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European Heart Journal Advance Access originally published online on August 27, 2009
European Heart Journal 2009 30(19):2369-2413; doi:10.1093/eurheartj/ehp285
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© The European Society of Cardiology 2009. All rights reserved. For permissions please email: journals.permissions@oxfordjournals.org

Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009)

The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC)

Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and by the International Society of Chemotherapy (ISC) for Infection and Cancer

Authors/Task Force Members, Gilbert Habib, (Chairperson) (France)*, Bruno Hoen, (France), Pilar Tornos, (Spain), Franck Thuny, (France), Bernard Prendergast, (UK), Isidre Vilacosta, (Spain), Philippe Moreillon, (Switzerland), Manuel de Jesus Antunes, (Portugal), Ulf Thilen, (Sweden), John Lekakis, (Greece), Maria Lengyel, (Hungary), Ludwig Müller, (Austria), Christoph K. Naber, (Germany), Petros Nihoyannopoulos, (UK), Anton Moritz, (Germany) and Jose Luis Zamorano, (Spain)

ESC Committee for Practice Guidelines (CPG), Alec Vahanian, (Chairperson) (France), Angelo Auricchio, (Switzerland), Jeroen Bax, (The Netherlands), Claudio Ceconi, (Italy), Veronica Dean, (France), Gerasimos Filippatos, (Greece), Christian Funck-Brentano, (France), Richard Hobbs, (UK), Peter Kearney, (Ireland), Theresa McDonagh, (UK), Keith McGregor, (France), Bogdan A. Popescu, (Romania), Zeljko Reiner, (Croatia), Udo Sechtem, (Germany), Per Anton Sirnes, (Norway), Michal Tendera, (Poland), Panos Vardas, (Greece) and Petr Widimsky, (Czech Republic)

Document Reviewers, Alec Vahanian, (CPG Review Coordinator) (France), Rio Aguilar, (Spain), Maria Grazia Bongiorni, (Italy), Michael Borger, (Germany), Eric Butchart, (UK), Nicolas Danchin, (France), Francois Delahaye, (France), Raimund Erbel, (Germany), Damian Franzen, (Germany), Kate Gould, (UK), Roger Hall, (UK), Christian Hassager, (Denmark), Keld Kjeldsen, (Denmark), Richard McManus, (UK), José M. Miró, (Spain), Ales Mokracek, (Czech Republic), Raphael Rosenhek, (Austria), José A. San Román Calvar, (Spain), Petar Seferovic, (Serbia), Christine Selton-Suty, (France), Miguel Sousa Uva, (Portugal), Rita Trinchero, (Italy) and Guy van Camp, (Belgium)

* Corresponding author. Gilbert Habib, Service de Cardiologie, CHU La Timone, Bd Jean Moulin, 13005 Marseille, France. Tel: +33 4 91 38 63 79, Email: gilbert.habib@free.fr

The first 150 words of the full text of this article appear below.


   A. Preamble
 
Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome, as well as the risk/benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules).

. . . [Full Text of this Article]


   B. Justification/scope of the problem
 

   C. Epidemiology
 
A changing epidemiology
Incidence of infective endocarditis
Types of infective endocarditis
Microbiology
1. Infective endocarditis with positive blood cultures
a. Infective endocarditis due to streptococci and enterococci
b. Staphylococcal infective endocarditis
2. Infective endocarditis with negative blood cultures because of prior antibiotic treatment
3. Infective endocarditis frequently associated with negative blood cultures
4. Infective endocarditis associated with constantly negative blood cultures

   D. Pathophysiology
 
The valve endothelium
Transient bacteraemia
Microbial pathogens and host defences

   E. Preventive measures
 
Evidence justifying the use of antibiotic prophylaxis for infective endocarditis in previous ESC recommendations
Reasons justifying revision of previous ESC Guidelines
1. Incidence of bacteraemia after dental procedures and during daily routine activities
2. Risks and benefits of prophylaxis
3. Lack of scientific evidence for the efficacy of infective endocarditis prophylaxis
Principles of the new ESC Guidelines
1. Patients with the highest risk of infective endocarditis (Table 4)
2. Highest risk procedures (Table 5)
a. Dental procedures
b. Other at-risk procedures
Limitations and consequences of the new ESC Guidelines

   F. Diagnosis
 
Clinical features
Echocardiography
Microbiological diagnosis
1. Blood cultures
2. Culture-negative infective endocarditis and atypical organisms
3. Histological/immunological techniques
4. Molecular biology techniques
Diagnostic criteria and their limitations

   G. Prognostic assessment at admission
 

   H. Antimicrobial therapy: principles and methods
 
General principles
Penicillin-susceptible oral streptococci and group D streptococci
Penicillin-resistant oral streptococci and group D streptococci
Streptococcus pneumoniae, β-haemolytic streptococci (groups A, B, C, and G)
Nutritionally variant streptococci
Staphylococcus aureus and coagulase-negative staphylococci
Methicillin-resistant and vancomycin-resistant staphylococci
Enterococcus spp
Gram-negative bacteria
1. HACEK-related species
2. Non-HACEK species
Blood culture-negative infective endocarditis
Fungi
Empirical therapy
Outpatient parenteral antibiotic therapy for infective endocarditis

   I. Complications and indications for surgery in left-sided native valve infective endocarditis, Part 1. Indications and optimal timing of surgery
 
Heart failure
1. Heart failure in infective endocarditis
2. Indications and timing of surgery in the presence of heart failure in infective endocarditis (Table 19)
Uncontrolled infection
1. Persisting infection
2. Perivalvular extension in infective endocarditis
3. Indications and timing of surgery in the presence of uncontrolled infection in infective endocarditis (Table 19)
Persistent infection
Signs of locally uncontrolled infection
Infection by microorganisms infrequently cured by antimicrobial therapy
Prevention of systemic embolism
1. Embolic events in infective endocarditis
2. Predicting the risk of embolism
3. Indications and timing of surgery to prevent embolism in infective endocarditis (Table 19)

   Part 2. Principles, methods, and immediate results of surgery
 
Pre- and peri-operative management
1. Coronary angiography
2. Extracardiac infection
3. Intra-operative echocardiography
Surgical approach and techniques
Operative mortality, morbidity, and post-operative complications

   J. Other complications of infective endocarditis, Part 1. Neurological complications, antithrombotic therapy
 
Neurological complications
Antithrombotic therapy

   Part 2. Other complications (infectious aneurysms, acute renal failure, rheumatic complications, splenic abscess, myocarditis, pericarditis)
 
Infectious aneurysms
Acute renal failure
Rheumatic complications
Splenic abscess
Myocarditis, pericarditis

   K. Outcome after discharge and long-term prognosis
 
Recurrences: relapses and reinfections
Heart failure and need for valvular surgery
Long-term mortality
Follow-up

   L. Specific situations, Part 1. Prosthetic valve endocarditis
 
Definition and pathophysiology
Diagnosis
Prognosis and treatment

   Part 2. Infective endocarditis on pacemakers and implantable defibrillators
 
Definition and pathophysiology of cardiac device infections
Diagnosis
Treatment (Table 24)

   Part 3. Right-sided infective endocarditis
 
Epidemiology
Diagnosis and complications
Prognosis and treatment
1. Antimicrobial therapy
2. Surgery

   Part 4. Infective endocarditis in congenital heart disease
 

   Part 5. Infective endocarditis in the elderly
 

   Part 6. Infective endocarditis during pregnancy
 

   Abbreviations and acronyms
 

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