p.65 抽出テキスト

early and 1-year mortality rates between males and females.853,855,857 The abovementioned population study from Scotland showed lower mortality rates for women during the study period.27 Although surgery has been demonstrated to be protective against mortality in several clinical scenarios (see Section 8), surgery is performed less frequently in female patients with IE.855,856 In a study using the National Inpatient Sample of 81 942 patients hospitalized for IE over an 11-year period, women were 43% less likely to undergo valve replacement surgery, a significant difference that remained after adjusting for confounding factors.855 The reason for decreased surgery in female IE patients is unknown and requires further investigation. Female sex has also been identified as an independent risk factor for mortality in prediction models for patients with IE undergoing surgery.416 However, a single-centre study suggested that worse observed surgical outcomes in female patients with IE was related to their increased risk factors and severity of presentation, rather than gender per se.854 In addition, a large multicentre registry of 4300 patients undergoing surgery for IE failed to identify female gender as an independent predictor of mortality.852

15 Key messages

Prevention: • Populations at high risk of IE include patients with previous IE, patients with surgical or transcatheter prosthetic valves or post-cardiac valve repair, and patients with untreated CHD and surgically corrected CHD. • Prevention of IE comprise hygienic measures (including oral hygiene) for all individuals and antibiotic prophylaxis for patients at high risk of IE undergoing oro-dental procedures.

The Endocarditis Team: • The diagnosis and management of patients with IE should be discussed with the Endocarditis Team, which includes healthcare professionals with the expertise to diagnose and treat IE and its complications. • Uncomplicated IE can be managed in a Referring Centre that remains in early and regular communication with the Endocarditis Team of the Heart Valve Centre. • Patients with complicated IE should be treated in the Heart Valve Centre, which must offer a wide range of ancillary specialty support including onsite cardiac surgery expertise.

Diagnosis: • The diagnosis of IE is based on major criteria, which include positive blood cultures and valvular and perivalvular/periprosthetic anatomic and metabolic lesions detected on imaging, and on minor criteria which have been updated to include frequent embolic vascular dissemination including asymptomatic lesions detected by imaging only. • Clear diagnostic algorithms have been established to diagnose NVE, PVE, and right-sided IE.

Antimicrobial therapy – principles and methods: • Successful treatment of IE relies on microbial eradication by antimicrobial drugs. Surgery contributes by removing infected material and draining abscesses. • Antibiotic treatment of PVE should last longer (≥6 weeks) than that of NVE (2–6 weeks). • In both NVE and PVE, the duration of treatment is based on the first day of effective antibiotic therapy (negative blood culture in the case of initial positive blood culture), not on the day of surgery. • The initial choice of empirical treatment depends on the use of previous antibiotic therapy, whether IE is NVE or PVE (and if so, when surgery was performed [early vs. late PVE]), the place where the infection took place (community, nosocomial, or non-nosocomial healthcare-associated IE), and knowledge of the local epidemiology. • The antibiotic treatment of IE has two phases. The first phase consists of 2 weeks of in-hospital i.v. treatment. In this initial phase, cardiac surgery should be performed if indicated, infected foreign bodies should be removed, and cardiac as well as extracardiac abscesses should be drained. In the second phase, in selected patients, the antibiotic treatment can be completed within an outpatient parenteral or oral antibiotic programme for up to 6 weeks. • Aminoglycosides are not recommended in staphylococcal NVE because their clinical benefits have not been demonstrated. In IE caused by other microorganisms in which aminoglycosides are indicated, they should be prescribed in a single daily dose to reduce nephrotoxicity. • Rifampin should be used only in IE involving foreign material, such as PVE, after 3–5 days of effective antibiotic therapy. • When daptomycin is indicated, it must be given at high doses (10 mg/ kg once daily) and combined with a second antibiotic (beta-lactams or fosfomycin in beta-lactam allergic patients) to increase activity and avoid the development of resistance. • OPAT can only start when a TOE shows absence of local progression and complications (e.g. severe valvular dysfunction). • In the OPAT programme, patients continue with the same antibiotics administered in the acute phase, if possible.

Indications for surgery and management of main infective endocarditis complications: • There are three main reasons to undergo surgery in the setting of acute IE: HF, uncontrolled infection, and prevention of septic embolization. • While surgery during the acute phase of IE is usually performed on an urgent basis (i.e. the patient undergoes surgery within 3–5 days), some cases require emergency surgery (i.e. within 24 h), irrespective of the pre-operative duration of antibiotic treatment.

Other complications of infective endocarditis: • Stroke may be the first presenting symptom in patients with IE. Unexplained fever accompanying a stroke in a patient with risk factors for IE should trigger the suspicion of IE. • Epicardial pacemaker implantation should be considered in patients undergoing surgery for IE with complete AVB and other risk factors. • MRI or PET/CT are indicated in patients with suspected spondylodiscitis and vertebral osteomyelitis complicating IE.

Surgical therapy principles and methods: • The indication to perform invasive coronary angiography or CTA prior to surgery for IE should be based on the presence of cardiovascular risk factors in patients with aortic valve IE. • Surgery should not be delayed in patients with non-haemorrhagic stroke and clear indications for surgery. In patients with significant Downloaded from academic.oup.com/eurheartj/article/44/39/3948/7243107 by guest on 07 October 2026