Prophylaxis and treatment of infective endocarditis in adults: a concise guide

Abstract

-Infective endocarditis (IE) is a lifethreatening disease with substantial morbidity and mortality which affects individuals with underlying structural cardiac defects who develop bacteraemia, often as a result of dental, gastrointestinal, genitourinary, respiratory or cardiac invasive/surgical procedures. Prompt recognition of the clinical diagnosis by a wide variety of medical personnel, early involvement of specialist cardiologists, cardiac surgeon and a microbiologist, and prompt treatment with the most appropriate antimicrobial agents offer the greatest chance of improving the outcome for these patients. The guidance given here to clinicians involved in the management of patients with IE briefly covers diagnosis, antibiotic prophylaxis, medical treatment and the indications for surgery.

Bacteraemia due to dental flossing

“…Infection of prosthetic heart valves or the endocardium can also cause thrombus formation. Fragments of this thrombus can dislodge and these emboli can lodge in other areas such as the brain, lung, coronary arteries, gastro-intestinal tract, retina, spleen and the extremities of the limbs where they may cause further complications (Ramsdale et al 2004). …”

“…British Cardiac Society guidelines note that evidence for significant bacteraemia after many gastrointestinal, genitourinary, respiratory or cardiac procedures has not been proven, although it notes that cases of infective endocarditis have been reported to follow these procedures (Ramsdale et al 2004). …”

An infective endocarditis audit illustrates why dental guidelines in general need to be kept clear, simple and unambiguous

“…4 Nevertheless, throughout the history of IE prophylaxis, professional organisa tions have sought to identify and stratify the groups of patients considered to be at risk, as well as list those procedures for which antibiotic cover should be supplied, [5][6][7][8][9][10] although none of them have ever reached complete consensus with each other. 11 For a long time the UK dental guide lines for IE had been based on the 1993 guidance issued by the British Soci ety of Antimicrobial Chemotherapy (BSAC), 5 which was published in the British National Formulary (BNF).…”

“…Nev ertheless, by May 2004 extensive new IE guidelines issued jointly by the British Cardiac Society and the Royal College of Physicians (BCS RCP) had emerged. 6 One of the main changes they intro duced was the abandonment of the pre sumption that all dental procedures that cause significant bleeding would need antibiotic cover in patients suscepti ble of developing IE. This was because research had shown that bleeding fol lowing dental treatment was a poor pre dictor of odontogenic bacteraemia.…”

Vascular access strategy for delivering long-term antimicrobials to patients with infective endocarditis: device type, risk of infection and mortality

“…In spite of appropriate antimicrobial therapy, IE has an inhospital mortality of approximately 20%. 1 A previous UK IE guideline has recommended administration of antimicrobials via a large central vein, 2 and Evidence-based Practice in Infection Control (EPIC2) guidelines for prevention of healthcare-associated infection recommend a tunnelled or totally implanted central venous catheter (CVC) for patients requiring long-term venous access. 3 Tunnelled and cuffed vascular access devices are intended for use where long durations of intravenous treatment are necessary (usually in excess of three months), 4 and the benefits of these devices may not be realized if used for shorter periods.…”