A narrative review of the interpretation of guidelines for the treatment of infective endocarditis

Abstract

The recommendations of the current guidelines and the position papers of professional societies from the European Society of Cardiology/European Society of Cardiothoracic Surgeons (ESC), the American College of Cardiology/American Heart Association/Society of Thoracic Surgeon (ACC/AHA/STS) and American Association of Thoracic Surgeon (AATS) regarding management of patients with valvular heart endocarditis were updated over the past decade. However, some of the recommendations appear to contradict one another. Given the changing paradigms on how the disease manifests, our aim was to review the respective guidelines and highlight these differences whilst drawing attention to the subsequent studies from which they were derived. In particular, concerns regarding antibiotic prophylaxis and therapy, imaging modality for diagnosis and follow-up, cerebrovascular sequalae and timing of surgery are appraised in detail. We also identified the novel techniques used such as transcatheter therapies and advances in imaging modalities used for diagnosis and treatment of this condition. The lack of randomised control trials (RCTs) does raise several issues regarding applicability of findings in day-to-day practice. Therefore, the focus of upcoming studies should be on clearly defined multicenter RCTs to provide more robust evidence for the management and treatment of infective endocarditis as future guidelines will be based on the outcomes of these trials.

Keywords: Infective endocarditis; guidelines; treatment and management.

Figure 1

Class of recommendation (COR) and the level of evidence (LOE) that establishes the degree of choice for a treatment.

Figure 2

Show the applied strategy of integrated imaging in patients with suspected infective endocarditis (IE). In patients included in the subgroup with possible IE after initial evaluation by TTE and TEE a cardiac CT imaging, metabolic imaging or transverse imaging of the head and viscera by CT scan or MRI is indicated to achieve a precise early diagnosis. For suspected IE a ¹⁸FDG-PET/CT or a cross-sectional imaging by CT or MRI (or metabolic imaging) scans may assist with detection of complications, such as abscess, mycotic aneurysm, infarct, or hemorrhage in patients with definite IE. *, ¹⁸F-PDG SPECT/CT is useful in patients with prosthetic valves or cardiac implantable electronic devices. IE, infective endocarditis; CT, computed tomography; ¹⁸FDG-PET/CT, 18-fluorodeoxyglucose positron emission; MRI, magnetic resonance imaging; NVE, native valve endocarditis; PVE, prosthetic valve endocarditis; TEE, transoesophageal echocardiography TTE, transthoracic echocardiography; SPECT, single-photon emission computed tomography.

Figure 3

Includes 20 yrs 4 RCT of IE published from 2001 to 2012. IE, infective endocarditis; IVDU, intravenous drug user; MSSA, methicillin-sensitive Staphylococcus aureus; NVE, native valve endocarditis; PVE, prosthetic valve endocarditis; RCT, randomized controlled trial.

Figure 4

Includes 20 yrs 3 RCT of IE published from 1996 to 1998. IVDU, intravenous drug user; MSSA, methicillin-sensitive Staphylococcus aureus; RCT, randomized controlled trial.

Figure 5

Indications for surgery in AHA. *, defined as “during initial hospitalization and before completion of a full course of antibiotics.” HF, heart failure; NVE, native valve infective endocarditis; PVE, prosthetic valve infective endocarditis; VRE, vancomycin-resistant Enterococcus.

Figure 6

Indications for surgery in ESC. ^†, defined as: emergency surgery = performed within 24 h; urgent surgery = within a few days; elective surgery = after at least 1 to 2 weeks of antibiotic therapy. HACEK, Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species; HF, heart failure; NVE, native valve infective endocarditis; PVE, prosthetic valve infective endocarditis; VRE, vancomycin-resistant Enterococcus.