endocarditis crash course for students learning

Endocarditis

1. Endocardita
infectioasa

2. Scopul problemei
Epidemiologie
Fiziopatologie
Diagnostic
Evaluarea prognosticului
Terapia antimicrobiana : principii si metode
Complicatii
Situatii specifice
Masuri de preventie

3. leziunea caracteristica = VEGETATIA
- masa amorfa de marime variabila care contine
trombocite, fibrina, microorganisme, celule inflamatorii
- implica valvele (cel mai frecvent),defecte septale,
cordaje, endocardul mural
- leziuni similare clinic si patologic: shunturi
arteriovenoase, arterioarteriale (persistenta de canal
arterial), coarctatia de aorta

4. Endocardita cu stafilococ auriu pe VM

5. Scopul problemei
Incidenta si mortalitate nemodificate de 30 ani
Prognostic nefavorabil si mortalitate crescuta
Necesita colaborare interdisciplinara
Ghiduri bazate pe opinia expertilor (lipsesc studii
randomizate, metaanalize)

6. Epidemiologie
Profil modificat: - pacienti varstnici
- pacienti fara valvulopatii cunoscute
- pacienti protezati valvular
Noi factori predispozanti:
- proteze valvulare
- scleroza valvulara degenerativa
- abuz de droguri i.v.
- proceduri invazive
Variatii geografice ale patogenului implicat

7. Epidemiologie : incidenta
Variabila : 3-10 cazuri /100000 pers/an
Creste cu varsta
B:F ≥ 2:1
F – prognostic mai nefavorabil

8. Epidemiologie : tipuri
Dupa localizare: E.I. stanga - pe valve native
- pe valve protetice
- precoce (<1 an)
- tardiva (>1 an )
E.I. dreapta
E.I. in relatie cu dispozitive
(pacemaker; cardiodefibrilator)
Dupa modalitatea de dobandire:
- dobandita in comunitate
- asociata cu ingrijirea sanatatii - nosocomiala
(spitalizare >48 h inainte)
- nonnosocomiala

- asociata cu abuzul de droguri i.v.

9. E.I. activa
- febra persistenta si hemoculturi pozitive sau
- morfologie inflamatorie activa descoperita cu ocazia
interventiei chirurgicale sau
- pacient aflat inca sub terapie antibiotica sau
- evidenta histopatologica de EI activa
Recurente
- recadere (< 6 luni; acelasi microorganism)
- reinfectie (> 6luni; alt sau acelasi microorganism )

10. Epidemiologie : microbiologie
E.I. cu hemoculturi pozitive (85%) : stafilococi, streptococi,
enterococi
E.I. cu hemoculturi negative datorita tratamentului antibiotic
in prealabil
E.I. frecvent asociata cu hemoculturi negative (HACEK,
Brucella, fungi); HACEK- Haemophilus, Actinobacillus,
Cardiobacterium, Eikenella, Kingella
E.I. constant asociata cu hemoculturi negative (Coxiella,
Chlamydia, Bartonella)

11. EI cu streptococ viridans pe bicuspidie
aortica

12. Leziune endocardiaca
Sau endoteliala
Vegetatie sterila
Vegetatie
Trombocite, fibrina
NBTE
Nonbacterial thrombotic
endocarditis
Bacteriemie

Cel mai frecvent de
partea structurii cu
presiune mica
Leziune
caracteristica
Endoteliul intact
e
nontrombogenic
Endoteliul traumatizat – jet
turbulent (in zona de impact sau
pe versantul cu presiune joasa)

13. Suspiciune clinica
sufluri de regurgitare noi
evenimente embolice cu origine necunoscuta
sepsis cu origine necunoscuta (mai ales asociat cu
germeni care pot cauza EI)
cel mai frecvent semn de EI: FEBRA
- poate lipsi la varstnici, imunocompromisi,
tratament antibiotic; organisme atipice
- asociata cu frisoane, anorexie, scadere
ponderala

14. Suspiciune clinica
FEBRA
•boala valvulara sau cardiaca preexistenta
•alte conditii predispozante pentru EI si interventii recente
asociate cu bacteriemie
•evidente de insuficienta cardiaca
•noi tulburari de conducere

15. FEBRA
•fenomene vasculare sau imunologice: evenimente
embolice, pete Roth, hemoragii subunghiale,leziuni
Janeway, noduli Osler
•semne si simptome neurologice focale sau nespecifice
•evidenta de embolie pulmonara sau infiltrate (EI dreapta)
•abcese periferice ( splenice, renale, cerebrale,
vertebrale) de cauza necunoscuta
•culturi pozitive cu organisme tipice pt. EI sau serologie
pozitiva pt. Febra Q (Coxiella burneti)

16. Leziuni Janeway

17. Abcese miocardice Abces renal

18. Abces cerebral occipital
stang
Infarct hemoragic
occipital drept

19. Discita L4-L5

20. Diagnostic:clinic
Artralgii, mialgii, chiar artrite
Simptome neurologice - date de AVC embolic
- hemoragii intracraniene prin
ruptura anevrismelor micotice
- encefalita prin microabcese
- meningita purulenta
- cefalee, convulsii, encefalopatie
 Insuficienta renala - data de : - glomerulonefrita
mediata prin complexe
imune
- infarcte renale
- medicatie nefrotoxica

21. IMA inferior prin embolizare CD din EI pe
VA

22. Roth’s spot
Anevrism micotic
End.stafilococica-petesii
Hemoragii conjuctivale

23. Noduli Osler Noduli Osler

24. Diagnostic : teste de laborator
Anemie :normocroma, normocitara,hiposideremica
poate lipsi in EI acuta
Leucocitoza cu neutrofilie - mai frecvent in EI acuta
Probe inflamatorii : VSH,Fibrinogen, Proteina C-
reactiva
Factor reumatoid
CIC, complement scazut – in GN difuza
Sumar urina : proteinurie, hematurie microscopica

25. Diagnostic :imagistic
Ecocardiografia
- TTE de prima intentie
- TEE daca TTE este normala dar suspiciunea
clinica este inalta
- se pot repeta dupa 7-10 zile daca prima
examinare este normala
- se pot repeta cand se suspecteaza noi
complicatii (sufluri noi, embolism, abcese, I.C., febra
persistenta, BAV)
- la sfarsitul terapiei antibiotice (evaluare functie
si morfologie valve, functie cardiaca)

26. Diagnostic:ecocardiografie
Valve
protetice
Device
intracardiac
TTE
calitate
slaba
TEE
Suspiciune clinica de EI
inalta scazuta
TEE Stop
NegativaPozitiva
Suspiciune clinica de EI
TTE
Daca TEE initiala este negativa dar ramane suspiciunea de
EI, se repeta TEE in 7-10 zile

27. CT multislice
-detectia abceselor/pseudoanevrismelor (acuratete
similara cu TEE);
- extensia si consecintele extensiei perivalvulare
- in EI aortica da relatii despre VA, aorta ascendenta
- angiografie coronariana
-evaluare leziuni cerebrale
RMN
- detectia leziunilor cerebrale
SPECT/CT; PET/CT
-informatii suplimentare la cei cu EI suspectata si
dificultati diagnostice

28. Abces de SIV:risc de BAV

29. Diagnostic: microbiologic
Hemoculturi :- 3 seturi (aerob/anaerob) cu 10 ml sange
din vena periferica, la 30 min interval
- nu se asteapta puseu febril
Examinare anatomopatologica a tesutului rezecat
valvular sau a fragmentului embolic
Tehnici histologice/imunologice
Tehnici de biologie moleculara (PCR)

31. Abces la nivelul valvei mitrale

32. Postoperator – fragmente de valva cu vegetatie

33. Material excizat – vegetatie valva aortica

34. 3 hemoculturi independente incubate
in conditii de aerobioza si anaerobioza
Culturi
pozitive
Tablou clinic/echo sugestiv
de EI ?
nu da
Reevaluare pacient
&diagnostic
alternativ
Culturi negative
la 48 h
Tablou clinic/echo sugestiv de
EI ?
nuda
Start
terapia
antibiotica
Sfat cu lab de microb
Investigatii aditionale
nu
Tratament
medical
da
Reevaluare
pacient&diagnostic
alternativ
Necesita
chirurgie?
Considera tratament pentru EI
cu culturi negative( modifica
regimul functie de organismul
identificat)
Trimite valva/material
embolic excizat pentru
analize

35. Definitions of the 2023 European Society of Cardiology modified
diagnostic criteria of infective endocarditis

41. TEE la pacient cu vegetatie pe VA si IAo

42. TEE : vegetatie pe VM cu ruptura de
cordaj si IM severa

43. TEE: vegetatie mare pe VM

44. EI pe VA

45. Evaluarea prognosticului la internare
Rata mortalitatii in spital :9,6-26%
Caracteristicile pacientului:
- varstnic
- EI pe proteza
- DZ insulinonecesitant
- comorbiditati: boala pulmonara, renala,
imunosupresie
Prezenta complicatiilor EI (IC, AVC, IRen, perianulare,
soc septic)
Microorganism (S.auriu, fungi, BGN)

46. Evaluare prognostic la internare
Ecocardiografie:
- complicatii perianulare
- regurgitatii severe valvulare stangi
- FE a VS scazuta
- HTAP
- vegetatii mari
- disfunctie protetica severa
- inchidere prematura a VM sau alte semne ale cresterii
presiunii diastolice

47. Terapia antimicrobiana : principii
Succesul se bazeaza pe eradicarea patogenului
Chirurgia are rol in indepartarea tesutului infectat si
drenarea abceselor
Sunt de preferat regimuri bactericide decat cele
bateriostatice
Depinde de sensibilitatea si rezistenta germenilor
Exista scheme speciale de tratament in ghiduri
Specifica fiecarei regiuni geografice

48. Terapia antimicrobiana : principii
Aminoglicozidele actioneaza sinergic cu inhibitorii de
perete celular (betalactami si glicopeptide) pentru
activitatea bactericida; sunt utile pentru scurtarea
duratei terapiei (streptococi orali) si la eradicarea
organismelor problematice ( enterococi)
Terapia pentru EI pe proteze dureaza mai mult decat
pentru valve native ( cel putin 6 saptamani fata de 2-6
saptamani)
La PVE data de stafilococ regimul trebuie sa includa si
Rifampicina

50. Penicillin-susceptible oral streptococci
and Streptococcus gallolyticus group

52. Recommendations for antibiotic regimens for initial empirical
treatment of infective endocarditis (before pathogen
identification)

55. EVALUAREA EFICIENŢEI TERAPIEI ANTIINFECŢIOASE
1.Apirexia
2.Hemoculturi: negative
după 3-4 z de terapie
adecvată
3. Normalizare număr
leucocite: atenţie la
leucopenia data de
anumite AB (ex:
vancomicina)
4. Teste de inflamaţie:
0
2
4
6
8
10
13579111315171921232528
VSH
fibrinogen
proteina C
reactiva
procalcitonina

58. Complicatii
Complicatii neurologice :
- 15-30%simptomatice
- mai frecvente dupa stafilococ auriu
- mortaliate crescuta
- AVC ischemic sau hemoragic
- AIT
- embolism cerebral silentios (35-60%)
- anevrism infectios simptomatic sau asimptomatic
- abces cerebral
- meningita
- encefalopatie toxica

60. Complicatii
Anevrisme infectioase (micotice) – localizare frecventa
intracranian
IRA
Complicatii reumatice (artralgii, mialgii, dureri de spate,
artrite periferice)
Abcese splenice/ruptura
Miocardita, pericardita
TULBURARI DE CONDUCERE = EXTENSIA INFECTIEI

61. CT : Abces splenic

62. Anevrism micotic cerebral

63. Anevrism micotic art. femurala stanga la
femeie consumatoare de droguri cu EI
cu stafilococ

64. post-discharge follow-up

65. Situatii specifice
Proteze valvulare (20%)
- cea mai severa forma
- dificil de diagnosticat, tratat
- patogeneza diferita functie de tipul de contaminare
(precoce/tardiva)si tipul de valva
- TEE
- infectiile fungice, BGN si stafilococ sunt mai frecvente
- terapie similara cu NVE dar de durata mai lunga si cu
asociere de Rifampicina pt. stafilococ
- tratament chirurgical frecvent necesar

66. TTE – vegetatie pe bioproteza pozitie
aortica

67. TEE: vegetatie pe proteza mecanica
mitrala

68. Proteza Starr-Edwards infectata cu
St.epidermidis

69. EI pe pacemaker sau ICD
- boala severa asociata cu mortalitate crescuta
- trebuie diferentiata de infectia locala a dispozitivului
- mecanism :contaminarea de catre flora locala
bacteriologica in momentul implantarii
- embolism pulmonar septic frecvent
- pentru diagnostic TEE si hemoculturi
-terapie antibiotica prelungita si indepartarea
dispozitivului
-Reimplantare la cel putin 72 h de hemoculturi negative

71. EI dreapta
- 5-10%
- mai frecventa la utilizatorii de droguri i.v. (mai ales
serpozitivi HIV)
- poate apare la cei cu pacemaker, ICD, cateter venos
central, boli cardiace congenitale
- cel mai frecvent VT dar si VP
- 60-90% data de stafilococ auriu
- simptome: febra persistenta, bacteriemie, embolism
pulmonar septic
- prognostic relativ bun pe NVE dar risc crescut de
recurente

72. EI pe VT cu abcese pulmonare (droguri
i.v.)

73. Profilaxia EI – sumar (1)
Nu exista dovezi convingatoare cum ca
procedurile dentare cu sau fara sangerari vizibile
se asociaza cu EI
Bacteriemiile asa numite “fiziologice” sau legate
de activitati precum periajul, masticatia s.a au un
risc probabil mai mare de EI decat interventiile
dentare
Nu exista dovezi privind eficacitatea profilaxiei in
cazul procedurilor dentare, cu exceptia poate a
extractiilor

74. Profilaxia EI – sumar (2)
Complianta la profilaxie este scazuta atat la
medici cat si la pacienti
Profilaxia inaintea majoritatii procedurilor
dentare in cadrul unei populatii largi nu este
cost-eficienta si poate duce la decese legate
de antibioterapie
Profilaxia bazata pe parametrii individuali
este mai ieftina si de obicei sigura

75. Populatii la risc pentru EI
Risc inalt de EI
•IE anterior
•cu valve protetice implantate chirurgical (bioprotezele
mitrale i aortice pot fi asociate cu risc crescut de EI în
ș
comparaie cu protezele mecanice), cu valve protetice
ț
implantate transcateter (protezele aortice i pulmonare
ș
transcateter) i cu orice material utilizat pentru repararea
ș
valvelor cardiace ;
•cu dispozitive de închidere a defectului septal, dispozitive
de închidere a urechiusii stângi, grefe vasculare, filtre de
venă cavă i unturi ventriculo-atriale ale sistemului
ș ș
venos central sunt considerate în această categorie de
risc în primele 6 luni de la implantare.

76. •cu boală cardiacă congenitală (CHD) (fără a se include
anomalii valvulare congenitale izolate): CHD cianotice
netratate i cei a căror intervenie chirurgicală include
ș ț
material protetic, inclusiv conducte valvulare sau unturi
ș
sistemico- pulmonare
•Pacienii cu CHD supu i închiderii trans cateter atriale
ț ș
sau ventriculare a defectului septului cu dispozitive sau
intervenii chirurgicale cu material protetic nonvalvular au,
ț
de asemenea risc crescut dar predominant în primele 6
luni după intervenie chirurgicală.
ț
•cu dispozitive ventriculare “bridge to destination”

77. risc intermediar de EI
(i) boală cardiacă reumatică (RHD);
(ii) boală valvulară degenerativă nereumatică;
(iii) anomalii congenitale ale valvei, inclusiv boala valvei
aortice bicuspide;
(iv) dispozitive electronice implantate cardiovasculare
(CIED);
(v) cardiomiopatie hipertrofică

78. Măsuri generale de prevenire care trebuie urmate la
pacienții
cu risc ridicat și intermediar de endocardită infecțioasă

79. Pacienii trebuie încurajai să menină igiena dentară de
ț ț ț
două ori pe zi i să solicite igiena dentară profesională i
ș ș
urmărire de cel puin două ori pe an (cu risc ridicat) i
ț ș
anual pentru alii.
ț
Igienă cutanată strictă, inclusiv tratamentul optimizat al
afeciunilor cronice ale pielii.
ț
 Dezinfectarea rănilor.
 Antibiotice curative pentru orice focar de infecie
ț
bacteriană.
 Fără automedicaie cu antibiotice.
ț

80. Măsuri stricte de control al infeciilor pentru orice
ț
procedură cu risc.
Descurajarea piercing-ului i a tatuajului.
ș
Limitarea cateterelor de perfuzie i a procedurilor
ș
invazive. cand este posibil.
 Ar trebui să se respecte cu strictee pachetele de
ț
îngrijire pentru canulele centrale i periferice.
ș

81. Recommendations for antibiotic prophylaxis in
patients with cardiovascular diseases undergoing
oro-dental procedures at increased risk for infective
endocarditis

82. Recomandari :profilaxie
A.Proceduri dentare:
Profilaxia antibiotica se face doar la proceduri care necesita manipulare
de gingie sau regiune periapicala a dintelui sau perforarea mucoasei orale
(IIa, C)
Profilaxia antibiotica nu e recomandata pentru anestezie locala in
tesuturi neinfectate, indepartarea suturilor, RX dentar; traumatisme limba
sau mucoasa orala (III C)
B. Proceduri la nivelul tractului respirator
Profilaxia antibiotica nu e recomandata , inclusiv la bronhoscopie,
laringoscopie, IOT (III C)
C. Proceduri la nivelul tractului gastrointestinal sau urogenital
Profilaxia antibiotica nu e recomandata pentru gastroscopii,
colonoscopii, cistoscopii, TEE (IIIC)
D. Piele si tesuturi moi
Profilaxia antibiotica nu e recomandata pentru nicio procedura (IIIC)
Recomandari: profilaxie

83. mai multe proceduri medicale non-dentare invazive au
fost asociate cu risc crescut de EI, inclusiv
•interventii cardiovasculare,
• proceduri ale pielii i tratarea rănilor,
ș
• transfuzie, dializă, puncie măduvă osoasă i proceduri
ț ș
endoscopice.
 Din acest motiv, în timpul tuturor acestor proceduri ar
trebui să se asigure un mediu operaional aseptic pentru
ț
a minimiza riscul de IE.
 recomandare clasa IIb i nu clasa III
ș

84. Profilaxia recomandată pentru
procedurile dentare cu risc inalt
Doză unică cu 30-60 de minute înainte de procedură
Amoxicilină sau ampicilină: 2g po sau im/iv (adult); 50
mg/kg po/iv (copil)
 - alternativă Cephalexin 2 g po, Cefazolin sau
Ceftriaxone 1 g iv/im
Alergie la penicilină sau ampicilină:
Azitromicină/Claritromicină 500mg p.o.; Doxiciclină 100
mg po

85. Greseli frecvente in EI → dificultati de
diagnostic
 Administrarea precoce de AB inainte de prelevarea
hemoculturii
Conceptia gresita ca EI este intodeauna o boala
catastrofala → eroare de diagnostic la pacienti cu forma
subacuta si evolutie mai benigna.
Anamneza incompleta (depedenta de droguri i-v?)

88. Take Home Messages
• Infective endocarditis (IE) is a severe form of valve
disease still associated with a high mortality (15–30% in-
hospital mortality).
 • IE is a rare disease, with reported incidences ranging
from 3 to 10 cases/100 000 people per year.
 • The epidemiological profile of IE has changed over the
last few years, with newer predisposing factors – valve
prostheses, degenerative valve sclerosis, intravenous
drug abuse (IVDA), intracardiac device (CDRIE),
associated with the increased use of invasive procedures
at risk for bacteremia.
 • Health care-associated IE represents up to 30% cases
of IE, justifying aseptic measures during venous
catheters manipulation and during any invasive
procedures.

89. Prevention
There is a lack of scientific evidence for the efficacy of
infective endocarditis prophylaxis. Thus, antibiotic
prophylaxis is recommended only for patients with the
highest risk of IE undergoing the highest risk dental
procedures.
 • Good oral hygiene and regular dental review are more
important than antibiotic prophylaxis to reduce the risk of
IE.
 • Aseptic measures are mandatory during venous
catheter manipulation and during any invasive
procedures in order to reduce the rate of health care-
associated IE.
 • Although prophylaxis should be restricted to high-risk
patients, preventive measures should be maintained or
extended to all patients and in particular to those with
cardiac disease.

90. 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.

91. 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.

92. 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.

93. 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.

94. 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.

95. 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.

96. Main complications of left-sided valve IE
and their management
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.

97. 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.

98. 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 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.

99. 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

100. 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.

101. • 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.