Infective Endocarditis Guidelines: The Challenges of Adherence—A Survey of Infectious Diseases Clinicians

Abstract

Background Guidelines exist to aid clinicians in managing patients with infective endocarditis (IE), but the degree of adherence with guidelines by infectious disease (ID) physicians is largely unknown. Methods An electronic survey assessing adherence with selected IE guidelines was emailed to 1409 adult ID physician members of the Infectious Diseases Society of America’s Emerging Infections Network. Results Five hundred fifty-seven physicians who managed IE responded. Twenty percent indicated that ID was NOT consulted on every case of IE at their hospitals, and 13% did not recommend transthoracic echocardiography (TTE) for all IE cases. The duration of antimicrobial therapy was timed from the first day of negative blood cultures by 91% of respondents. Thirty-four percent of clinicians did not utilize an aminoglycoside for staphylococcal prosthetic valve IE (PVE). Double β-lactam therapy was “usually” or “almost always” employed by 83% of respondents for enterococcal IE. For patients with active IE who underwent valve replacement and manifested positive surgical cultures, 6 weeks of postoperative antibiotics was recommended by 86% of clinicians. Conclusions The finding that adherence was &90% with core guideline recommendations that all patients with suspected IE be seen by ID and that all patients undergo TTE is noteworthy. Aminoglycoside therapy of IE appears to be declining with double β-lactam regimens emerging as the preferred treatment for enterococcal IE. The duration of postoperative antimicrobial therapy for patients undergoing valve replacement during acute IE is poorly defined and represents an area for which additional evidence is needed.

Adherence to 2015 ESC Guidelines for the Treatment of Infective Endocarditis: A Retrospective Multicentre Study (LEIOT Study)

“…In effect, Lebeaux and colleagues hypothesized that these may not be necessary in staphylococcal PVE [ 27 ], and aminoglycoside-sparing regimens were also described for streptococcal IE [ 5 ] treatment. Consistent with the literature [ 11 , 21 , 22 ], our experience found that the main reason for the lack of rifampin or aminoglycoside rested on the risk of adverse events. On the other hand, daptomycin was the primary cause of in excess deviations.…”

“…Before the 2015 ESC guidelines were issued, a comparable international survey was conducted by Beraud and colleagues on more than 800 physicians: heterogeneity in the management of IE was very high, especially regarding antimicrobial treatment [ 21 ]. More recently, another survey with reference to both European and American guidelines showed similar results [ 22 ]. This study evaluated how the results of these surveys reflected physicians’ behaviour in a real-life clinical setting.…”

“…For blood-culture-negative IE, local epidemiology and a patient’s risk factors should be substantially taken into consideration. Moreover, the level of evidence that supports guidelines was only elevated for a small percentage of recommendations [ 22 , 23 ]. Another item of interest to understand the scarce adherence to IE guidelines was well analysed in a recent Japanese study.…”

“…The last European guidelines suggested the addition of gentamicin and rifampin to the treatment backbone (cloxacillin for MSSA and vancomycin or daptomycin for MRSA) for staphylococcal PVE cases to increase the bactericidal activity and to reach the dormant bacteria in the biofilm [ 1 ]. While rifampin administration is quite heterogeneous—91% of interviewed physicians described using rifampin for PVE in a recent survey from the Unites States [ 22 ]—the absence of rifampin is one of the most frequent deviations from guidelines in the abovementioned study published by Tissot-Dupont [ 11 ], and aminoglycosides seem to meet less favour. In effect, Lebeaux and colleagues hypothesized that these may not be necessary in staphylococcal PVE [ 27 ], and aminoglycoside-sparing regimens were also described for streptococcal IE [ 5 ] treatment.…”

Deconstructing the Dogma: Systematic Literature Review and Meta-analysis of Adjunctive Gentamicin and Rifampin in Staphylococcal Prosthetic Valve Endocarditis

“…We have found that the history of combination therapy recommendations in the AHA/IDSA and European Society of Cardiology guidelines are based on expert opinion, foreign-body infection animal models with culture-based outcomes, or clinical studies that do not evaluate clinically relevant outcomes (eg, mortality and toxicity) [ 2 , 3 , 6–8 ]. Nonetheless, these guideline recommendations have significant uptake, as a 2020 survey of 557 infectious diseases physicians found 66% used aminoglycosides and 93% used rifampin for staphylococcal PVE [ 30 ]. The AHA/IDSA guidelines, which were published prior to the 2 largest retrospective studies in this review, neither demonstrating benefit of combination therapy with gentamicin or rifampin, give combination therapy for staphylococcal PVE a class I (benefits much greater than risks) recommendation with a level of evidence of B (data derived from observational studies or a single randomized or nonrandomized trial).…”