guidelines in Focus, in the management of infective endocarditis

1. GUIDELINES ON THE
PREVENTION, DIAGNOSIS, AN
D TREATMENT OF INFECTIVE
ENDOCARDITIS
European Society of Cardiology
(version 2009)

2. Prophylaxsis

Indications: IIa
1.
2.
3.
4.
Prosthetic valves
Previous IE
Cyanotic Congenital heart disease, without
surgical repair, or with residual defects
Congenital heart disease with complete repair
with prosthetic material up to 6 months after
procedure

3. Prophylaxsis

Recommendations:
1.
2.
3.

Dental procedures requiring manipulation of the
gingiva or perforation of oral mucosa
Respiratory tract procedures? Not indicated
Gastrointestinal or urogenital procedures? Not
indicated
ANTIBIOTIC CHOICE:


Amoxicillin or ampicillin: 2g po/iv 30-60 min before
procedure
Allergy to penicillin: clindamycin 600mg po/iv 30-60
min before procedure

4. Diagnosis
Modified Duke’s Criteria

Major criteria
1.
Blood Cultures:
1.
2.
3.
2.
Typical microorganisms consistent with IE from two
separate bottles
Persistent positive blood cultures
Single positive blood culture for Coxiella burnetii
Echocardiography :
1.
2.
Vegetation/abscess/ new partial dehiscence of
prosthetic valve
New valvular regurge

5. 
Minor Criteria:
1.
2.
3.
4.
5.
Predisposition: heart disease/ IVDU
Fever
Vascular phenomena
Immunologic phenomena
Positive blood culture but does not meet major
criteria

6. Definite diagnosis of IE




2 MAJOR
1 MAJOR+ 3 MINOR
5 MINOR
POSSIBLE DIAGNOSIS: 1 MAJOR+ 1
MINOR or 3 MINOR

7. PREDICTORS OF POOR
OUTCOME













Old age
Prosthetic valve
IDDM
Heart failure
Renal failure
Stroke
Septic shock
S. Aureus
Fungi
Gram –ve bacilli
Large vegetation
Low ejection fraction
Severe valve regurge

8. Antimicrobial Treatment

9. Oral Streptococci

Standard treatment:
1.
2.
3.

Two week treatment:
1.
2.

Penicillin G 12-18 million U/day in 6 divided doses
(4 weeks)
Amoxicillin 100-200mg/kg/day in 4-6 doses (4
weeks)
Ceftriaxone 2g/d 1 dose (4 weeks)
Penicillin G or Amoxicillin or Ceftriaxone (2 weeks)
With Gentamicin 3mg/kg/day(2 weeks)
Penicillin allergy:

vancomycin 30mg/kg/day in 2 doses

10. Staphylococcus

Native valve:
1.
2.
3.

Flucloxacillin or Oxacillin 12g/d in 6 doses (4-6
weeks)
PLUS Gentamicin (3-5 days)
Penicillin allergy: vancomycin+gentamicin
Prosthetic valve:
1.
2.
3.
4.
Flucloxacillin or Oxacillin (6 weeks)
PLUS Rifampicin 1200mg/d 2 doses (6 weeks)
PLUS Gentamicin 3mg/kg/d (2 weeks)
Vancomycin for penicillin allergy

11. Enterococcus


Amoxicillin/ ampicillin 200mg/kg/d 4 doses (46 weeks)
PLUS Gentamicin (4-6 weeks)

12. Empirical treatment

NATIVE VALVE:
 Ampicillin/sulbactam
 OR
Amoxicillin/clavulanate
 WITH Gentamicin
OR
 Vancomycin
with gentamicin with ciprofloxacin

13. 
PROSTHETIC VALVE: (within 12 months
post surgery)
 VANCOMYCIN
(6 weeks)
 WITH RIFAMPICIN
 WITH GENTAMICIN (2 weeks)

Prothetic valve >12 months post surgery:
follow same protocol for native valve

14. Surgical Indications
1.
2.
3.
Refractory heart failure
Uncontrolled infection
Prevention of embolism