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ESC infective endocarditis guidelines boost role of imaging in diagnosis

ESC Guidelines published recently on infective endocarditis boost the role of imaging in diagnosis of this deadly disease.

“We emphasise the need for a multimodality imaging approach to diagnosing endocarditis,” said Professor Gilbert Habib, Chairperson of the guidelines Task Force. “While the 2009 guidelines1 focused on echocardiography, the 2015 guidelines show the important role of other imaging techniques such as PET-CT. These new imaging techniques are increasingly useful for the diagnosis and management of infective endocarditis and we recommend their use in a novel ESC diagnostic algorithm.”

The ESC Guidelines for the management of infective endocarditis are published today online in European Heart Journal2 and on the ESC Website.

For the first time, the guidelines recommend that an endocarditis team operating in a reference centre is crucial for the management of infective endocarditis. The team should include cardiologists, cardiac surgeons and specialists in infectious diseases, while reference centres should have immediate access to diagnostic procedures and cardiac surgery.

“A multidisciplinary approach is mandatory for the treatment of patients with infective endocarditis,” said Professor Habib. “In our centre we showed that this approach dramatically reduced one year mortality in patients with infective endocarditis from 18.5% to 8.2%. Management by an endocarditis team in a reference centre is one of the most important new recommendations.”

Also new are recommendations for specific situations including infective endocarditis in the intensive care unit, infective endocarditis associated with cancer, and marantic (non-bacterial) infective endocarditis.

Important recommendations are given for the combination of early diagnosis, early antibiotic therapy and early surgery. “Endocarditis is a deadly disease if treated too late,” said Professor Patrizio Lancellotti, co-Chairperson of the Task Force. “The new guidelines focus on methods to reduce delays in diagnosis, early introduction of antibiotics, and sending patients to a surgeon very early. The 2009 guidelines were the first to introduce the concept of optimal timing of surgery in patients with infective endocarditis and this is highlighted again in 2015.”

Antibiotic prophylaxis was a controversial area of discussion by the guidelines Task Force. One of the main changes in the 2009 guidelines was the reduction of prophylaxis because there was no real scientific proof of its efficacy and it may be potentially dangerous. Thus, antibiotic prophylaxis was recommended only for patients with the highest risk of infective endocarditis undergoing the highest risk dental procedures. Similar changes were proposed by the American guidelines. Good oral hygiene and regular dental review were considered to have a more important role in reducing the risk of infective endocarditis.

Professor Habib said: “Recent publications have underlined the risk of increasing incidence of infective endocarditis since the previous guidelines, suspected to be related to the reduced antibiotic prophylaxis. However, the evidence was considered by the Task Force to be too low to modify the 2009 guidelines. Therefore the present guidelines continue to recommend antibiotic prophylaxis only for patients at the highest risk. Studies, ideally randomised, are needed to answer this very difficult question.”

Antibiotic therapy was another controversial topic, with new antibiotic strategies recommended to treat staphylococcal endocarditis. Professor Lancellotti said: “A consensus was difficult to obtain in this particular subgroup of patients with the most severe form of infective endocarditis. Ongoing studies on this topic will be useful.”

Professor Habib concluded: “Endocarditis is a changing disease that is still associated with a high mortality (10-26% in-hospital mortality). We hope the new guidelines will help physicians to focus on prevention rather than prophylaxis to reduce the incidence of infective endocarditis, particularly in the field of nosocomial (hospital-acquired) endocarditis. Mortality can be reduced by multidisciplinary management in endocarditis centres. And we urge physicians to send patients with infective endocarditis for early surgical assessment as soon as possible.”