fdokumen.id

3076ESC GuidelinesMitja Lainscak (Slovenia), Adelino F. Leite-Moreira (Portugal), Gregory Y.H. Lip (UK), Carlos A. Mestresc(Spain/United Arab Emirates), Massimo F. Piepoli (Italy), Prakash P. Punjabi (UK), Claudio Rapezzi (Italy),Raphael Rosenhek (Austria), Kaat Siebens (Belgium), Juan Tamargo (Spain), and David M. Walker (UK)The disclosure forms of all experts involved in the development of these guidelines are available on the ESC nting the European Association of Nuclear Medicine (EANM); bRepresenting the European Society of Clinical Microbiology and Infectious Diseases (ESCMID); andRepresenting the European Association for Cardio-Thoracic Surgery (EACTS).cOnline publish-ahead-of-print 29 August 2015- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - KeywordsEndocarditis † Cardiac imaging † Valve disease † Echocardiography † Prognosis † Guidelines † Infection †Nuclear imaging † Cardiac surgery † Cardiac device † Prosthetic heart valves † Congenital heart disease †Pregnancy † Prophylaxis † PreventionAbbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . .1. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2. Justification/scope of the problem . . . . . . . . . . . . . . . . . .3. Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3.1 Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3.2 Population at risk . . . . . . . . . . . . . . . . . . . . . . . . .3.3 Situations and procedures at risk . . . . . . . . . . . . . . .3.3.1 Dental procedures . . . . . . . . . . . . . . . . . . . . .3.3.2 Other at-risk procedures . . . . . . . . . . . . . . . . .3.4 Prophylaxis for dental procedures . . . . . . . . . . . . . .3.5 Prophylaxis for non-dental procedures . . . . . . . . . . .3.5.1 Respiratory tract procedures . . . . . . . . . . . . . . .3.5.2 Gastrointestinal or genitourinary procedures . . . .3.5.3 Dermatological or musculoskeletal procedures . . .3.5.4 Body piercing and tattooing . . . . . . . . . . . . . . .3.5.5 Cardiac or vascular interventions . . . . . . . . . . . .3.5.6 Healthcare-associated infective endocarditis . . . . .4. The ‘Endocarditis Team’ . . . . . . . . . . . . . . . . . . . . . . . .5. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5.1 Clinical features . . . . . . . . . . . . . . . . . . . . . . . . . .5.2 Laboratory findings . . . . . . . . . . . . . . . . . . . . . . . .5.3 Imaging techniques . . . . . . . . . . . . . . . . . . . . . . . .5.3.1 Echocardiography . . . . . . . . . . . . . . . . . . . . . .5.3.2 Multislice computed tomography . . . . . . . . . . . .5.3.3 Magnetic resonance imaging . . . . . . . . . . . . . . .5.3.4 Nuclear imaging . . . . . . . . . . . . . . . . . . . . . . .5.4 Microbiological diagnosis . . . . . . . . . . . . . . . . . . . .5.4.1 Blood culture– positive infective endocarditis . . . .5.4.2 Blood culture– negative infective endocarditis . . . .5.4.3 Histological diagnosis of infective endocarditis . . .5.4.4 Proposed strategy for a microbiological diagnosticalgorithm in suspected IE . . . . . . . . . . . . . . . . . . . . .5.5 Diagnostic criteria . . . . . . . . . . . . . . . . . . . . . . . .6. Prognostic assessment at admission . . . . . . . . . . . . . . . . .7. Antimicrobial therapy: principles and methods . . . . . . . . . .7.1 General principles . . . . . . . . . . . . . . . . . . . . . . . .7.2 Penicillin-susceptible oral streptococci and Streptococcusbovis group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3088.3089.3090.3091.3091.30927.3 Penicillin-resistant oral streptococci and Streptococcus bovisgroup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30927.4 Streptococcus pneumoniae, beta-haemolytic streptococci(groups A, B, C, and G) . . . . . . . . . . . . . . . . . . . . . . . . .30927.5 Granulicatella and Abiotrophia (formerly nutritionallyvariant streptococci) . . . . . . . . . . . . . . . . . . . . . . . . . . .30947.6 Staphylococcus aureus and coagulase-negativestaphylococci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30947.7 Methicillin-resistant and vancomycin-resistantstaphylococci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30947.8 Enterococcus spp. . . . . . . . . . . . . . . . . . . . . . . . . .30947.9 Gram-negative bacteria . . . . . . . . . . . . . . . . . . . . . .30967.9.1 HACEK-related species . . . . . . . . . . . . . . . . . . .30967.9.2 Non-HACEK species . . . . . . . . . . . . . . . . . . . . .30977.10 Blood culture– negative infective endocarditis . . . . . . .30977.11 Fungi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30977.12 Empirical therapy . . . . . . . . . . . . . . . . . . . . . . . . .30977.13 Outpatient parenteral antibiotic therapy for infectiveendocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30988. Main complications of left-sided valve infective endocarditis andtheir management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30998.1 Heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30998.1.1 Heart failure in infective endocarditis . . . . . . . . . .30998.1.2 Indications and timing of surgery in the presence ofheart failure in infective endocarditis . . . . . . . . . . . . . . .31008.2 Uncontrolled infection . . . . . . . . . . . . . . . . . . . . . . .31008.2.1 Persisting infection . . . . . . . . . . . . . . . . . . . . . .31008.2.2 Perivalvular extension in infective endocarditis . . . .31008.2.3 Indications and timing of surgery in thepresence of uncontrolled infection in infectiveendocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31018.2.3.1 Persistent infection . . . . . . . . . . . . . . . . . . .31018.2.3.2 Signs of locally uncontrolled infection . . . . . . .31018.2.3.3 Infection by microorganisms at low likelihood ofbeing controlled by antimicrobial therapy . . . . . . . . . .31018.3 Prevention of systemic embolism . . . . . . . . . . . . . . . .31018.3.1 Embolic events in infective endocarditis . . . . . . . . .31018.3.2 Predicting the risk of embolism . . . . . . . . . . . . . .3101Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 14, 2016Table of Contents

3077ESC Guidelines12.8.2 Infective endocarditis associated with cancer13. To do and not to do messages from the guidelines . . .14. Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3115.3115.3116.3117Abbreviations and OFASPECTTOETTEWBCthree-dimensionalacquired immune deficiency syndromebis in die (twice daily)blood culture-negative infective endocarditiscardiac device-related infective endocarditiscongenital heart diseasecardiac implantable electronic devicecoagulase-negative staphylococciCommittee for Practice GuidelinesC-reactive proteincomputed tomographyEnterococcusEuropean Society of Cardiologyerythrocyte sedimentation rateEuropean System for Cardiac OperativeRisk Evaluationfluorodeoxyglucoseheart failurehuman immunodeficiency virushigh-level aminoglycoside resistanceintramuscularintravenousInternational Collaboration on Endocarditisintensive care unitinfectious diseaseinfective endocarditisimmunoglobulinintravenous drug abuserminimum inhibitory concentrationmagnetic resonancemagnetic resonance imagingmethicillin-resistant Staphylococcus aureusmultislice computed tomographymethicillin-susceptible Staphylococcus aureusnon-bacterial thrombotic endocarditisNational Institute for Health and Care Excellencenative valve endocarditisoutpatient parenteral antibiotic therapypenicillin binding proteinpolymerase chain reactionpositron emission tomographyprosthetic valve endocarditisSequential Organ Failure Assessmentsingle-photon emission computed tomographytransoesophageal echocardiographytransthoracic echocardiographywhite blood cellDownloaded from http://eurheartj.oxfordjournals.org/ by guest on January 14, 20168.3.3 Indications and timing of surgery to prevent embolismin infective endocarditis . . . . . . . . . . . . . . . . . . . . . . .31019. Other complications of infective endocarditis . . . . . . . . . . .31029.1 Neurological complications . . . . . . . . . . . . . . . . . . .31029.2 Infectious aneurysms . . . . . . . . . . . . . . . . . . . . . . . .31039.3 Splenic complications . . . . . . . . . . . . . . . . . . . . . . .31039.4 Myocarditis and pericarditis . . . . . . . . . . . . . . . . . . .31049.5 Heart rhythm and conduction disturbances . . . . . . . . .31049.6 Musculoskeletal manifestations . . . . . . . . . . . . . . . . .31049.7 Acute renal failure . . . . . . . . . . . . . . . . . . . . . . . . .310410. Surgical therapy: principles and methods . . . . . . . . . . . . . .310510.1 Operative risk assessment . . . . . . . . . . . . . . . . . . .310510.2 Preoperative and perioperative management . . . . . . .310510.2.1 Coronary angiography . . . . . . . . . . . . . . . . . . .310510.2.2 Extracardiac infection . . . . . . . . . . . . . . . . . . . .310510.2.3 Intraoperative echocardiography . . . . . . . . . . . .310510.3 Surgical approach and techniques . . . . . . . . . . . . . . .310510.4 Postoperative complications . . . . . . . . . . . . . . . . . .310611. Outcome after discharge: follow-up and long-term prognosis 310611.1 Recurrences: relapses and reinfections . . . . . . . . . . .310611.2 Short-term follow-up . . . . . . . . . . . . . . . . . . . . . . .310711.3 Long-term prognosis . . . . . . . . . . . . . . . . . . . . . . .310712. Management of specific situations . . . . . . . . . . . . . . . . . .310712.1 Prosthetic valve endocarditis . . . . . . . . . . . . . . . . . .310712.1.1 Definition and pathophysiology . . . . . . . . . . . . .310712.1.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . .310712.1.3 Prognosis and treatment . . . . . . . . . . . . . . . . . .310812.2 Infective endocarditis affecting cardiac implantableelectronic devices . . . . . . . . . . . . . . . . . . . . . . . . . . . .310812.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . .310812.2.2 Definitions of cardiac device infections . . . . . . . .310812.2.3 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . .310812.2.4 Risk factors . . . . . . . . . . . . . . . . . . . . . . . . . .310912.2.5 Microbiology . . . . . . . . . . . . . . . . . . . . . . . . .310912.2.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . .310912.2.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .310912.2.8 Antimicrobial therapy . . . . . . . . . . . . . . . . . . .310912.2.9 Complete hardware removal (device and leadextraction) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .310912.2.10 Reimplantation . . . . . . . . . . . . . . . . . . . . . . .311012.2.11 Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . .311012.3 Infective endocarditis in the intensive care unit . . . . . .311112.3.1 Organisms . . . . . . . . . . . . . . . . . . . . . . . . . . .311112.3.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . .311112.3.3 Management . . . . . . . . . . . . . . . . . . . . . . . . .311112.4 Right-sided infective endocarditis . . . . . . . . . . . . . . .311112.4.1 Diagnosis and complications . . . . . . . . . . . . . . .311212.4.2 Prognosis and treatment . . . . . . . . . . . . . . . . . .311212.4.2.1 Antimicrobial therapy . . . . . . . . . . . . . . . . .311212.4.2.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . .311212.5 Infective endocarditis in congenital heart disease . . . . .311312.6 Infective endocarditis during pregnancy . . . . . . . . . . .311312.7 Antithrombotic therapy in infective endocarditis . . . . .311412.8 Non-bacterial thrombotic endocarditis and endocarditisassociated with cancers . . . . . . . . . . . . . . . . . . . . . . . . .311412.8.1 Non-bacterial thrombotic endocarditis . . . . . . . .3114

3078ESC Guidelines1. PreambleTable 1Classes of recommendationsClasses ofrecommendationsSuggested wording to useClass IEvidence and/or generalagreement that a given treatmentor procedure is beneficial, useful,effective.Is recommended/isindicatedClass IIConflicting evidence and/or adivergence of opinion about theusefulness/efficacy of the giventreatment or procedure.Class IIaWeight of evidence/opinion is infavour of usefulness/efficacy.Should be consideredClass IIbUsefulness/efficacy is less wellestablished by evidence/opinion.May be consideredClass IIIEvidence or general agreementthat the given treatment orprocedure is not useful/effective,and in some cases may be harmful.Is not recommendedDownloaded from http://eurheartj.oxfordjournals.org/ by guest on January 14, 2016Guidelines summarize and evaluate all available evidence on a particular issue at the time of the writing process, with the aim of assisting health professionals in selecting the best management strategiesfor an individual patient with a given condition, taking into accountthe impact on outcome, as well as the risk –benefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in theirdaily practice. However, the final decisions concerning an individualpatient must be made by the responsible health professional(s) inconsultation with the patient and caregiver as appropriate.A great number of Guidelines have been issued in recent years bythe European Society of Cardiology (ESC) as well as by other societies and organisations. Because of the impact on clinical practice,quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can befound on the ESC website riting-ESC-Guidelines). ESC Guidelines represent the official position of the ESC on a given topic and are regularly updated.Members of this Task Force were selected by the ESC to represent professionals involved with the medical care of patientswith this pathology. Selected experts in the field undertook acomprehensive review of the published evidence for management(including diagnosis, treatment, prevention and rehabilitation) ofa given condition according to ESC Committee for PracticeGuidelines (CPG) policy. A critical evaluation of diagnostic andtherapeutic procedures was performed, including assessment ofthe risk –benefit ratio. Estimates of expected health outcomes forlarger populations were included, where data exist. The level ofevidence and the strength of the recommendation of particularmanagement options were weighed and graded according to predefined scales, as outlined in Tables 1 and 2.The experts of the writing and reviewing panels provided declarations of interest forms for all relationships that might be perceived asreal or potential sources of conflicts of interest. These forms werecompiled into one file and can be found on the ESC website (http://www.escardio.org/guidelines). Any changes in declarations of interest that arise during the writing period must be notified to the ESCand updated. The Task Force received its entire financial supportfrom the ESC without any involvement from the healthcareindustry.The ESC CPG supervises and coordinates the preparation of newGuidelines produced by task forces, expert groups or consensus panels. The Committee is also responsible for the endorsement process of these Guidelines. The ESC Guidelines undergo extensivereview by the CPG and external experts. After appropriate revisions the Guidelines are approved by all the experts involved inthe Task Force. The finalized document is approved by the CPGfor publication in the European Heart Journal. The Guidelineswere developed after careful consideration of the scientific andmedical knowledge and the evidence available at the time oftheir dating.The task of developing ESC Guidelines covers not only integration of the most recent research, but also the creation of educational tools and implementation programmes for the recommendations.To implement the guidelines, condensed pocket guidelines versions,summary slides, booklets with essential messages, summary cardsfor non-specialists, and an electronic version for digital applications(smartphones, etc.) are produced. These versions are abridged andthus, if needed, one should always refer to the full text version,which is freely available on the ESC website. The National Societiesof the ESC are encouraged to endorse, translate and implement allESC Guidelines. Implementation programmes are needed because it

3079ESC Guidelineshas been shown that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations.Surveys and registries are needed to verify that real-life daily practice is in keeping with what is recommended in the guidelines, thuscompleting the loop between clinical research, writing of guidelines,disseminating them and implementing them into clinical practice.Health professionals are encouraged to take the ESC Guidelinesfully into account when exercising their clinical judgment, as well asin the determination and the implementation of preventive, diagnostic or therapeutic medical strategies. However, the ESC Guidelinesdo not override in any way whatsoever the individual responsibilityof health professionals to make appropriate and accurate decisionsin consideration of each patient’s health condition and in consultation with that patient and the patient’s caregiver where appropriateand/or necessary. It is also the health professional’s responsibility toverify the rules and regulations applicable to drugs and devices at thetime of prescription.Levels of evidenceLevel ofevidence AData derived from multiple randomizedclinical trials or meta-analyses.Level ofevidence BData derived from a single randomizedclinical trial or large non-randomizedstudies.Level ofevidence CConsensus of opinion of the experts and/or small studies, retrospective studies,registries.2. Justification/scope of theproblemInfective endocarditis (IE) is a deadly disease.1,2 Despite improvements in its management, IE remains associated with high mortalityand severe complications. Until recently, guidelines on IE weremostly based on expert opinion because of the low incidence ofthe disease, the absence of randomized trials and the limited number of meta-analyses.3 – 7The 2009 ESC Guidelines on the prevention, diagnosis and treatment of IE8 introduced several innovative concepts, including limitation of antibiotic prophylaxis to the highest-risk patients, a focus onhealthcare-associated IE and identification of the optimal timing forsurgery. However, several reasons justify the decision of the ESC toupdate the previous guidelines: the publication of new large series ofIE, including the first randomized study regarding surgical therapy;9important improvements in imaging procedures,10 particularly in thefield of nuclear imaging; and discrepancies between previous guidelines.5 – 8 In addition, the need for a collaborative approach involvingprimary care physicians, cardiologists, surgeons, microbiologists,infectious disease (ID) specialists and frequently other specialists—namely the ‘Endocarditis Team’—has been underlined recently11,12and will be developed in these new guidelines.3. Prevention3.1 RationaleThe principle of antibiotic prophylaxis for IE was developed on thebasis of observational studies and animal models and aimed at preventing the attachment of bacteria onto the endocardium after transient bacteraemia following invasive procedures. This concept led tothe recommendation for antibiotic prophylaxis in a large number ofpatients with predisposing cardiac conditions undergoing a widerange of procedures.13The restriction of indications for antibiotic prophylaxis was initiated in 2002 because of changes in pathophysiological conceptions and risk– benefit analyses as follows:14† Low-grade but repeated bacteraemia occurs more frequently during daily routine activities such as toothbrushing, flossing or chewing, and even more frequently in patients with poor dental health.15The accountability of low-grade bacteraemia was demonstrated inan animal model.16 The risk of IE may therefore be related more tocumulative low-grade bacteraemia during daily life rather than sporadic high-grade bacteraemia after dental procedures.† Most case –control studies did not report an association betweeninvasive dental procedures and the occurrence of IE.17 – 19† The estimated risk of IE following dental procedures is very low.Antibiotic prophylaxis may therefore avoid only a small numberof IE cases, as shown by estimations of 1 case of IE per 150 000dental procedures with antibiotics and 1 per 46 000 for procedures unprotected by antibiotics.20† Antibiotic administration carries a small risk of anaphylaxis, whichmay become significant in the event of widespread use. However,the lethal risk of anaphylaxis seems very low when using oralamoxicillin.21† Widespread use of antibiotics may result in the emergence ofresistant microorganisms.13† The efficacy of antibiotic prophylaxis on bacteraemia and the occurrence of IE has only been proven in animal models. The effecton bacteraemia in humans is controversial.15† No prospective randomized controlled trial has investigated theefficacy of antibiotic prophylaxis on the occurrence of IE and it isunlikely that such a trial will be conducted given the number ofsubjects needed.22These points have been progressively taken into account in mostguidelines, including the 2009 ESC guidelines,5,8,23 – 26 and led tothe restriction of antibiotic prophylaxis to the highest-risk patients(patients with the highest incidence of IE and/or highest risk ofadverse outcome from IE).In 2008 the National Institute for Health and Care Excellence(NICE) guidelines went a step further and advised against any antibiotic prophylaxis for dental and non-dental procedures whateverDownloaded from http://eurheartj.oxfordjournals.org/ by guest on January 14, 2016Table 2The main objective of the current Task Force was to provide clearand simple recommendations, assisting healthcare providers in theirclinical decision making. These recommendations were obtained byexpert consensus after thorough review of the available literature.An evidence-based scoring system was used, based on a classification of the strength of recommendations and the levels of evidence.

3080† The remaining uncertainties regarding estimations of the risk ofIE, which play an important role in the rationale of NICEguidelines.† The worse prognosis of IE in high-risk patients, in particular thosewith prosthetic IE.† The fact that high-risk patients account for a much smaller number than patients at intermediate risk, thereby reducing potentialharm due to adverse events of antibiotic prophylaxis.3.2 Population at riskPatients with the highest risk of IE can be placed in three categories(Table 3):(1) Patients with a prosthetic valve or with prosthetic material usedfor cardiac valve repair: these patients have a higher risk of IE, ahigher mortality from IE and more often develop complicationsof the disease than patients with native valves and an identicalpathogen.37 This also applies to transcatheter-implanted prostheses and homografts.(2) Patients with previous IE: they also have a greater risk of new IE,higher mortality and higher incidence of complications than patients with a first episode of IE.38(3) Patients with untreated cyanotic congenital heart disease(CHD) and those with CHD who have postoperative palliativeshunts, conduits or other prostheses.39,40 After surgical repairwith no residual defects, the Task Force recommends prophylaxis for the first 6 months after the procedure until endothelialisation of the prosthetic material has occurred.Table 3 Cardiac conditions at highest risk of infectiveendocarditis for which prophylaxis should beconsid

ESC Councils: Council for Cardiology Practice (CCP), Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council on Cardiovascular Primary Care (CCPC). ESC Working Groups: Cardiovascular Pharmacotherapy, Cardiovascular Surgery,Grown-up Congenital HeartDisease, Myocardial and Pericardial Diseases, Pulmonary Circulation