p.66 抽出テキスト
pre-operative haemorrhagic stroke, a delay in operative management (≥4 weeks) is generally recommended. • The decision of not offering surgery when indicated should be made in the setting of an Endocarditis Team. Outcome after discharge – follow-up and long-term prognosis: • Relapse is a repeat episode of IE caused by the same microorganism and represents a failure of treatment, and mandates a search for a persistent focus of infection and an evaluation towards surgical therapy. • Reinfection is an infection caused by a different microorganism, usually more than 6 months after the initial episode. • Once antibiotic treatment has been completed, blood cultures should be performed. • Patients discharged after the first episode of IE should remain under close surveillance for potential long-term complications. Management of specific situations: • Antibiotic prophylaxis to prevent CIED-related IE before dental and other non-cardiac interventions is not warranted. • A single positive blood culture with no other clinical evidence of infection should not result in removal of the CIED. Complete CIED removal is recommended for all patients with confirmed infection of the lead(s). • The indication for CIED reimplantation should always be reevaluated and no part of the removed system should be reimplanted. In pacemaker-dependent patients, an active-fixation lead may be introduced and connected to an external pacemaker for up to 6 weeks. • Surgical treatment of right-sided IE is indicated in patients with persistent bacteraemia, right ventricular dysfunction, recurrent septic pulmonary embolism and respiratory compromise, and involvement of left-sided structures. • Multidisciplinary care of CHD patients with IE, from diagnosis to treatment, should be provided in specialized CHD centres with expertise in CHD cardiac imaging, CHD surgery, and intensive care. Patient-centred care and shared decision-making in infective endocarditis: • In patients with IE, shared decision-making enables the integration of patients’ preferences, values, and priorities to achieve a good treatment decision. • In patients with IE and without support networks or severely impacted by social determinants, a recovery plan developed in collaboration with the patient should be established, highlighting the information about the risk of recurrence and preventive measures. Sex differences: • Female sex is less common in patients diagnosed with IE, being present in approximately one-third of cases. 16 Gaps in evidence • The majority of the recommendations with a level of evidence B are based on observational studies rather than single RCTs or meta-analyses from RCTs. Prevention: • In the intermediate or unknown risk condition groups, there is no evidence to recommend antibiotic prophylaxis. • There is currently no evidence to support the use of antibiotic prophylaxis after the implantation of a left atrial appendage occlusion device. Diagnosis: • More data on the accuracy of diagnosis of culture-negative IE using molecular biology techniques, or the determination of bacterial/fungal cell-free DNA in blood samples, is required. • Standardization of the methodology to assess the size of the vegetations has not been established. • More data on the diagnostic performance of intracardiac echocardiography in PVE are needed. • The role of [18F]FDG-PET/CT(A) in NVE needs to be established. • Routine use of imaging tests to screen the presence of embolic events, especially brain imaging, is not well established. • In fungal endocarditis, the role of molecular and biochemical indicators to establish the diagnosis is not well studied. Antimicrobial therapy – principles and methods: • Clinical trials are needed to assess the efficacy and safety of recommended antimicrobial treatment regimens and new combinations or antimicrobials. Many recommendations come from clinical trials for bacteraemia and not for IE. • Effective antibiotic treatment in patients with highly penicillinresistant oral streptococci should be investigated. • Randomized data to establish the best medical strategy in staphylococcal IE are required. • Effective antibiotic treatments for patients with HLAR E. faecalis IE and hypersensitivity to beta-lactams need further research. • Effective treatments for vancomycin-resistant enterococcal IE need further research. • Randomized head-to-head comparisons of different antibiotics to better judge efficacy and toxicity (e.g. for aminoglycosides) are needed. • The duration of antibiotic treatment has been established empirically and no randomized data have been published. • The efficacy of combined antifungal therapy has not been studied. • The empirical use of an aminoglycoside-sparing empirical combination regimen has not been extensively studied. • More data on implementation of oral treatment in large studies are needed. Indications for surgery and management of main infective endocarditis complications: • The indication of surgical treatment in patients with IE rely mainly on expert opinion based on observational studies. • RCTs are required to establish the indication and timing of surgery in patients with: • Increased surgical risk. • Large vegetations but without other indications for surgery. • Cerebral emboli or bleeding. • Patients with uncontrolled infection. • More data on the need and timing of coronary angiogram before endocarditis surgery. • There is a lack of information on timing and sequence of interventions in patients with multiple septic sources. • More data are needed on the efficacy and safety of vegetation extraction systems in right-sided IE. ESC Guidelines 4013 Downloaded from academic.oup.com/eurheartj/article/44/39/3948/7243107 by guest on 07 October 2026