CT ¹⁸F‑fluorodeoxyglucose positron emission tomography computed tomography, SPECT single photon emission computed tomography, CTA computed tomography angiography, ICE intracardiac echocardiogram, SWAB Stichting Werkgroep Antibiotica Beleid (Dutch Working Party on Antibiotic Policy). ^a[1, 25]. ^b[26]. ^cConsider referring to a tertiary referral centre when there is definite IE and one or more of the following: congenital heart disease in pregnancy, prosthetic valve endocarditis, heart failure, perivalvular extension or uncontrolled infection, embolic events or cerebrovascular accident, arrhythmia or conduction disturbances

Fig. 3

Different examples of major imaging diagnostic criteria: two cases of positive transoesophageal echocardiogram (a, b), one case of positive ¹⁸F‑FDG PET/CT (c, d) and one case of positive cardiac CT (e, f). a A case of a mechanical aortic valve with signs of vegetation (red arrow). The red arrow in b also indicates a vegetation on the aortic valve bioprosthesis, whereas the white arrow indicates a possible abscess of the aortic root. In c (fused PET/CT images) and in d (non-attenuated PET images) the white arrows indicate ¹⁸F‑FDG uptake around the aortic valve bioprosthesis as a sign of possible infection. The red arrow in e indicates a vegetation on one of the leaflets of an aortic valve bioprosthesis. Finally, the red arrow in f indicates a mycotic aneurysm alongside the aortic valve bioprosthesis