ESC 2023 2023 ESC Guidelines for the management of endocarditis
European Society of Cardiology｜循環器 / 弁膜疾患 / 感染症｜95 ページ｜チャンク 976｜推奨 208 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.8 | I | C | General prevention measures are recommended in individuals at high and intermediate risk of IE. | Table 3 New recommendations |
| p.8 | I | C | Antibiotic prophylaxis is recommended in patients with ventricular assist devices. | Table 3 New recommendations |
| p.8 | IIb | C | Antibiotic prophylaxis may be considered in recipients of heart transplant. | Table 3 New recommendations |
| p.8 | IIb | C | Systemic antibiotic prophylaxis may be considered for high-risk patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems. | Table 3 New recommendations |
| p.8 | I | B | Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections. | Table 3 New recommendations |
| p.9 | I | C | Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment. | |
| p.9 | IIa | C | Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures. | |
| p.9 | I | B | TOE is recommended when the patient is stable before switching from intravenous to oral antibiotic therapy. | |
| p.9 | I | B | magnetic resonance in infective endocarditis Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE. | |
| p.9 | I | B | [18F]FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE. | |
| p.9 | IIb | B | [18F]FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE. | |
| p.9 | I | B | Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive. | |
| p.9 | I | B | Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and/or MRI) are recommended in symptomatic patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria. | |
| p.9 | IIa | C | WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable. | |
| p.9 | IIb | B | Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients. | |
| p.9 | IIa | A | Outpatient parenteral antibiotic treatment should be considered in patients with left-sided IE caused by Streptococcus spp., E. faecalis, S. aureus, or CoNS who were receiving appropriate i.v. antibiotic treatment for at least 10 days (or at least 7 days after cardiac surgery), are clinically stable, and who do not show signs of abscess formation or valve abnormalities requiring surgery on TOE. | |
| p.9 | III | C | Outpatient parenteral antibiotic treatment is not recommended in patients with IE caused by highly difficult-to-treat microorganisms, liver cirrhosis (Child– Pugh B or C), severe cerebral nervous system emboli, untreated large extracardiac abscesses, heart valve complications, or other severe conditions requiring surgery, severe post-surgical complications, and in PWID-related IE. | |
| p.9 | IIb | C | In embolic stroke, mechanical thrombectomy may be considered if the expertise is available in a timely manner. | |
| p.9 | III | C | Thrombolytic therapy is not recommended in embolic stroke due to IE. | |
| p.9 | IIa | C | atrioventricular block and infective endocarditis Immediate epicardial pacemaker implantation should be considered in patients undergoing surgery for valvular IE and complete AVB if one of the following predictors of persistent AVB is present: pre-operative conduction abnormality, S. aureus infection, aortic root abscess, tricuspid valve involvement, or previous valvular surgery. | |
| p.9 | I | C | endocarditis MRI or PET/CT is recommended in patients with suspected spondylodiscitis and vertebral osteomyelitis complicating IE. | |
| p.9 | I | C | TTE/TOE is recommended to rule out IE in patients with spondylodiscitis and/or septic arthritis with positive blood cultures for typical IE microorganisms. | |
| p.9 | IIa | C | More than 6-week antibiotic therapy should be considered in patients with osteoarticular IE-related lesions caused by difficult-to-treat microorganisms, such as S. aureus or Candida spp., and/or complicated with severe vertebral destruction or abscesses. | |
| p.9 | I | B | requiring surgery for infective endocarditis In haemodynamically stable patients with aortic valve vegetations who require cardiac surgery and are high risk of CAD, a high-resolution multislice coronary CTA is recommended. | |
| p.9 | I | C | Invasive coronary angiography is recommended in patients requiring heart surgery who are high risk of CAD, in the absence of aortic valve vegetations. | |
| p.9 | IIa | C | In emergency situations, valvular surgery without pre-operative coronary anatomy assessment regardless of CAD risk should be considered. | |
| p.9 | IIb | C | Invasive coronary angiography may be considered despite the presence of aortic valve vegetations in selected patients with known CAD or at high risk of significant obstructive CAD. | |
| p.9 | IIa | C | infective endocarditis In patients with intracranial haemorrhage and unstable clinical status due to HF, uncontrolled infection, or persistent high embolic risk, urgent or emergency surgery should be considered weighing the likelihood of a meaningful neurological outcome. Continued | |
| p.10 | IIa | C | with transcatheter mitral and tricuspid valve repair. | Table 4 Revised recommendations |
| p.10 | I | C | post-discharge follow-up Patient education on the risk of recurrence and preventive measures, with emphasis on dental health, and based on the individual risk profile, is recommended during follow-up. | |
| p.10 | I | C | Addiction treatment for patients following PWID-related IE is recommended. | |
| p.10 | IIa | C | Cardiac rehabilitation including physical exercise training should be considered in clinically stable patients based on an individual assessment. | |
| p.10 | IIb | C | Psychosocial support may be considered to be integrated in follow-up care, including screening for anxiety and depression, and referral to relevant psychological treatment. | |
| p.10 | I | C | prosthetic valve endocarditis Surgery is recommended for early PVE (within 6 months of valve surgery) with new valve replacement and complete debridement. | |
| p.10 | I | B | endocarditis Complete system extraction without delay is recommended in patients with definite CIED-related IE under initial empirical antibiotic therapy. | |
| p.10 | IIa | C | Extension of antibiotic treatment of CIED-related endocarditis to (4–)6 weeks following device extraction should be considered in the presence of septic emboli or prosthetic valves. | |
| p.10 | IIb | B | Use of an antibiotic envelope may be considered in select high-risk patients undergoing CIED reimplantation to reduce risk of infection. | |
| p.10 | IIa | C | Antibiotic prophylaxis should be considered for patients at highest risk of IE: (1) Patients with any prosthetic valve, including a transcatheter valve, or those in whom any prosthetic material was used for cardiac valve repair. (2) Patients with a previous episode of IE. (3) Patients with CHD: (a) Any type of cyanotic CHD. (b) Any type of CHD repaired with a prosthetic material, whether placed surgically or by percutaneous techniques, up to 6 months after the procedure or lifelong if residual shunt. | Table 4 Revised recommendations |
| p.10 | IIb | C | In non-S. aureus CIED-related endocarditis without valve involvement or lead vegetations, and if follow-up blood cultures are negative without septic emboli, 2 weeks of antibiotic treatment may be considered | |
| p.10 | III | C | following device extraction. Removal of CIED after a single positive blood culture, with no other clinical evidence of infection, is not recommended. | |
| p.10 | IIa | B | Tricuspid valve repair should be considered instead of valve replacement, when possible. | |
| p.10 | IIa | C | Surgery should be considered in patients with right-sided IE who are receiving appropriate antibiotic therapy and present persistent bacteraemia/sepsis after at least 1 week of appropriate antibiotic therapy. | |
| p.10 | IIa | C | Prophylactic placement of an epicardial pacing lead should be considered at the time of tricuspid valve surgical procedures. | |
| p.10 | IIb | C | Debulking of right intra-atrial septic masses by aspiration may be considered in select patients who are high risk of surgery. | |
| p.10 | I | B | Antibiotic prophylaxis is recommended in patients with previous IE. | Table 4 Revised recommendations |
| p.10 | I | C | Antibiotic prophylaxis is recommended in patients with surgically implanted prosthetic valves and with any material used for surgical cardiac valve repair. | Table 4 Revised recommendations |
| p.10 | I | C | Antibiotic prophylaxis is recommended in patients with transcatheter implanted aortic and pulmonary valvular prostheses. Antibiotic prophylaxis should be considered in patients | Table 4 Revised recommendations |
| p.11 | I | B | and an ‘Endocarditis Team’ to improve the outcomes. | |
| p.11 | I | C | ≥10 mm and other indications for surgery. | |
| p.11 | IIa | B | Patients with complicated IE should be evaluated and managed at an early stage in a reference centre, with immediate surgical facilities and the presence of a multidisciplinary ‘Endocarditis Team’, including an infectious disease specialist, a microbiologist, a cardiologist, imaging specialists, a cardiac surgeon and, if | |
| p.11 | IIa | B | needed, a specialist in CHD. For patients with uncomplicated IE managed in a non-reference centre, early and regular communication with the reference centre and, when needed, visits to the reference centre should be made. | |
| p.11 | IIa | C | TOE should be considered in patients with suspected IE, even in cases with positive TTE, except in isolated right-sided native valve IE with good quality TTE examination and unequivocal echocardiographic finding. | |
| p.11 | IIa | B | Aortic or mitral NVE with vegetations >10 mm, associated with severe valve stenosis or regurgitation, and low operative risk (urgent surgery should be considered). | |
| p.11 | IIb | C | Aortic or mitral NVE or PVE with isolated large vegetations (>15 mm) and no other indication for surgery (urgent surgery may be considered). | |
| p.11 | IIa | B | Intracranial infectious aneurysms should be looked for in patients with IE and neurological symptoms. CT or MRA should be considered for diagnosis. If non-invasive techniques are negative and the suspicion of intracranial aneurysm remains, conventional angiography should be considered. endocarditis | |
| p.11 | I | C | Routine antibiotic prophylaxis is recommended before device implantation. TOE is recommended in patients with suspected cardiac device-related infective endocarditis with positive or negative blood cultures, independent of the results of TTE, to evaluate lead-related endocarditis and heart valve infection. | |
| p.11 | IIb | C | In patients with NVE or PVE and an intracardiac device with no evidence of associated device infection, complete hardware extraction may be considered. | |
| p.11 | I | C | Antibiotic prophylaxis is recommended in patients with untreated cyanotic CHD, and patients treated with surgery or transcatheter procedures with post-operative palliative shunts, conduits, or other prostheses. After surgical repair, in the absence of residual defects or valve prostheses, antibiotic prophylaxis is recommended only for the first 6 months after the procedure. Diagnosis and management of patients with complicated | |
| p.11 | I | B | IE are recommended to be performed at an early stage in a Heart Valve Centre, with immediate surgical facilities For patients with uncomplicated IE managed in a Referring Centre, early and regular communication between the local and the Heart Valve Centre Endocarditis Teams is recommended to improve the outcomes of the patients. | |
| p.11 | I | C | TOE is recommended in patients with suspected IE, even in cases with positive TTE, except in isolated right-sided native valve IE with good quality TTE examination and unequivocal echocardiographic findings. | |
| p.11 | IIb | B | Urgent surgery is recommended in IE with vegetation Urgent surgery may be considered in aortic or mitral IE with vegetation ≥10 mm and without severe valve dysfunction or without clinical evidence of embolism and low surgical risk. | |
| p.11 | I | B | Brain CT or MRA is recommended in patients with IE and suspected infective cerebral aneurysms. | |
| p.11 | IIa | B | If non-invasive techniques are negative and the suspicion of infective aneurysm remains, invasive angiography should be considered. | |
| p.11 | I | A | I B Antibiotic prophylaxis covering S. aureus is recommended for CIED implantation. | |
| p.11 | I | B | TTE and TOE are both recommended in case of suspected CIED-related IE to identify vegetations. | |
| p.11 | IIa | C | Complete CIED extraction should be considered in case of valvular IE, even without definite lead involvement, taking into account the identified pathogen and requirement for valve surgery. | |
| p.12 | I | B | the presence of major bleeding. | |
| p.12 | IIa | C | Complete hardware removal should be considered on the basis of occult infection without another apparent source of infection. | |
| p.12 | IIa | C | When indicated, definite reimplantation should be postponed if possible, to allow a few days or weeks of antibiotic therapy. | |
| p.12 | IIa | C | • Microorganisms difficult to eradicate (e.g. persistent fungi) or bacteraemia for >7 days (e.g. S. aureus, P. aeruginosa) despite adequate antimicrobial therapy; or • Persistent tricuspid valve vegetations >20 mm after recurrent pulmonary emboli with or without concomitant right HF; or • Right HF secondary to severe tricuspid regurgitation with poor response to diuretic therapy. Interruption of antiplatelet therapy is recommended in | |
| p.12 | IIa | C | In cases of possible CIED-related IE or occult Gram-positive bacteraemia or fungaemia, complete system removal should be considered in case bacteraemia/fungaemia persists after a course of antimicrobial therapy. | |
| p.12 | IIb | C | In cases of possible CIED-related IE with occult Gram-negative bacteraemia, complete system removal may be considered in case of persistent/relapsing bacteraemia after a course of antimicrobial therapy. | |
| p.12 | I | C | If CIED reimplantation is indicated after extraction for CIED-related IE, it is recommended to be performed at a site distant from the previous generator, as late as possible, once signs and symptoms of infection have 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. | |
| p.12 | I | B | appropriate antibiotic therapy for the following scenarios: Right ventricular dysfunction secondary to acute severe tricuspid regurgitation non-responsive to diuretics. | |
| p.12 | I | B | Persistent vegetation with respiratory insufficiency requiring ventilatory support after recurrent pulmonary emboli. | |
| p.12 | I | C | Large residual tricuspid vegetations (>20 mm) after recurrent septic pulmonary emboli. | |
| p.12 | I | C | Patients with simultaneous involvement of left-heart structures. | |
| p.12 | I | C | Interruption of antiplatelet or anticoagulant therapy is recommended in the presence of major bleeding (including intracranial haemorrhage). | |
| p.14 | I | B | with previous IE.47,84,86 | Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis |
| p.14 | I | C | Antibiotic prophylaxis is recommended in patients with ventricular assist devices.102 | Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis |
| p.14 | IIb | C | recipients of heart transplant.105–107 | Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis |
| p.14 | III | C | patients at low risk for IE.11,51 | Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis |
| p.14 | I | C | General prevention measures are recommended in individuals at high and intermediate risk for IE. Antibiotic prophylaxis is recommended in patients | Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis |
| p.14 | I | C | Antibiotic prophylaxis is recommended in patients with surgically implanted prosthetic valves and with any material used for surgical cardiac valve repair.47,87–89 | Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis |
| p.14 | I | C | Antibiotic prophylaxis is recommended in patients with transcatheter implanted aortic and pulmonary valvular prostheses.91–94 Antibiotic prophylaxis is recommended in patients with untreated cyanotic CHD, and patients treated | Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis |
| p.14 | I | C | with surgery or transcatheter procedures with post-operative palliative shunts, conduits, or other prostheses. After surgical repair, in the absence of residual defects or valve prostheses, antibiotic prophylaxis is recommended only for the first 6 months after the procedure.8,47,97,101 | Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis |
| p.14 | IIa | C | Antibiotic prophylaxis should be considered in patients with transcatheter mitral and tricuspid valve repair.95 Antibiotic prophylaxis may be considered in Antibiotic prophylaxis is not recommended in other CHD, congenital heart disease; IE, infective endocarditis. aClass of recommendation. bLevel of evidence. | Recommendation Table 1 — Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis |
| p.16 | I | A | recommended before placement of a CIED.116–118 | Recommendation Table 3 — Recommendations for infective endocarditis prevention in cardiac procedures |
| p.16 | III | C | Systematic skin or nasal decolonization without screening for S. aureus is not recommended. | |
| p.16 | I | B | Antibiotic prophylaxis is recommended in dental extractions, oral surgery procedures, and procedures requiring manipulation of the gingival or periapical region of the teeth.11,49,51,108 | Recommendation Table 2 — Recommendations for infective endocarditis prevention in high-risk patients |
| p.16 | IIb | C | Systemic antibiotic prophylaxis may be considered for high-riskc patients undergoing an invasive diagnostic or therapeutic procedure of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems.6,11 | Recommendation Table 2 — Recommendations for infective endocarditis prevention in high-risk patients |
| p.16 | I | A | Pre-operative screening for nasal carriage of S. aureus is recommended before elective cardiac surgery or transcatheter valve implantation to treat carriers.113,114 Peri-operative antibiotic prophylaxis is | Recommendation Table 3 — Recommendations for infective endocarditis prevention in cardiac procedures |
| p.16 | I | B | Optimal pre-procedural aseptic measures of the site of implantation is recommended to prevent CIED infections.119 | Recommendation Table 3 — Recommendations for infective endocarditis prevention in cardiac procedures |
| p.16 | I | B | Periprocedural antibiotic prophylaxis is recommended in patients undergoing surgical or transcatheter implantation of a prosthetic valve, intravascular prosthetic, or other foreign material.120 | Recommendation Table 3 — Recommendations for infective endocarditis prevention in cardiac procedures |
| p.16 | I | C | Surgical standard aseptic measures are recommended during the insertion and manipulation of catheters in the catheterization laboratory environment. | Recommendation Table 3 — Recommendations for infective endocarditis prevention in cardiac procedures |
| p.16 | IIa | C | Elimination of potential sources of sepsis (including of dental origin) should be considered ≥2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, except in urgent procedures. | Recommendation Table 3 — Recommendations for infective endocarditis prevention in cardiac procedures |
| p.16 | IIa | C | Antibiotic prophylaxis covering for common skin flora including Enterococcus spp. and S. aureus should be considered before TAVI and other transcatheter valvular procedures.121 4 The Endocarditis Team | |
| p.18 | I | B | Diagnosis and management of patients with complicated IE are recommended to be performed at an early stage in a Heart Valve Centre, with immediate surgical facilities and an ‘Endocarditis Team’ to improve the outcomes.36–41,122,123,125,126 | Recommendation Table 4 — Recommendations for the Endocarditis Team |
| p.18 | I | B | For patients with uncomplicated IE managed in a Referring Centre, early and regular communication between the local and the Heart Valve Centre endocarditis teams is recommended to improve the outcomes of the patients.36–41,122,123,125,126 IE, infective endocarditis. aClass of recommendation. bLevel of evidence. 5 Diagnosis | Recommendation Table 4 — Recommendations for the Endocarditis Team |
| p.22 | I | B | modality in suspected IE.166,179 | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | I | C | Intra-operative echocardiography is recommended in all cases of IE requiring surgery.181 | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | I | B | A. Diagnosis TTE is recommended as the first-line imaging TOE is recommended in all patients with clinical suspicion of IE and a negative or non-diagnostic TTE.166,178,179 | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | I | B | TOE is recommended in patients with clinical suspicion of IE, when a prosthetic heart valve or an intracardiac device is present.166,178,179 | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | I | C | Repeating TTE and/or TOE within 5–7 days is recommended in cases of initially negative or inconclusive examination when clinical suspicion of IE remains high.178 | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | I | C | TOE is recommended in patients with suspected IE, even in cases with positive TTE, except in isolated right-sided native valve IE with good quality TTE examination and unequivocal echocardiographic | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | IIa | B | findings.165,166,179 Performing an echocardiography should be considered in S. aureus, E. faecalis, and some Streptococcus spp. bacteraemia.19,149,174 B. Follow-up under medical therapy | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | I | B | Repeating TTE and/or TOE is recommended as soon as a new complication of IE is suspected (new murmur, embolism, persisting fever and bacteraemia, HF, abscess, AVB).165,166,179 | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | I | B | TOE is recommended when patient is stable before switching from intravenous to oral antibiotic therapy.43,180 | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | IIa | B | During follow-up of uncomplicated IE, repeat TTE and/ or TOE should be considered to detect new silent complications. The timing of repeat TTE and/or TOE depends on the initial findings, type of microorganism, and initial response to therapy.165,166,179 C. Intra-operative echocardiography | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.22 | I | C | D. Following completion of therapy TTE and/or TOE are recommended at completion of antibiotic therapy for evaluation of cardiac and valve morphology and function in patients with IE who did not undergo heart valve surgery.182–184 | Recommendation Table 5 — Recommendations for the role of echocardiography in infective endocarditis |
| p.23 | I | B | Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE.33,168,169 | Recommendation Table 6 — Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis |
| p.23 | I | B | [18F]FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE.22,129,209,210,237–239 | Recommendation Table 6 — Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis |
| p.23 | I | B | Cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive.20,168,169,185,186 | Recommendation Table 6 — Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis |
| p.23 | I | B | Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and/or MRI) are recommended in symptomaticc patients with NVE and PVE to detect peripheral lesions or add minor diagnostic criteria.22,197– 200,210,213,240,241 | Recommendation Table 6 — Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis |
| p.23 | IIa | C | WBC SPECT/CT should be considered in patients with high clinical suspicion of PVE when echocardiography is negative or inconclusive and when PET/CT is unavailable.213–216 | Recommendation Table 6 — Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis |
| p.23 | IIb | B | [18F]FDG-PET/CT(A) may be considered in possible CIED-related IE to confirm the diagnosis of IE.22,129,209,210,237,238 | Recommendation Table 6 — Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis |
| p.23 | IIb | B | Brain and whole-body imaging (CT, [18F]FDG-PET/ CT, and MRI) in NVE and PVE may be considered for screening of peripheral lesions in asymptomatic patients.188,197–201 | Recommendation Table 6 — Recommendations for the role of computed tomography, nuclear imaging, and magnetic resonance in infective endocarditis |
| p.34 | IIb | C | 1800 mg/day i.v. in 3 doses OR 8–12 g/day i.v. in 4 doses 1800 mg/day i.v. in 3 doses OR 8–12 g/day i.v. in 4 doses | |
| p.34 | IIb | C | 12 g/day i.v. in 6 doses OR 1800 mg/day i.v. in 3 doses OR 8–12 g/day i.v. in 4 doses | |
| p.38 | IIb | C | following doses: | Recommendation Table 10 — Recommendations for antibiotic regimens for initial empirical treatment of infective endocarditis (before pathogen identification)a |
| p.38 | IIa | C | In patients with community-acquired NVE or late PVE (≥12 months post-surgery), ampicillin in combination with ceftriaxone or with (flu)cloxacillin and gentamicin should be considered using the following doses:255 Adult antibiotic dosage and route Ampicillin 12 g/day i.v. in 4–6 doses Ceftriaxone 4 g/day i.v. or i.m. in 2 doses (Flu)cloxacillin 12 g/day i.v. in 4–6 doses Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose Paediatric antibiotic dosage and route Ampicillin 200–300 mg/kg/day i.v. in 4–6 doses, up to maximum of 12 g/day Ceftriaxone 100 mg/kg i.v. or i.m. in 1 dose (Flu)cloxacillin 200–300 mg/kg/day i.v. in 4–6 equally divided doses Gentamicind 3 mg/kg/day i.v. or i.m. in 3 equally divided doses | Recommendation Table 10 — Recommendations for antibiotic regimens for initial empirical treatment of infective endocarditis (before pathogen identification)a |
| p.38 | IIb | C | In patients with early PVE (<12 months post-surgery) or nosocomial and non-nosocomial healthcare-associated IE, vancomycin or daptomycin combined with gentamicin and rifampin may be considered using the following doses:395 Adult antibiotic dosage and route Vancomycine 30 mg/kg/day i.v. in 2 doses Daptomycin 10 mg/kg/day i.v. in 1 dose Gentamicind 3 mg/kg/day i.v. or i.m. in 1 dose Rifampin 900–1200 mg i.v. or orally in 2 or 3 doses Paediatric antibiotic dosage and route Vancomycine 40 mg/kg/day i.v. in 2–3 equally divided doses Gentamicind 3 mg/kg/day i.v. or i.m. in 3 equally divided doses Rifampin 20 mg/kg/day i.v. or orally in 3 equally divided doses up to maximum of 900 mg/day Allergy to beta-lactams In patients with community-acquired NVE or late PVE (≥12 months post-surgery) who are allergic to | Recommendation Table 10 — Recommendations for antibiotic regimens for initial empirical treatment of infective endocarditis (before pathogen identification)a |
| p.40 | IIa | A | Outpatient parenteral or oral antibiotic treatment should be considered in patients with left-sided IE caused by Streptococcus spp., E. faecalis, S. aureus, or CoNS who were receiving appropriate i.v. antibiotic treatment for at least 10 days (or at least 7 days after cardiac surgery), are clinically stable, and who do not show signs of abscess formation or valve abnormalities requiring surgery on TOE.43,401 | Recommendation Table 11 — Recommendations for outpatient antibiotic treatment of infective endocarditis |
| p.40 | III | C | Outpatient parenteral antibiotic treatment is not recommended in patients with IE caused by highly difficult-to-treat microorganisms,c liver cirrhosis (Child-Pugh B or C), severe cerebral nervous system emboli, untreated large extracardiac abscesses, heart valve complications, or other severe conditions requiring surgery, severe post-surgical complications, and PWID-related IE. | Recommendation Table 11 — Recommendations for outpatient antibiotic treatment of infective endocarditis |
| p.44 | I | B | (i) Heart failure Emergencyd surgery is recommended in aortic or mitral NVE or PVE with severe acute regurgitation, obstruction, or fistula causing refractory pulmonary oedema or cardiogenic shock.420,423,424,429,476,477 | Recommendation Table 12 — Recommendations for the main indications of surgery in infective endocarditis (native valve endocarditis and prosthetic valve endocarditis)a |
| p.44 | I | B | Urgentd surgery is recommended in aortic or mitral NVE or PVE with severe acute regurgitation or obstruction causing symptoms of HF or echocardiographic signs of poor haemodynamic tolerance.5,420–422,429 | Recommendation Table 12 — Recommendations for the main indications of surgery in infective endocarditis (native valve endocarditis and prosthetic valve endocarditis)a |
| p.44 | I | B | (ii) Uncontrolled infection Urgentd surgery is recommended in locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation, prosthetic dehiscence, new AVB).5,420,421,429,445 | Recommendation Table 12 — Recommendations for the main indications of surgery in infective endocarditis (native valve endocarditis and prosthetic valve endocarditis)a |
| p.44 | I | C | Urgentd or non-urgent surgery is recommended in IE caused by fungi or multiresistant organisms according to the haemodynamic condition of the patient.420 | Recommendation Table 12 — Recommendations for the main indications of surgery in infective endocarditis (native valve endocarditis and prosthetic valve endocarditis)a |
| p.44 | IIa | B | Urgentd surgery should be considered in IE with persistently positive blood cultures >1 week or persistent sepsis despite appropriate antibiotic therapy and adequate control of metastatic foci.436,437 | Recommendation Table 12 — Recommendations for the main indications of surgery in infective endocarditis (native valve endocarditis and prosthetic valve endocarditis)a |
| p.44 | IIa | C | Urgentd surgery should be considered in PVE caused by S. aureus or non-HACEK Gram-negative bacteria5,385,449 (iii) Prevention of embolism | Recommendation Table 12 — Recommendations for the main indications of surgery in infective endocarditis (native valve endocarditis and prosthetic valve endocarditis)a |
| p.44 | I | C | Urgentd surgery is recommended in IE with vegetation ≥10 mm and other indications for surgery.5,460,465,466,471,478 | Recommendation Table 12 — Recommendations for the main indications of surgery in infective endocarditis (native valve endocarditis and prosthetic valve endocarditis)a |
| p.44 | IIb | B | Urgentd surgery may be considered in aortic or mitral IE with vegetation ≥10 mm and without severe valve dysfunction or without clinical evidence of embolism and low surgical risk.460,463,465,473,478 | Recommendation Table 12 — Recommendations for the main indications of surgery in infective endocarditis (native valve endocarditis and prosthetic valve endocarditis)a |
| p.45 | I | B | and suspected infective cerebral aneurysms.490 | Recommendation Table 13 — Recommendations for the treatment of neurological complications of infective endocarditis |
| p.45 | III | C | Thrombolytic therapy is not recommended in embolic stroke due to IE.481,491 | Recommendation Table 13 — Recommendations for the treatment of neurological complications of infective endocarditis |
| p.45 | I | C | Brain CT or MRA is recommended in patients with IE Neurosurgery or endovascular therapy is recommended for large aneurysms, those with continuous growth despite optimal antibiotic therapy, and ruptured intracranial infective cerebral | Recommendation Table 13 — Recommendations for the treatment of neurological complications of infective endocarditis |
| p.45 | IIa | B | aneurysms.485 If non-invasive techniques are negative and the suspicion of infective aneurysm remains, invasive angiography should be considered.488 | Recommendation Table 13 — Recommendations for the treatment of neurological complications of infective endocarditis |
| p.45 | IIb | C | In embolic stroke, mechanical thrombectomy may be considered if the expertise is available in a timely manner.484 | Recommendation Table 13 — Recommendations for the treatment of neurological complications of infective endocarditis |
| p.46 | IIa | C | Immediate epicardial pacemaker implantation should be considered in patients undergoing surgery for valvular IE and complete AVB if one of the following predictors of persistent AVB is present: pre-operative conduction abnormality, S. aureus infection, aortic root abscess, tricuspid valve involvement, or previous valvular surgery.515 AVB, atrioventricular block; IE, infective endocarditis. aClass of recommendation. bLevel of evidence. | Recommendation Table 14 — Recommendations for pacemaker implantation in patients with complete atrioventricular block and infective endocarditis |
| p.47 | I | C | MRI or PET/CT is recommended in patients with suspected spondylodiscitis and vertebral osteomyelitis complicating IE.30,32,206,524 | Recommendation Table 15 — Recommendations for patients with musculoskeletal manifestations of infective endocarditis |
| p.47 | I | C | TTE/TOE is recommended to rule out IE in patients with spondylodiscitis and/or septic arthritis with positive blood cultures for typical IE microorganisms.247,248,517–521,523 | Recommendation Table 15 — Recommendations for patients with musculoskeletal manifestations of infective endocarditis |
| p.47 | IIa | C | More than 6-week antibiotic therapy should be considered in patients with osteoarticular IE-related lesions caused by difficult-to-treat microorganisms, such as S. aureus or Candida spp., and/or complicated with severe vertebral destruction or abscesses.523,525,530 | Recommendation Table 15 — Recommendations for patients with musculoskeletal manifestations of infective endocarditis |
| p.48 | I | B | In haemodynamically stable patients with aortic valve vegetations who require cardiac surgery and are high risk for CAD, a high-resolution multislice coronary CTA is recommended.185,546 | Recommendation Table 16 — Recommendations for pre-operative coronary anatomy assessment in patients requiring surgery for infective endocarditis |
| p.48 | I | C | Invasive coronary angiography is recommended in patients requiring heart surgery who are high risk for CAD, in the absence of aortic valve vegetations. | Recommendation Table 16 — Recommendations for pre-operative coronary anatomy assessment in patients requiring surgery for infective endocarditis |
| p.48 | IIa | C | In emergency situations, valvular surgery without pre-operative coronary anatomy assessment regardless of CAD risk should be considered.543,545 | Recommendation Table 16 — Recommendations for pre-operative coronary anatomy assessment in patients requiring surgery for infective endocarditis |
| p.48 | IIb | C | Invasive coronary angiography may be considered despite the presence of aortic valve vegetations in selected patients with known CAD or at high risk of significant obstructive CAD.193,543,544 | Recommendation Table 16 — Recommendations for pre-operative coronary anatomy assessment in patients requiring surgery for infective endocarditis |
| p.50 | I | B | indicated, is recommended without delay.454,468 | Recommendation Table 17 — Indications and timing of cardiac surgery after neurological complications in active infective endocarditis |
| p.50 | I | B | After a transient ischaemic attack, cardiac surgery, if After a stroke, surgery is recommended without any delay in the presence of HF, uncontrolled infection, abscess, or persistent high embolic risk, as long as coma is absent and the presence of cerebral haemorrhage has been excluded by cranial CT or | Recommendation Table 17 — Indications and timing of cardiac surgery after neurological complications in active infective endocarditis |
| p.50 | IIa | C | MRI.451,468,473,567,568,570–578 Following intracranial haemorrhage, delaying cardiac surgery >1 month, if possible, with frequent re-assessment of the patient’s clinical condition and imaging should be considered.571 | Recommendation Table 17 — Indications and timing of cardiac surgery after neurological complications in active infective endocarditis |
| p.50 | IIa | C | In patients with intracranial haemorrhage and unstable clinical status due to HF, uncontrolled infection or persistent high embolic risk, urgent or emergency surgery should be considered weighing the likelihood of a meaningful neurological outcome.199,581–584 | Recommendation Table 17 — Indications and timing of cardiac surgery after neurological complications in active infective endocarditis |
| p.52 | I | C | PWID-related IE is recommended.606,607 | Recommendation Table 18 — Recommendations for post-discharge follow-up |
| p.52 | I | C | Patient education on the risk of recurrence and preventive measures, with emphasis on dental health, and based on the individual risk profile, is © ESC 2023 recommended during follow-up.608 Addiction treatment for patients following | Recommendation Table 18 — Recommendations for post-discharge follow-up |
| p.52 | IIa | C | Cardiac rehabilitation including physical exercise training should be considered in clinically stable patients based on an individual assessment.605,609 | Recommendation Table 18 — Recommendations for post-discharge follow-up |
| p.52 | IIb | C | Psychosocial support may be considered to be integrated in follow-up care, including screening for anxiety and depression, and referral to relevant psychological treatment.605,609 IE, infective endocarditis; PWID, persons who inject drugs. aClass of recommendation. bLevel of evidence. | Recommendation Table 18 — Recommendations for post-discharge follow-up |
| p.53 | I | C | Surgery is recommended for early PVE (within 6 months of valve surgery) with new valve replacement and complete debridement. 621,635 PVE, prosthetic valve endocarditis. aClass of recommendation. bLevel of evidence. | Recommendation Table 19 — Recommendations for prosthetic valve endocarditis |
| p.57 | I | A | Antibiotic prophylaxis covering S. aureus is recommended for CIED implantation.118 | Recommendation Table 20 — Recommendations for cardiovascular implanted electronic device-related infective endocarditis |
| p.57 | I | B | TTE and TOE are both recommended in case of suspected CIED-related IE to identify vegetations.692–694 | Recommendation Table 20 — Recommendations for cardiovascular implanted electronic device-related infective endocarditis |
| p.57 | I | B | Complete system extraction without delay is recommended in patients with definite CIED-related IE under initial empirical antibiotic therapy.698,699 | Recommendation Table 20 — Recommendations for cardiovascular implanted electronic device-related infective endocarditis |
| p.57 | I | C | Obtaining at least three sets of blood cultures is recommended before prompt initiation of empirical antibiotic therapy for CIED infection,710 covering methicillin-resistant staphylococci and Gram-negative bacteria. | Recommendation Table 20 — Recommendations for cardiovascular implanted electronic device-related infective endocarditis |
| p.57 | I | C | If CIED reimplantation is indicated after extraction for CIED-related IE, it is recommended to be performed at a site distant from the previous generator, as late as possible, once signs and symptoms of infection have 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.701,711 | Recommendation Table 20 — Recommendations for cardiovascular implanted electronic device-related infective endocarditis |
| p.58 | IIa | C | Complete CIED extraction should be considered in case of valvular IE, even without definite lead involvement, taking into account the identified pathogen and requirement for valve surgery. | |
| p.58 | IIa | C | In cases of possible CIED-related IE with occult Gram-positive bacteraemia or fungaemia, complete system removal should be considered in case bacteraemia/fungaemia persists after a course of antimicrobial therapy.673–676 | |
| p.58 | IIa | C | Extension of antibiotic treatment of CIED-related endocarditis to (4–6) weeks following device extraction should be considered in the presence of septic emboli or prosthetic valves.702 | |
| p.58 | IIb | B | Use of an antibiotic envelope may be considered in select high-risk patients undergoing CIED reimplantation to reduce risk of infection.688,689 | |
| p.58 | IIb | C | In cases of possible CIED-related IE with occult Gram-negative bacteraemia, complete system removal may be considered in case of persistent/ relapsing bacteraemia after a course of antimicrobial therapy.680,690,691 | |
| p.58 | IIb | C | In non-S. aureus CIED-related endocarditis without valve involvement or lead vegetations, and if follow-up blood cultures are negative without septic emboli, 2 weeks of antibiotic treatment may be considered following device extraction. | |
| p.58 | III | C | Removal of CIED after a single positive blood culture, with no other clinical evidence of infection, is not recommended.675 | |
| p.60 | I | C | after recurrent septic pulmonary emboli.145,471 | Recommendation Table 21 — Recommendations for the surgical treatment of right-sided infective endocarditis |
| p.60 | I | C | left-heart structures.749 | Recommendation Table 21 — Recommendations for the surgical treatment of right-sided infective endocarditis |
| p.60 | IIa | B | of valve replacement, when possible.479 | Recommendation Table 21 — Recommendations for the surgical treatment of right-sided infective endocarditis |
| p.60 | I | B | appropriate antibiotic therapy for the following scenarios: Right ventricular dysfunction secondary to acute severe tricuspid regurgitation non-responsive to diuretics.479 | Recommendation Table 21 — Recommendations for the surgical treatment of right-sided infective endocarditis |
| p.60 | I | B | Persistent vegetation with respiratory insufficiency requiring ventilatory support after recurrent pulmonary emboli.479,755 Large residual tricuspid vegetations (>20 mm) Patients with simultaneous involvement of | Recommendation Table 21 — Recommendations for the surgical treatment of right-sided infective endocarditis |
| p.60 | IIa | C | Tricuspid valve repair should be considered instead Surgery should be considered in patients with right-sided IE who are receiving appropriate antibiotic therapy and present persistent bacteraemia/sepsis after at least 1 week of | Recommendation Table 21 — Recommendations for the surgical treatment of right-sided infective endocarditis |
| p.60 | IIa | C | appropriate antibiotic therapy.436,755 Prophylactic placement of an epicardial pacing lead should be considered at the time of tricuspid valve surgical procedures.733 | Recommendation Table 21 — Recommendations for the surgical treatment of right-sided infective endocarditis |
| p.60 | IIb | C | Debulking of right intra-atrial septic masses by aspiration may be considered in selected patients who are high risk for surgery.753 IE: infective endocarditis. aClass of recommendation. bLevel of evidence. | Recommendation Table 21 — Recommendations for the surgical treatment of right-sided infective endocarditis |
| p.62 | III | C | patients with IE.481,491 | |
| p.62 | I | C | Interruption of antiplatelet or anticoagulant therapy is recommended in the presence of major bleeding (including intracranial haemorrhage).482,483 | Recommendation Table 22 — Recommendations for the use of antithrombotic therapy in infective endocarditis |
| p.62 | IIa | C | In patients with intracranial haemorrhage and a mechanical valve, reinitiating unfractionated heparin should be considered as soon as possible following multidisciplinary discussion.817 | Recommendation Table 22 — Recommendations for the use of antithrombotic therapy in infective endocarditis |
| p.62 | IIa | C | In the absence of stroke, replacement of oral anticoagulant therapy by unfractionated heparin under close monitoring should be considered in cases where indication for surgery is likely (e.g. S. aureus IE).451,817 Thrombolytic therapy is not recommended in IE, infective endocarditis. aClass of recommendation. bLevel of evidence. | |
| p.67 | I | B | Antibiotic prophylaxis is recommended in patients with previous IE. | |
| p.67 | I | C | General prevention measures are recommended in individuals at high and intermediate risk of IE. | |
| p.67 | I | C | Antibiotic prophylaxis is recommended in patients with transcatheter implanted aortic and pulmonary valvular prostheses. | |
| p.67 | I | C | Antibiotic prophylaxis is recommended in patients with ventricular assist devices. | |
| p.67 | III | C | Antibiotic prophylaxis is not recommended in other patients at low risk of IE. | |
| p.67 | I | A | Peri-operative antibiotic prophylaxis is recommended before placement of a CIED. | |
| p.67 | I | B | Optimal pre-procedural aseptic measures of the site of implantation are recommended to prevent CIED infections. | |
| p.68 | III | C | Systematic skin or nasal decolonization without screening for S. aureus is not recommended. | |
| p.68 | I | B | TTE is recommended as the first-line imaging modality in suspected IE. | |
| p.68 | I | B | TOE is recommended in all patients with clinical suspicion of IE and a negative or non-diagnostic TTE. | |
| p.68 | I | B | TOE is recommended in patients with clinical suspicion of IE, when a prosthetic heart valve or an intracardiac device is present. | |
| p.68 | I | B | TOE is recommended when the patient is stable before switching from intravenous to oral antibiotic therapy. | |
| p.68 | I | C | Intra-operative echocardiography is recommended in all cases of IE requiring surgery. | |
| p.68 | I | B | Cardiac CTA is recommended in patients with possible NVE to detect valvular lesions and confirm the diagnosis of IE. | |
| p.68 | I | B | [18F]FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE. | |
| p.72 | I | C | Urgent surgery is recommended in IE with vegetation ≥10 mm and other indications for surgery. | |
| p.72 | I | B | Brain CT or MRA is recommended in patients with IE and suspected infective cerebral aneurysms. | |
| p.72 | III | C | Thrombolytic therapy is not recommended in embolic stroke due to IE. | |
| p.72 | I | C | MRI or PET/CT is recommended in patients with suspected spondylodiscitis and vertebral osteomyelitis complicating IE. | |
| p.72 | I | B | After a transient ischaemic attack, cardiac surgery, if indicated, is recommended without delay. | |
| p.72 | I | C | Addiction treatment for patients following PWID-related IE is recommended. | |
| p.72 | I | C | Surgery is recommended for early PVE (within 6 months of valve surgery) with new valve replacement and complete debridement. | |
| p.72 | I | A | Antibiotic prophylaxis covering S. aureus is recommended for CIED implantation. | |
| p.72 | I | B | TTE and TOE are both recommended in cases of suspected CIED-related IE to identify vegetations. | |
| p.73 | III | C | Removal of CIED after a single positive blood culture, with no other clinical evidence of infection, is not recommended. | |
| p.73 | I | B | Right ventricular dysfunction secondary to acute severe tricuspid regurgitation non-responsive to diuretics. | |
| p.73 | I | B | Persistent vegetation with respiratory insufficiency requiring ventilatory support after recurrent pulmonary emboli. | |
| p.73 | I | C | Large residual tricuspid vegetations (>20 mm) after recurrent septic pulmonary emboli. | |
| p.73 | I | C | Patients with simultaneous involvement of left-heart structures. | |
| p.73 | III | C | Thrombolytic therapy is not recommended in patients with IE. |