The document provides guidelines for the management of infective endocarditis from the European Society of Cardiology. It discusses definitions of infective endocarditis, recommendations for antibiotic prophylaxis, the role of echocardiography in diagnosis, etiologic agents, predictors of poor outcome, surgical indications, and treatment of various microorganisms including streptococci, staphylococci, enterococci, and culture-negative cases. It also addresses management considerations for infective endocarditis in specific patient populations such as those with prosthetic valves, congenital heart disease, or pregnancy.

1. 2015 ESC Guidelines for the
management of infective
endocarditis
THE TASK FORCE FOR THE MANAGEMENT OF INFECTIVE ENDOCARDITIS OF
THE EUROPEAN SOCIETY OF CARDIOLOGY (ESC)
DR RISHI A BHARGAVA

2. INFECTIVE ENDOCARDITIS
 Infection of the endocardial surface of the heart, which may
include one or more heart valves, the mural endocardium, or a
septal defect.
 Varieties of IE that were uncommon in the early antibiotic era have
become prominent.
 Cases of NIE, IVDA IE, and PVE have markedly increased.
 Valvular infections have entered the era of IE caused by
intravascular devices and procedures.

3. Definitions

4. Prophylaxis

5. Patients requiring antibiotic
prophylaxis:-

6. Non specific
prevention
measures in
high and
intermediate
risk patient

7. Procedure requiring antibiotics
prophylaxis

8. Contd….

9. Recommended prophylaxis for
high risk procedures in high risk
patients

10. Recommendations for cardiac and vascular
procedures

11. ECHOCARDI-
OGRAPHY IN
DIAGNOSIS

12. Use of TTE and TEE:-
Follow up during treatment
Intra op during cardiac surgery
After completion of therapy

13. Indication For Echocardiography In
I.E.

15. The etiologic agents
•Streptococci: 60%-80% .
•Viridans streptococci: 30%-40% .
•Other streptococci: 15%-25%.
•Enterococci: 5%-18% .
•Coagulase-positive organisms: 10%-27%
•Coagulase-negative organisms: 1 %-3%
•Gram-negative aerobic bacilli: 1% -13%
•Fungi: 2%-4% Staphylococci: 20%-35%

16. Also more commonly seen -Pseudomonas aeruginosa , esp in
pentazocine addict
Candida is commonly implicated in heroin addict
The most common etiologic agent of infective endocarditis
- S. aureus
IV drug users

17. In patients with prosthetic valves, the microbiology is
somewhat dependent on
 early (<12 months after valve replacement) versus
 late (>I2 months) endocarditis.

18. Staphylococci- 40% to 60% of the cases of
early onset prosthetic valve endocarditis.
Coagulase-negative staphylococci - 30% to
35% of cases,
S. Aureus - 20% to 25%.
Late onset PVE – organisms same as native
valve disease.

19. • Fungal endocarditis -
• IV drug users,
• Recently undergonecardiovascular surgery,
• Received prolonged IV antibiotic therapy.

20. HACEK organisms
HACEK is an acronym for a group of
fastidious, slow-growing, gram-negative
bacteria
Account for approximately 5% to 10% of cases
of community-acquired endocarditis.

21. •H: Haemophilus parainfluenzae,
Haemophilus aphrophilus,
Haemophilus paraphrophilus, .
Haemophilus influenzae .
•A : Actinobacillus
actinomycetemcomitans .
•C : Cardiobacterium hominis .
•E : Eikenella corrodens
•K: Kingella kingae, Kingella
denitrificans

22. Investigation
of rare
causes of I.E.
(blood
culture -ve)

24. Modified Duke’s criteria

25. Definition Of
Different
Criteria

26. ESC
Algorithm For
Diagnosis Of
I.E.

28. Predictors of
poor outcome
in patient with
infective
endocardiris

30. Streptococcal bovis and oral
streptococci
Penicillin susceptible –
 standard treatment – 2wk vs 4wk
 beta lactam allergic
Penicillin aresistant
 Standard treatment
 Beta lactam allergic

31. Antibiotic
treatment -
oral
streptococci
and
streptococci
bovis-
penicillin
susceptible

32. Penicillin resistance :

33. Antibiotic treatment - staphylo-
cocci
 Native valve –
Methicilin susceptible /
methicillin resistant or pencilillin allergic
 Prosthetic valve
Methicilin susceptible /
methicillin resistant or pencilillin allergic
No role of gentamicin in native valve staph infection.
Rifampicin is added 3-5 days after starting antibiotics in prosthetic
valve endocarditis.

34. Antibiotic
treatment -
staphylo-
cocci

35. Antibiotic
treatment
- staphylo-
cocci –
prosthetic
valve

36. Antibiotic
treatment
- entero-
cocci –
prosthetic
valve

37.  Antibiotic treatment of blood
culture negative infective
endocarditis

38. Antibiotic
treatment of
blood culture
negative
infective
endocarditis

39. Empirical treatment

40. Empirical
treatment
of acutely
severe ill
patient

41. Outpatient
Parenteral
Antibiotic
Therapy
(OPAT)

42. SURGICAL
MANAGEMENT

43. Indication
and timing of
surgery in left
sided valve
infective
endocarditis

44. Indication for surgical treatment
of right sided infective
endocarditis

45. Factors
associated
with
increase
rate of
relapse

46. Cardiac device related
infective endocarditis
(CDRIE)

47. Diagnosis

48. Principles of
Treatment

49. Mode
of
device
removal

50. Re-implantation

51. Prophylaxis

52. I.E. In congenital heart
diseases

53.  Fewer systematic studies.
 Incidence is lower in children(o.o4% per year ) than in adult(0.1%)
 CHD with multiple lesion is at higher risk than simple lesion.
 Mortality of 4-10 %. Prognosis is better than other forms.
 Surgical repair of CHD reduces the risk, provided there is no residual
shunt.
 Artificial valve substrate may increase the risk.

54. I.E. during pregnancy

55.  Incidence – 0.006%.
 Higher inpatients with cardiac disease and further more
in pt with prosthetic valves.
 Maternal mortality is approximately 33% ,with most death
relating to HF or an embolic event.
 Foetal mortality is about 29%.
 Rapid detection and appropriate treatment is important.
 Despite the high foetal mortality , urgent surgery should
be performed in pt who present with HF due to acute
regurgitation.

56. “……..not to forget, they originated
millions of years before us ; and how to
survive, probably know better than us!!
“