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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e160

CLINICAL STATEMENTS AND GUIDELINES infected focus (such as intravascular catheter removal). In the absence of 1) prolonged bacteremia lasting >4 days, 2) a permanent intracardiac device, 3) hemodialysis dependency, or 4) spinal infection or nonvertebral osteomyelitis, the risk of IE is relatively low, and routine TEE may not be necessary.22,53,54,74

12.3 Medical Therapy

Recommendations for Medical Therapy for IE Referenced studies that support the recommendations are summarized in Online Data Supplement 42. COR LOE Recommendations

1 B-NR 1.  In patients with IE, appropriate antibiotic therapy should be initiated and continued after blood cultures are obtained, with guidance from antibiotic sensitivity data and the infectious disease experts on the MDT.1–7

1 B-R 2.  Patients with suspected or confirmed IE associated with drug use should be referred to addiction treatment for opioid substitution therapy.8–10

2a B-NR 3.  In patients with IE and with evidence of cerebral embolism or stroke, regardless of the other indications for anticoagulation, it is reasonable to temporarily discontinue anticoagulation.11–24

2b B-R 4.  In patients with left-sided IE caused by streptococcus, Enterococcus faecalis, S. aureus, or coagulase-negative staphylococci deemed stable by the MDT after initial intravenous antibiotics, a change to oral antibiotic therapy may be considered if TEE before the switch to oral therapy shows no paravalvular infection, if frequent and appropriate follow-up can be assured by the care team, and if a follow-up TEE can be performed 1 to 3 days before the completion of the antibiotic course.25

2b B-NR 5.  In patients receiving VKA anticoagulation at the time of IE diagnosis, temporary discontinuation of VKA anticoagulation may be considered.13,26–34

3: Harm C-LD 6.  Patients with known VHD should not receive antibiotics before blood cultures are obtained for unexplained fever.22,35,36

Synopsis

Details of specific antimicrobial regimens have been published previously by the AHA, European Society of Cardiology, and British Society for Antimicrobial Chemotherapy and are not repeated in this guideline. In patients on anticoagulant therapy for AF or a mechanical heart valve, continued anticoagulation is associated with a higher risk of intracranial bleeding, particularly after an embolic event. In patients with suspected intravenous drug use, effective long-term therapy includes referral to an addiction treatment program. In a select subset of patients with a stable clinical course, it may be possible to convert from intravenous to oral antibiotics if TEE confirms the absence of paravalvular extension of the infection. In addition to antibiotic therapy, early surgical intervention often (approximately 50% of the time) is needed to manage infection and the sequelae of valve leaflet and paravalvular tissue destruction (Figure 15).1,2,37–42

Recommendation-Specific Supportive Text

1.	 Optimal treatment of IE is based on the appropriately timed initiation of antimicrobial therapy that is effective against the specific infective organism involved. Empirical therapy may be necessary in patients with septic shock or patients who show high-risk signs on presentation. Although no RCTs have been performed with regard to the use of antibiotic therapy in IE, the mortality rate before the antibiotic age neared 100%. Specific antimicrobial regimens, depending on the causative microorganism, have been published by the British Society for Antimicrobial Chemotherapy and the AHA. Because there are continuous changes in antimicrobial sensitivity over time, as well as regional and site-specific differences in antimicrobial susceptibility profiles, concomitant management with the assistance of a consultant thoroughly familiar with these patterns is imperative.1–7 2.	 Drug use–associated endocarditis is associated with a significantly higher complexity of care, with increased rates of readmission, reinfection, and recurrent need for repeat interventions, and its incidence has risen 12-fold over the past decade. Addiction specialists are an important part of the Heart Valve Team for this patient population. Addiction studies have shown that treatment outcomes for behavioral interventions alone for opioid use disorders are dismal, with >80% of patients returning to drug use. Some data show that patients who used pharmacotherapy, such as agonist therapy (opioid substitution therapy), in addition to behavioral treatments had a 50% reduction in relapse compared with those who used behavioral therapies alone.8–10 3.	 Stroke in patients with IE can have several mechanisms, including hemorrhagic transformation of an ischemic infarct, septic erosion of an atherosclerotic vessel without aneurysm formation, and rupture of a mycotic aneurysm. Up to 35% of all patients with IE develop clinically evident systemic emboli. If more sensitive tests, such as magnetic resonance imaging, are used, a much higher proportion of patients with IE have evidence of emboli. In these patients, the most common cause of stroke is septic embolus

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