ESC Guidelines 2023 PDF for the Management of Endocarditis

European Heart Journal (2023) 00, 1–95 ESC GUIDELINES https://doi.org/10.1093/eurheartj/ehad193 2023 ESC Guidelines for the management of endocarditis...

European Heart Journal (2023) 00, 1–95 ESC GUIDELINES https://doi.org/10.1093/eurheartj/ehad193 2023 ESC Guidelines for the management of endocarditis Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 Developed by the task force on the management of endocarditis of the European Society of Cardiology (ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Nuclear Medicine (EANM) Authors/Task Force Members: Victoria Delgado *†, (Chairperson) (Spain), Nina Ajmone Marsan ‡, (Task Force Co-ordinator) (Netherlands), Suzanne de Waha‡, (Task Force Co-ordinator) (Germany), Nikolaos Bonaros (Austria), Margarita Brida (Croatia), Haran Burri (Switzerland), Stefano Caselli (Switzerland), Torsten Doenst (Germany), 1 Stephane Ederhy (France), Paola Anna Erba (Italy), Dan Foldager (Denmark), Emil L. Fosbøl (Denmark), Jan Kovac (United Kingdom), Carlos A. Mestres (South Africa), Owen I. Miller (United Kingdom), Jose M. Miro 2 (Spain), Michal Pazdernik (Czech Republic), Maria Nazarena Pizzi (Spain), 3 Eduard Quintana (Spain), Trine Bernholdt Rasmussen (Denmark), Arsen D. Ristić (Serbia), Josep Rodés-Cabau (Canada), Alessandro Sionis (Spain), Liesl Joanna Zühlke (South Africa), Michael A. Borger *†, (Chairperson) (Germany), and ESC Scientific Document Group * Corresponding authors: Victoria Delgado, Cardiology, Hospital University Germans Trias i Pujol, Badalona, Spain, and Institute for Health Science Research Germans Trias i Pujol (IGTP), Badalona, Spain. Tel: +34 934 65 12 00, E-mail: [email protected]; and Michael A. Borger, University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany. Tel: +49-341- 865-0, E-mail: [email protected] † The two Chairpersons contributed equally to the document and are joint corresponding authors. ‡ The two Task Force Co-ordinators contributed equally to the document. Author/Task Force Member affiliations are listed in author information. 1 Representing the European Association of Nuclear Medicine (EANM) 2 Representing the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) 3 Representing the European Association for Cardio-Thoracic Surgery (EACTS) ESC Clinical Practice Guidelines (CPG) Committee: listed in the Appendix. ESC subspecialty communities having participated in the development of this document: Associations: Association of Cardiovascular Nursing & Allied Professions (ACNAP), Association for Acute CardioVascular Care (ACVC), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), and Heart Failure Association (HFA). Councils: Council for Cardiology Practice, Council on Stroke. Working Groups: Adult Congenital Heart Disease, Cardiovascular Surgery. Patient Forum The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]). © The European Society of Cardiology 2023. All rights reserved. For permissions please e-mail: [email protected]. 2 ESC Guidelines Document Reviewers: Bernard Iung, (CPG Review Co-ordinator) (France), Bernard Prendergast, (CPG Review Co-ordinator) (United Kingdom), Magdy Abdelhamid (Egypt), Marianna Adamo (Italy), Riccardo Asteggiano (Italy), Larry M. Baddour (Unites States of America), Jelena Čelutkienė (Lithuania), John Chambers (United Kingdom), Jean-Claude Deharo (France), Wolfram Doehner (Germany), Laura Dos Subira (Spain), Xavier Duval (France), Volkmar Falk (Germany), Laurent Fauchier (France), Nuria Fernandez-Hidalgo (Spain), Christian Giske2 (Sweden), Anežka Gombošová (Czechia), Gilbert Habib (France), Borja Ibanez (Spain), Tiny Jaarsma (Sweden), Lars Køber (Denmark), Konstantinos C. Koskinas (Switzerland), Dipak Kotecha (United Kingdom), Ulf Landmesser (Germany), Sandra B. Lauck (Canada), Basil S. Lewis (Israel), Maja-Lisa Løchen Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 (Norway), John William McEvoy (Ireland), Borislava Mihaylova (United Kingdom), Richard Mindham (United Kingdom), Lis Neubeck (United Kingdom), Jens Cosedis Nielsen (Denmark), Jean-François Obadia (France), Agnes A. Pasquet (Belgium), Steffen Petersen (United Kingdom), Eva Prescott (Denmark), Susanna Price (United Kingdom), Amina Rakisheva (Kazakhstan), Archana Rao (United Kingdom), François Rouzet (France), Jonathan Sandoe (United Kingdom), Renate B. Schnabel (Germany), Christine Selton-Suty (France), Lars Sondergaard (Denmark), Martin Thornhill (United Kingdom), Konstantinos Toutouzas (Greece), Nico Van de Veire (Belgium), Isidre Vilacosta (Spain), Christiaan Vrints (Belgium), and Olaf Wendler (United Kingdom) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and simultaneously published in a supplementary document to the guidelines. The report is also available on the ESC website www.escardio.org/Guidelines See the European Heart Journal online for supplementary documents that include background information and evidence tables. Keywords Guidelines Antibiotics Cardiac imaging Cardiac implantable electronic device Cardiac surgery Complications Computed tomography Congenital heart disease Diagnosis Echocardiography Endocarditis Infection Nuclear imaging Positron emission tomography Prevention Prognosis Prosthetic heart valve Valve disease 5.3.1. Blood culture-positive infective endocarditis.......................... 19 Table of contents 5.3.2. Blood culture-negative infective endocarditis......................... 19 1. Preamble...................................................................................................................... 6 5.3.3. Proposed strategy for a microbiological diagnostic 2. Introduction............................................................................................................... 8 algorithm in suspected infective endocarditis...................................... 20 2.1. What is new..................................................................................................... 8 5.4. Imaging techniques....................................................................................... 20 3. Prevention................................................................................................................ 12 5.4.1. Echocardiography................................................................................ 20 3.1. Rationale........................................................................................................... 12 5.4.2. Computed tomography.................................................................... 22 3.2. Populations at risk of infective endocarditis..................................... 13 5.4.3. Magnetic resonance imaging........................................................... 22 3.3. Situations and procedures at risk.......................................................... 14 5.4.4. Nuclear imaging positron emission tomography/ 3.3.1. Dental procedures.............................................................................. 14 computed tomography (angiography) and single photon 3.3.2. Non-dental procedures.................................................................... 14 emission tomography/computed tomography.................................... 23 3.3.3. Cardiac or vascular interventions................................................. 15 5.5. Diagnostic criteria........................................................................................ 24 3.4. Patient education.......................................................................................... 15 5.5.1. Modifications for the diagnosis of infective endocarditis... 24 4. The Endocarditis Team...................................................................................... 16 5.5.1.1. Major criteria – microbiology................................................ 26 5. Diagnosis................................................................................................................... 18 5.5.1.2. Major criteria – imaging............................................................ 26 5.1. Clinical features............................................................................................. 18 5.5.1.3. Minor criteria................................................................................ 27 5.2. Laboratory findings...................................................................................... 19 5.5.1.4. Microbiological criteria............................................................. 27 5.3. Microbiological diagnosis........................................................................... 19 5.5.1.5. Infective endocarditis classification...................................... 28 Disclaimer. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy, and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular, in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic, or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. ESC Guidelines 3 5.5.2. The new 2023 European Society of Cardiology diagnostic 9.5. Heart rhythm and conduction disturbances.................................... 46 algorithms............................................................................................................ 28 9.6. Musculoskeletal manifestations.............................................................. 46 6. Prognostic assessment at admission............................................................. 28 9.6.1. Osteoarticular infective endocarditis-related infections..... 46 7. Antimicrobial therapy: principles and methods....................................... 28 9.6.2. Rheumatological manifestations.................................................... 47 7.1. General principles........................................................................................ 28 9.7. Acute renal failure........................................................................................ 47 7.2. Penicillin-susceptible oral streptococci and 10. Surgical therapy: principles and methods................................................ 47 Streptococcus gallolyticus group........................................................................ 30 10.1. Pre-operative and peri-operative management............................ 47 7.3. Oral streptococci and Streptococcus gallolyticus group 10.1.1. Coronary angiography.................................................................... 47 Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 susceptible, increased exposure or resistant to penicillin................... 30 10.1.2. Extracardiac infection...................................................................... 48 7.4. Streptococcus pneumoniae, β-haemolytic streptococci 10.1.3. Intra-operative echocardiography.............................................. 48 (groups A, B, C, and G)...................................................................................... 32 10.2. Other intra-operative considerations............................................... 48 7.5. Granulicatella and Abiotrophia (formerly nutritionally variant 10.3. Surgical approach and techniques...................................................... 48 streptococci)........................................................................................................... 32 10.3.1. Choice of valve prosthesis............................................................ 49 7.6. Staphylococcus aureus and coagulase-negative staphylococci..... 32 10.4. Timing of surgery after ischaemic and haemorrhagic stroke.. 50 7.7. Methicillin-resistant staphylococci......................................................... 32 10.5. Post-operative complications............................................................... 50 7.8. Enterococcus spp............................................................................................ 35 10.6. Management of antithrombotic therapy after surgery.............. 51 7.9. Gram-negative bacteria.............................................................................. 36 11. Outcome after discharge: follow-up and long-term prognosis...... 51 7.9.1. Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, 11.1. Recurrences: relapses and reinfections............................................ 51 and Kingella-related species......................................................................... 36 11.2. First year follow-up................................................................................... 52 7.9.2. Non-Haemophilus, Aggregatibacter, Cardiobacterium, 11.3. Long-term prognosis................................................................................ 52 Eikenella, and Kingella species...................................................................... 37 12. Management of specific situations.............................................................. 52 7.10. Blood culture-negative infective endocarditis............................... 37 12.1. Prosthetic valve endocarditis................................................................ 52 7.11. Fungi................................................................................................................ 37 12.1.1. Definition and pathophysiology.................................................. 53 7.12. Empirical therapy....................................................................................... 37 12.1.2. Diagnosis............................................................................................... 53 7.13. Outpatient parenteral or oral antibiotic therapy for infective 12.1.3. Prognosis and treatment............................................................... 53 endocarditis............................................................................................................. 38 12.2. Endocarditis in the elderly..................................................................... 53 7.13.1. Parenteral and oral step-down antibiotic treatment......... 39 12.3. Transcatheter prosthetic valve endocarditis.................................. 54 7.13.2. Other considerations for outpatient oral or parenteral 12.3.1. Endocarditis following transcatheter aortic valve antimicrobial therapy...................................................................................... 39 implantation........................................................................................................ 54 8. Indications for surgery and management of main infective 12.3.1.1. Diagnosis...................................................................................... 54 endocarditis complications.................................................................................... 40 12.3.1.2. Prognosis and treatment....................................................... 54 8.1. Pre-operative risk assessment................................................................ 40 12.3.2. Endocarditis following transcatheter pulmonary valve 8.2. Heart failure.................................................................................................... 40 implantation........................................................................................................ 54 8.2.1. Heart failure in infective endocarditis......................................... 40 12.3.2.1. Diagnosis...................................................................................... 55 8.2.2. Indications and timing of surgery in the presence of heart 12.3.2.2. Prognosis and treatment....................................................... 55 failure in infective endocarditis................................................................... 42 12.4. Infective endocarditis affecting cardiac implantable 8.3. Uncontrolled infection............................................................................... 42 electronic devices.................................................................................................. 55 8.3.1. Septic shock and persistent infection......................................... 42 12.4.1. Definitions of cardiac device infections................................... 55 8.3.2. Locally uncontrolled infection........................................................ 42 12.4.2. Pathophysiology and microbiology............................................ 55 8.3.3 Indications and timing of surgery in the presence of 12.4.3. Risk factors.......................................................................................... 55 uncontrolled infection.................................................................................... 43 12.4.4. Prophylaxis........................................................................................... 55 8.3.3.1. Persistent infection..................................................................... 43 12.4.5. Diagnosis............................................................................................... 55 8.3.3.2. Locally uncontrolled infection............................................... 43 12.4.6. Antimicrobial therapy...................................................................... 57 8.3.3.3. Infection with resistant or virulent organisms................ 43 12.4.7. Device extraction.............................................................................. 57 8.4. Prevention of systemic embolism......................................................... 43 12.4.8. Device reimplantation..................................................................... 57 8.4.1. Incidence of embolic events in infective endocarditis.......... 43 12.5. Infective endocarditis in patients admitted to intensive care 8.4.2. Predicting the risk of embolism..................................................... 43 units............................................................................................................................ 58 8.4.3. Indications and timing of surgery to prevent embolism in 12.5.1. Causative microorganisms............................................................ 58 infective endocarditis...................................................................................... 43 12.5.2. Diagnosis............................................................................................... 58 9. Other complications of infective endocarditis......................................... 44 12.5.3. Management........................................................................................ 58 9.1. Neurological complications...................................................................... 44 12.6. Right-sided infective endocarditis....................................................... 58 9.1.1. The role of cerebral imaging in infective endocarditis......... 45 12.6.1. Diagnosis and complications........................................................ 59 9.2. Infective aneurysms..................................................................................... 45 12.6.2. Endocarditis in people who inject drugs................................. 59 9.3. Splenic complications.................................................................................. 45 12.6.3. Prognosis and treatment............................................................... 59 9.4. Myocarditis and pericarditis..................................................................... 46 12.6.3.1. Antimicrobial therapy............................................................. 59 4 ESC Guidelines 12.6.3.2. Surgery.......................................................................................... 59 Recommendation Table 11 — Recommendations for outpatient 12.7. Infective endocarditis in congenital heart disease........................ 60 antibiotic treatment of infective endocarditis................................................ 40 12.8. Infective endocarditis in rheumatic heart disease........................ 61 Recommendation Table 12 — Recommendations for the main 12.9. Infective endocarditis during pregnancy.......................................... 61 indications of surgery in infective endocarditis (native valve 12.10. Infective endocarditis in immunocompromised patients....... 61 endocarditis and prosthetic valve endocarditis)............................................ 44 12.10.1. Solid organ transplant recipients............................................. 61 Recommendation Table 13 — Recommendations for the treatment 12.10.2. Patients with human immunodeficiency virus.................... 61 of neurological complications of infective endocarditis............................ 45 12.10.3. Patients with neutropaenia........................................................ 62 Recommendation Table 14 — Recommendations for pacemaker Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 12.11. Antithrombotic and anticoagulant therapy in infective implantation in patients with complete atrioventricular block and infective endocarditis................................................................................................ 46 endocarditis............................................................................................................. 62 Recommendation Table 15 — Recommendations for patients with 12.12. Non-bacterial thrombotic endocarditis........................................ 62 musculoskeletal manifestations of infective endocarditis......................... 47 12.13. Infective endocarditis and malignancy............................................ 63 Recommendation Table 16 — Recommendations for pre-operative 13. Patient-centred care and shared decision-making in infective coronary anatomy assessment in patients requiring surgery for endocarditis.................................................................................................................. 63 infective endocarditis................................................................................................ 48 13.1. What is patient-centred care and shared decision-making Recommendation Table 17 — Indications and timing of cardiac and why is it important?..................................................................................... 63 surgery after neurological complications in active infective 13.2. Patient-centred care and shared decision-making in infective endocarditis.................................................................................................................. 50 endocarditis............................................................................................................. 63 Recommendation Table 18 — Recommendations for 14. Sex differences.................................................................................................... 64 post-discharge follow-up........................................................................................ 52 15. Key messages....................................................................................................... 65 Recommendation Table 19 — Recommendations for prosthetic 16. Gaps in evidence................................................................................................. 66 valve endocarditis....................................................................................................... 53 17. ‘What to do’ and ‘What not to do’ messages from the Guidelines 67 Recommendation Table 20 — Recommendations for cardiovascular 18. Supplementary data........................................................................................... 73 implanted electronic device-related infective endocarditis...................... 57 19. Data availability.................................................................................................... 73 Recommendation Table 21 — Recommendations for the surgical 20. Author information........................................................................................... 73 treatment of right-sided infective endocarditis............................................. 60 21. Appendix................................................................................................................ 74 Recommendation Table 22 — Recommendations for the use of 22. References............................................................................................................. 74 antithrombotic therapy in infective endocarditis......................................... 62 List of tables Table 1 Classes of recommendations.................................................................. 6 Tables of Recommendations Table 2 Levels of evidence........................................................................................ 6 Recommendation Table 1 — Recommendations for antibiotic Table 3 New recommendations............................................................................ 8 prophylaxis in patients with cardiovascular diseases undergoing Table 4 Revised recommendations.................................................................... 10 oro-dental procedures at increased risk for infective endocarditis..... 14 Table 5 General prevention measures to be followed in patients at Recommendation Table 2 — Recommendations for infective high and intermediate risk of infective endocarditis................................... 13 endocarditis prevention in high-risk patients................................................. 16 Table 6 Prophylactic antibiotic regime for high-risk dental procedures 14 Recommendation Table 3 — Recommendations for infective Table 7 Members of the Endocarditis Team................................................. 16 endocarditis prevention in cardiac procedures............................................ 16 Table 8 Cardiac and non-cardiac risk factors................................................ 18 Recommendation Table 4 — Recommendations for the Table 9 Investigation of rare causes of blood culture-negative Endocarditis Team..................................................................................................... 18 infective endocarditis................................................................................................ 20 Recommendation Table 5 — Recommendations for the role of Table 10 Definitions of the 2023 European Society of Cardiology echocardiography in infective endocarditis..................................................... 22 modified diagnostic criteria of infective endocarditis.................................. 24 Recommendation Table 6 — Recommendations for the role of Table 11 Antibiotic treatment of blood culture-negative infective computed tomography, nuclear imaging, and magnetic resonance in endocarditis.................................................................................................................. 37 infective endocarditis................................................................................................ 23 Table 12 Features favouring a non-mechanical valve substitute in the Recommendation Table 7 — Recommendations for antibiotic setting of surgery for acute infective endocarditis...................................... 50 treatment of infective endocarditis due to oral streptococci and Table 13 Factors associated with an increased rate of relapse of Streptococcus gallolyticus group............................................................................. 30 infective endocarditis................................................................................................ 52 Recommendation Table 8 — Recommendations for antibiotic Table 14 ‘What to do’ and ‘What not to do’............................................... 67 treatment of infective endocarditis due to Staphylococcus spp.............. 33 Recommendation Table 9 — Recommendations for antibiotic treatment of infective endocarditis due to Enterococcus spp......................... 35 List of figures Recommendation Table 10 — Recommendations for antibiotic Figure 1 Management of patients with infective endocarditis................... 7 regimens for initial empirical treatment of infective endocarditis Figure 2 Education of high-risk patients to prevent infective (before pathogen identification).......................................................................... 38 endocarditis.................................................................................................................. 15 ESC Guidelines 5 Figure 3 Management of patients with infective endocarditis: EURO-ENDO European Infective Endocarditis Registry positioning of the Endocarditis Team............................................................... 17 HACEK Haemophilus, Aggregatibacter, Cardiobacterium, Figure 4 Microbiological diagnostic algorithm in culture-positive and Eikenella, and Kingella culture-negative infective endocarditis............................................................. 21 HF Heart failure Figure 5 European Society of Cardiology 2023 algorithm for HIV Human immunodeficiency virus diagnosis of native valve infective endocarditis............................................. 25 HLAR High-level aminoglycoside resistance Figure 6 European Society of Cardiology 2023 algorithm for diagnosis i.m. Intramuscular of prosthetic valve infective endocarditis................................................................. 26 i.v. Intravenous Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 Figure 7 European Society of Cardiology 2023 algorithm for ICD Implantable cardioverter defibrillator diagnosis of cardiac device-related infective endocarditis........................ 27 ICE-PCS International Collaboration on Figure 8 Phases of antibiotic treatment for infective endocarditis in Endocarditis-Prospective Cohort Study relation to outpatient parenteral antibiotic therapy and partial oral ICU Intensive care unit endocarditis treatment............................................................................................ 29 IE Infective endocarditis Figure 9 Flowchart to assess clinical stability based on the Partial Oral Ig Immunoglobulin Treatment of Endocarditis trial........................................................................... 39 MALDI-TOF MS Matrix-assisted laser desorption ionization Figure 10 Proposed surgical timing for infective endocarditis................ 41 time-of-flight mass spectrometry Figure 11 Surgery for infective endocarditis following stroke................ 49 MIC Minimum inhibitory concentration Figure 12 Algorithm differentiating relapse from reinfection................. 51 MRA Magnetic resonance angiography Figure 13 Management of cardiovascular implanted electronic MRI Magnetic resonance imaging device-related infective endocarditis................................................................. 56 MRSA Methicillin-resistant Staphylococcus aureus Figure 14 Concept of patient-centred care in infective endocarditis. 64 MSSA Methicillin-susceptible Staphylococcus aureus NBTE Non-bacterial thrombotic endocarditis Abbreviations and acronyms NIHSS National Institutes of Health Stroke Scale Score 18 NVE Native valve endocarditis [18F]FDG F-fluorodeoxyglucose NYHA New York Heart Association 99m 99mTc-HMPAO Technetium-hexamethylpropyleneamine OPAT Outpatient parenteral antibiotic therapy oxime PADIT Previous procedure on same pocket; Age; AIDS Acquired immune deficiency syndrome Depressed renal function; Immunocompromised; AEPEI Association for the Study and Prevention of Type of procedure Infective Endocarditis Study PALSUSE Prosthetic valve, age ≥70, large intracardiac ANCLA Anaemia, NYHA class IV, critical state, large destruction, Staphylococcus spp., urgent surgery, intracardiac destruction, surgery of thoracic aorta sex (female), EuroSCORE ≥10 APLs Antiphospholipid syndrome PBP Penicillin-binding protein AUC Area under the curve PCR Polymerase chain reaction AVB Atrioventricular block PET/CT Positron emission tomography/computed AVN Atrioventricular node tomography BCNIE Blood culture-negative infective endocarditis POET Partial Oral Treatment of Endocarditis (trial) BMI Body mass index PPV Positive predictive value CAD Coronary artery disease PVE Prosthetic valve endocarditis CHD Congenital heart disease PWID People who inject drugs CI Confidence interval RCT Randomized clinical trial CIED Cardiovascular implanted electronic device RHD Rheumatic heart disease CNS Central nervous system rRNA Ribosomal ribonucleic acid CoNS Coagulase-negative staphylococci SAPS Simplified Acute Physiology Score CPB Cardio-pulmonary bypass SLE Systemic lupus erythematous CRT Cardiac resynchronization therapy SOT Solid organ transplantation CT Computed tomography SPECT/CT Single photon emission tomography/computed CTA Computed tomography angiography tomography DIC Disseminated intravascular coagulation STS Society of Thoracic Surgeons DNA Deoxyribonucleic acid TAVI Transcatheter aortic valve implantation DSA Digital subtraction angiography TOE Transoesophageal echocardiography ECG Electrocardiogram TPVI Transcatheter pulmonary valve implantation EHRA European Heart Rhythm Association TTE Transthoracic echocardiography ESC European Society of Cardiology WBC White blood cell EUCAST European Committee on Antimicrobial WRAP-IT Worldwide Randomized Antibiotic Envelope Susceptibility Testing Infection Prevention Trial 6 ESC Guidelines 1. Preamble the patient’s caregiver where appropriate and/or necessary. It is also the health professional’s responsibility to verify the rules and regulations ap- Guidelines evaluate and summarize available evidence, with the aim of as- plicable in each country to drugs and devices at the time of prescription, sisting health professionals in proposing the best diagnostic or therapeutic and, where appropriate, to respect the ethical rules of their profession. approach for an individual patient with a given condition. Guidelines are in- ESC Guidelines represent the official position of the ESC on a given tended for use by health professionals and the European Society of topic and are regularly updated. ESC Policies and Procedures for for- Cardiology (ESC) makes its Guidelines freely available. mulating and issuing ESC Guidelines can be found on the ESC website ESC Guidelines do not override the individual responsibility of health (https://www.escardio.org/Guidelines). professionals to make appropriate and accurate decisions in consideration Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 The Members of this Task Force were selected by the ESC to represent of each patient’s health condition and in consultation with that patient or professionals involved with the medical care of patients with this Table 1 Classes of recommendations Definition Wording to use Classes of recommendations Class I Evidence and/or general agreement Is recommended or is indicated that a given treatment or procedure is beneficial, useful, effective. Class II Conflicting evidence and/or a divergence of opinion about the usefulness/ efficacy of the given treatment or procedure. Class IIa Weight of evidence/opinion is in Should be considered favour of usefulness/efficacy. Class IIb Usefulness/efficacy is less well May be considered established by evidence/opinion. Class III Evidence or general agreement that the Is not recommended given treatment or procedure is not © ESC 2023 ©ESC 2023 useful/effective, and in some cases may be harmful. Table 2 Levels of evidence Level of Data derived from multiple randomized clinical trials evidence A or meta-analyses. Level of Data derived from a single randomized clinical trial evidence B or large non-randomized studies. Level of Consensus of opinion of the experts and/or small studies, evidence C retrospective studies, registries. ©ESC 2023 © ESC 2023 ESC Guidelines 7 Patient with infective endocarditis Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 Blood culture Endocarditis Team Imaging Empiric antibiotic therapy i.v. Adjust antibiotic according to results of blood cultures Complications Yes No Continue appropriate antibiotic therapy Endocarditis Team Emergency Complications Cardiac surgery Urgent Yes Non-urgent No Continue appropriate Continue appropriate antibiotic therapy antibiotic therapy Antibiotic therapy i.v. in hospital or OPAT Patient-centred care Recovery plan Patient education - oral and general hygiene Figure 1 Management of patients with infective endocarditis. i.v., intravenous; OPAT, outpatient parenteral antibiotic therapy. 8 ESC Guidelines pathology. The selection procedure aimed to include members from of concern. The rate of resistance to azythromycin and clarithromycin is across the whole of the ESC region and from relevant ESC Subspecialty higher than that to penicillin.12 Whether changes in national guidelines on Communities. Consideration was given to diversity and inclusion, notably the use of antibiotic prophylaxis have resulted in an increase in the incidence with respect to gender and country of origin. The Task Force performed a of IE remains unclear.13–18 It is likely that the increased use of diagnostic critical evaluation of diagnostic and therapeutic approaches, including as- tools to diagnose IE is an important contributor to the increase in the inci- sessment of the risk-benefit ratio. The strength of every recommendation dence of IE. The use of echocardiography has probably increased in patients and the level of evidence supporting them were weighed and scored ac- with positive blood cultures for Enteroccus faecalis, Staphylococcus aureus, or cording to predefined scales as outlined below. The Task Force followed streptococci due to the associated increased risk of IE.19 In addition, com- Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 ESC voting procedures, and all approved recommendations were subject puted tomography (CT) and nuclear imaging techniques have increased the to a vote and achieved at least 75% agreement among voting members. number of definite IE cases particularly among patients with prosthetic The experts of the writing and reviewing panels provided declaration of valves and implantable cardiac devices.20–22 interest forms for all relationships that might be perceived as real or po- Data on the contemporary characterization of patients with IE have tential sources of conflicts of interest. Their declarations of interest were been taken into consideration to update the recommendations on the reviewed according to the ESC declaration of interest rules and can be diagnosis and management of patients with IE.5,19,23–41 Furthermore, found on the ESC website (http://www.escardio.org/Guidelines) and the recommendations on antibiotic therapy have been updated based have been compiled in a report published in a supplementary document on the susceptibility of various microorganisms defined by the with the guidelines. The Task Force received its entire financial support European Committee on Antimicrobial Susceptibility Testing from the ESC without any involvement from the healthcare industry. (EUCAST) clinical breakpoints.42 Recommendations on outpatient par- The ESC Clinical Practice Guidelines (CPG) Committee supervises and enteral antibiotic therapy (OPAT) or oral antibiotic treatment have co-ordinates the preparation of new guidelines and is responsible for the been included based on the results of the Partial Oral Treatment of approval process. ESC Guidelines undergo extensive review by the CPG Endocarditis (POET) randomized trial and other trials.43–46 Committee and external experts, including members from across the The main objective of the current Task Force was to provide clear whole of the ESC region and from relevant ESC Subspecialty and simple recommendations, assisting healthcare providers in their Communities and National Cardiac Societies. After appropriate revisions, clinical decision-making. These recommendations were obtained by ex- the guidelines are signed off by all the experts involved in the Task Force. pert consensus after thorough review of the available literature (see The finalized document is signed off by the CPG Committee for publica- Supplementary data, evidence tables online). An evidence-based scor- tion in the European Heart Journal. The guidelines were developed after ing system was used, based on a classification of the strength of recom- careful consideration of the scientific and medical knowledge and the evi- mendations and the levels of evidence. dence available at the time of their writing. Tables of evidence summariz- ing the findings of studies informing development of the guidelines are 2.1. What is new included. The ESC warns readers that the technical language may be mis- interpreted and declines any responsibility in this respect. Table 3 New recommendations Off-label use of medication may be presented in this guideline if a suf- ficient level of evidence shows that it can be considered medically ap- Recommendation Class Level propriate for a given condition. However, the final decisions Section 3. Recommendation Table 1 — Recommendations for concerning an individual patient must be made by the responsible health professional giving special consideration to: antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk of infective The specific situation of the patient. Unless otherwise provided for endocarditis by national regulations, off-label use of medication should be limited General prevention measures are recommended in to situations where it is in the patient’s interest with regard to the I C individuals at high and intermediate risk of IE. quality, safety, and efficacy of care, and only after the patient has been informed and has provided consent. Antibiotic prophylaxis is recommended in patients with I C Country-specific health regulations, indications by governmental ventricular assist devices. drug regulatory agencies, and the ethical rules to which health profes- Antibiotic prophylaxis may be considered in recipients IIb C sionals are subject, where applicable. of heart transplant. Section 3. Recommendation Table 2 — Recommendations for infective endocarditis prevention in high-risk patients 2. Introduction Systemic antibiotic prophylaxis may be considered for Infective endocarditis (IE) is a major public health challenge.1 In 2019, the high-risk patients undergoing an invasive diagnostic or estimated incidence of IE was 13.8 cases per 100 000 subjects per year, therapeutic procedure of the respiratory, IIb C and IE accounted for 66 300 deaths worldwide.2 Due to the associated gastrointestinal, genitourinary tract, skin, or high morbidity and mortality (1723.59 disability-adjusted life years and musculoskeletal systems. 0.87 death cases per 100 000 population, respectively), identification of Section 3. Recommendation Table 3 — Recommendations for the best preventive strategies has been the focus of research.2,3 Since the infective endocarditis prevention in cardiac procedures publication of the 2015 ESC Guidelines for the management of infective endo- carditis,4 important new data have been published mandating an update of Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED I B recommendations. First, the population at risk of IE has increased and new data on IE in different clinical scenarios have arisen.5–11 Furthermore, the infections. emerging and increasing antibiotic resistance among oral streptococci is Continued ESC Guidelines 9 Surgical standard aseptic measures are recommended Section 9. Recommendation Table 13 — Recommendations for during the insertion and manipulation of catheters in I C the treatment of neurological complications of infective the catheterization laboratory environment. endocarditis Antibiotic prophylaxis covering for common skin flora In embolic stroke, mechanical thrombectomy may be IIb C including Enterococcus spp. and S. aureus should be considered if the expertise is available in a timely manner. IIa C considered before TAVI and other transcatheter Thrombolytic therapy is not recommended in embolic valvular procedures. III C stroke due to IE. Section 5. Recommendation Table 5 — Recommendations for Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 Section 9. Recommendation Table 14 — Recommendations for the role of echocardiography in infective endocarditis pacemaker implantation in patients with complete TOE is recommended when the patient is stable before atrioventricular block and infective endocarditis I B switching from intravenous to oral antibiotic therapy. Immediate epicardial pacemaker implantation should be Section 5. Recommendation Table 6 — Recommendations for considered in patients undergoing surgery for valvular IE the role of computed tomography, nuclear imaging, and and complete AVB if one of the following predictors of IIa C magnetic resonance in infective endocarditis persistent AVB is present: pre-operative conduction Cardiac CTA is recommended in patients with possible abnormality, S. aureus infection, aortic root abscess, NVE to detect valvular lesions and confirm the I B tricuspid valve involvement, or previous valvular surgery. diagnosis of IE. Section 9. Recommendation Table 15 — Recommendations for [18F]FDG-PET/CT(A) and cardiac CTA are patients with musculoskeletal manifestations of infective recommended in possible PVE to detect valvular I B endocarditis lesions and confirm the diagnosis of IE. MRI or PET/CT is recommended in patients with [18F]FDG-PET/CT(A) may be considered in possible suspected spondylodiscitis and vertebral osteomyelitis I C IIa B CIED-related IE to confirm the diagnosis of IE. complicating IE. Cardiac CTA is recommended in NVE and PVE to TTE/TOE is recommended to rule out IE in patients diagnose paravalvular or periprosthetic complications if I B with spondylodiscitis and/or septic arthritis with I C echocardiography is inconclusive. positive blood cultures for typical IE microorganisms. Brain and whole-body imaging (CT, [18F]FDG-PET/ More than 6-week antibiotic therapy should be CT, and/or MRI) are recommended in symptomatic considered in patients with osteoarticular IE-related I B patients with NVE and PVE to detect peripheral lesions lesions caused by difficult-to-treat microorganisms, IIa C or add minor diagnostic criteria. such as S. aureus or Candida spp., and/or complicated WBC SPECT/CT should be considered in patients with with severe vertebral destruction or abscesses. high clinical suspicion of PVE when echocardiography is Section 10. Recommendation Table 16 — Recommendations for IIa C negative or inconclusive and when PET/CT is pre-operative coronary anatomy assessment in patients unavailable. requiring surgery for infective endocarditis Brain and whole-body imaging (CT, [18F]FDG-PET/ In haemodynamically stable patients with aortic valve CT, and MRI) in NVE and PVE may be considered for IIb B vegetations who require cardiac surgery and are high screening of peripheral lesions in asymptomatic I B risk of CAD, a high-resolution multislice coronary CTA patients. is recommended. Section 7. Recommendation Table 11 — Recommendations for Invasive coronary angiography is recommended in outpatient antibiotic treatment of infective endocarditis patients requiring heart surgery who are high risk of I C Outpatient parenteral antibiotic treatment should be CAD, in the absence of aortic valve vegetations. considered in patients with left-sided IE caused by In emergency situations, valvular surgery without Streptococcus spp., E. faecalis, S. aureus, or CoNS who pre-operative coronary anatomy assessment IIa C were receiving appropriate i.v. antibiotic treatment for regardless of CAD risk should be considered. IIa A at least 10 days (or at least 7 days after cardiac surgery), Invasive coronary angiography may be considered are clinically stable, and who do not show signs of despite the presence of aortic valve vegetations in IIb C abscess formation or valve abnormalities requiring selected patients with known CAD or at high risk of surgery on TOE. significant obstructive CAD. Outpatient parenteral antibiotic treatment is not Section 10. Recommendation Table 17 — Indications and timing recommended in patients with IE caused by highly of cardiac surgery after neurological complications in active difficult-to-treat microorganisms, liver cirrhosis (Child– infective endocarditis Pugh B or C), severe cerebral nervous system emboli, III C In patients with intracranial haemorrhage and unstable untreated large extracardiac abscesses, heart valve clinical status due to HF, uncontrolled infection, or complications, or other severe conditions requiring persistent high embolic risk, urgent or emergency IIa C surgery, severe post-surgical complications, and in surgery should be considered weighing the likelihood of PWID-related IE. a meaningful neurological outcome. Continued Continued 10 ESC Guidelines Section 11. Recommendation Table 18 — Recommendations for In non-S. aureus CIED-related endocarditis without post-discharge follow-up valve involvement or lead vegetations, and if follow-up blood cultures are negative without septic emboli, 2 IIb C Patient education on the risk of recurrence and weeks of antibiotic treatment may be considered preventive measures, with emphasis on dental health, I C following device extraction. and based on the individual risk profile, is recommended during follow-up. Removal of CIED after a single positive blood culture, with no other clinical evidence of infection, is not III C Addiction treatment for patients following I C recommended. Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 PWID-related IE is recommended. Cardiac rehabilitation including physical exercise Section 12. Recommendation Table 21 — Recommendations for training should be considered in clinically stable patients IIa C the surgical treatment of right-sided infective endocarditis based on an individual assessment. Tricuspid valve repair should be considered instead of IIa B Psychosocial support may be considered to be valve replacement, when possible. integrated in follow-up care, including screening for Surgery should be considered in patients with IIb C anxiety and depression, and referral to relevant right-sided IE who are receiving appropriate antibiotic IIa C psychological treatment. therapy and present persistent bacteraemia/sepsis after Section 12. Recommendation Table 19 — Recommendations for at least 1 week of appropriate antibiotic therapy. prosthetic valve endocarditis Prophylactic placement of an epicardial pacing lead should be considered at the time of tricuspid valve IIa C Surgery is recommended for early PVE (within 6 months of valve surgery) with new valve replacement I C surgical procedures. © ESC 2023 and complete debridement. Debulking of right intra-atrial septic masses by aspiration may be considered in select patients who are IIb C Section 12. Recommendation Table 20 — Recommendations for high risk of surgery. cardiovascular implanted electronic device-related infective endocarditis [18F]FDG-PET, 18F-fluorodeoxyglucose positron emission tomography; AVB, atrioventricular block; CAD, coronary artery disease; CIED, cardiovascular implanted Complete system extraction without delay is electronic device; CoNS, coagulase-negative staphylococci; CT, computed tomography; recommended in patients with definite CIED-related IE I B CTA, computed tomography angiography; HF, heart failure; IE, infective endocarditis; i.v., under initial empirical antibiotic therapy. intravenous; MRI, magnetic resonance imaging; NVE, native valve endocarditis; PET, positron emission tomography; PVE, prosthetic valve endocarditis; PWID, people who Extension of antibiotic treatment of CIED-related inject drugs; TAVI, transcatheter aortic valve implantation; TOE, transoesophageal endocarditis to (4–)6 weeks following device echocardiography; TTE, transthoracic echocardiography; WBC SPECT/CT, white blood IIa C cell single photon emission tomography/computed tomography. extraction should be considered in the presence of septic emboli or prosthetic valves. Use of an antibiotic envelope may be considered in select high-risk patients undergoing CIED IIb B reimplantation to reduce risk of infection. Continued Table 4 Revised recommendations Recommendations in 2015 version Class Level Recommendations in 2023 version Class Level Section 3. Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk of infective endocarditis Antibiotic prophylaxis should be considered for patients Antibiotic prophylaxis is recommended in patients with I B at highest risk of IE: previous IE. (1) Patients with any prosthetic valve, including a Antibiotic prophylaxis is recommended in patients with transcatheter valve, or those in whom any surgically implanted prosthetic valves and with any I C prosthetic material was used for cardiac valve repair. material used for surgical cardiac valve repair. IIa C (2) Patients with a previous episode of IE. Antibiotic prophylaxis is recommended in patients with (3) Patients with CHD: transcatheter implanted aortic and pulmonary valvular I C (a) Any type of cyanotic CHD. prostheses. (b) Any type of CHD repaired with a prosthetic Antibiotic prophylaxis should be considered in patients IIa C material, whether placed surgically or by with transcatheter mitral and tricuspid valve repair. Continued ESC Guidelines 11 percutaneous techniques, up to 6 months after Antibiotic prophylaxis is recommended in patients with the procedure or lifelong if residual shunt. untreated cyanotic CHD, and patients treated with surgery or transcatheter procedures with post-operative palliative shunts, conduits, or other prostheses. After I C surgical repair, in the absence of residual defects or valve prostheses, antibiotic prophylaxis is recommended only for the first 6 months after the procedure. Section 4. Recommendation Table 4 — Recommendations for the Endocarditis Team Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 Patients with complicated IE should be evaluated and Diagnosis and management of patients with complicated managed at an early stage in a reference centre, with IE are recommended to be performed at an early stage in immediate surgical facilities and the presence of a a Heart Valve Centre, with immediate surgical facilities multidisciplinary ‘Endocarditis Team’, including an IIa B and an ‘Endocarditis Team’ to improve the outcomes. I B infectious disease specialist, a microbiologist, a cardiologist, imaging specialists, a cardiac surgeon and, if needed, a specialist in CHD. For patients with uncomplicated IE managed in a For patients with uncomplicated IE managed in a Referring non-reference centre, early and regular communication Centre, early and regular communication between the IIa B I B with the reference centre and, when needed, visits to the local and the Heart Valve Centre Endocarditis Teams is reference centre should be made. recommended to improve the outcomes of the patients. Section 5. Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis TOE should be considered in patients with suspected IE, TOE is recommended in patients with suspected IE, even even in cases with positive TTE, except in isolated in cases with positive TTE, except in isolated right-sided IIa C I C right-sided native valve IE with good quality TTE native valve IE with good quality TTE examination and examination and unequivocal echocardiographic finding. unequivocal echocardiographic findings. Section 8. Recommendation Table 12 — Recommendations for the main indications of surgery in infective endocarditis (native valve endocarditis and prosthetic valve endocarditis) Aortic or mitral NVE with vegetations >10 mm, Urgent surgery is recommended in IE with vegetation associated with severe valve stenosis or regurgitation, and IIa B ≥10 mm and other indications for surgery. I C low operative risk (urgent surgery should be considered). Aortic or mitral NVE or PVE with isolated large Urgent surgery may be considered in aortic or mitral IE vegetations (>15 mm) and no other indication for surgery with vegetation ≥10 mm and without severe valve IIb C IIb B (urgent surgery may be considered). dysfunction or without clinical evidence of embolism and low surgical risk. Section 9. Recommendation Table 13 — Recommendations for the treatment of neurological complications of infective endocarditis Intracranial infectious aneurysms should be looked for in Brain CT or MRA is recommended in patients with IE and I B patients with IE and neurological symptoms. CT or MRA suspected infective cerebral aneurysms. should be considered for diagnosis. If non-invasive If non-invasive techniques are negative and the suspicion IIa B techniques are negative and the suspicion of intracranial of infective aneurysm remains, invasive angiography IIa B aneurysm remains, conventional angiography should be should be considered. considered. Section 12. Recommendation Table 20 — Recommendations for cardiovascular implanted electronic device-related infective endocarditis Routine antibiotic prophylaxis is recommended before Antibiotic prophylaxis covering S. aureus is recommended I B I A device implantation. for CIED implantation. TOE is recommended in patients with suspected cardiac TTE and TOE are both recommended in case of device-related infective endocarditis with positive or suspected CIED-related IE to identify vegetations. negative blood cultures, independent of the results of I C I B TTE, to evaluate lead-related endocarditis and heart valve infection. In patients with NVE or PVE and an intracardiac device Complete CIED extraction should be considered in case with no evidence of associated device infection, complete of valvular IE, even without definite lead involvement, IIb C IIa C hardware extraction may be considered. taking into account the identified pathogen and requirement for valve surgery. Continued 12 ESC Guidelines Complete hardware removal should be considered on the In cases of possible CIED-related IE or occult basis of occult infection without another apparent source Gram-positive bacteraemia or fungaemia, complete of infection. system removal should be considered in case IIa C bacteraemia/fungaemia persists after a course of IIa C antimicrobial therapy. In cases of possible CIED-related IE with occult Gram-negative bacteraemia, complete system removal IIb C may be considered in case of persistent/relapsing Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad193/7243107 by guest on 30 August 2023 bacteraemia after a course of antimicrobial therapy. When indicated, definite reimplantation should be If CIED reimplantation is indicated after extraction for postponed if possible, to allow a few days or weeks of CIED-related IE, it is recommended to be performed at a antibiotic therapy. site distant from the previous generator, as late as IIa C possible, once signs and symptoms of infection have I C abated and until blood cultures are negative for at least 72 h in the absence of vegetations, and negative for at least 2 weeks if vegetations were visualized. Section 12. Recommendation Table 21 — Recommendations for the surgical treatment of right-sided infective endocarditis Surgical treatment should be considered in the following scenarios: Surgery is recommended in patients with right-sided IE who are receiving appropriate antibiotic therapy for the following scenarios: Microorganisms difficult to eradicate (e.g. persistent Right ventricular dysfunction secondary to acute severe I B fungi) or bacteraemia for >7 days (e.g. S. aureus, P. tricuspid regurgitation non-responsive to diuretics. aeruginosa) despite adequate antimicrobial therapy; or Persistent vegetation with respiratory insufficiency Persistent tricuspid valve vegetations >20 mm after requiring ventilatory support after recurrent pulmonary I B recurrent pulmonary emboli with or without IIa C emboli. concomitant right HF; or Large residual tricuspid vegetations (>20 mm) after