Management

Seek expert help. Admit any patient with suspected IE to hospital for full investigation.

The management of infective endocarditis may be considered in terms of:

• management of the acutely ill patient (1)
• antibiotics. Antibiotic management of endocarditis, especially in culture-negative cases, is complex. The choice of regimens and ongoing input should be provided by an infection specialist. (2)
• surgery. Antibiotics are the standard treatment for native valve infective endocarditis, with surgery primarily reserved for patients with heart failure or inadequate response to antibiotic treatment. (3)
• with respect to antibiotic prophylaxis and dental procedures
  • the European Society of Cardiology (ESC) recommends that antibiotic prophylaxis should only be considered if the patient is at highest risk of IE and undergoing a dental procedure that requires manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa. The ESC considers a patient to be at highest risk of IE if they have (1):
    • A prosthetic valve, including a transcatheter valve or a valve in which any prosthetic material was used for valve repair
    • A history of a previous episode of IE
    • Untreated cyanotic congenital heart disease, or congenital heart disease that has been repaired with a prosthetic material (including valved conduits or systemic-to-pulmonary shunts)
    • A ventricular assist device, as destination therapy (considered high risk because of the associated morbidity and mortality).

In the UK, the National Institute for Health and Care Excellence (NICE) recommends that an at-risk patient undergoing interventional procedures should not be given antibiotic prophylaxis against IE routinely. However, NICE emphasises that antibiotic therapy is still necessary to treat active or potential infections. NICE considers a patient to be at risk if they have: (4)

• Acquired valvular heart disease with stenosis or regurgitation
• Hypertrophic cardiomyopathy
• Previous IE
• Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect, fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
• Valve replacement.

References

1. Delgado V, Ajmone Marsan N, de Waha S, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J. 2023 Oct 14;44(39):3948-4042.

2. Rajani R, Klein J. Infective endocarditis: A contemporary update. Clin. Med (Lond). 2020

3. Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012 Jun.

4. National Institute for Health and Care Excellence. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. July 2016 [internet publication].