Yesterday, at a Symposium dedicated to new ESC Guidelines on IE ("changing guidelines for a changing disease") experts who were members of the Task Force reviewed the most important aspects of the document.
The first concerns preventative measures. There is a debate on the indications for antibiotic prophylaxis, resulting in somewhat divergent opinions and recommendations. The new ESC recommendations favour a lower level of indications than in the past, stating that antibiotic prophylaxis should be limited to patients with the highest risk of IE undergoing the highest risk dental procedures.
However, reduced indications for antibiotic prophylaxis also mean that more emphasis should be placed on global oral hygiene and regular dental review. This reduced indication for antibiotic prophylaxis needs to be evaluated by prospective epidemiological studies.
Diagnosis is based on clinical judgement, echocardiographic imaging and bacteriological studies. Echocardiography should be performed rapidly as soon as IE is suspected, with TTE performed first and in most cases with TEE to follow.
At admission, the immediate assessment of the prognosis should be performed using simple clinical, microbiological and echocardiographical parameters, which will help the clinician choose the best therapeutic option.
The basis of treating IE is a combination of prolonged antimicrobial therapy and, when indicated, surgical eradication of the infective tissue. The Guidelines explain antibiotic treatment strategy in depth, as well as indications for surgery.
The Guidelines emphasise that the main indications for early surgery in the active phase are heart failure, uncontrolled infection and for the prevention of a haemodynamic event. New in the Guidelines are precise recommendations for timing; these differentiate between emergency surgery performed within 24 hours, urgent surgery within a few days, and elective surgery after one or two weeks of antibiotic therapy.
Detailed recommendations are also given for the difficult clinical situation of patients experiencing neurological complications.
Specific issues concerning patient subgroups are addressed – in particular prosthetic valve IE and cardiac device-related IE, which is difficult to diagnose but still has a poor prognosis and requires prolonged antibiotic therapy and device removal.