Prof. Gilbert Habib,
Prevention and patient education (B Prendergast, Oxford, GB) One of the main changes in new guidelines is the proposed reduction of prophylaxis, because there is no real scientific proof of its efficacy, and it may be potentially dangerous. Thus, antibiotic prophylaxis is now recommended only for patients with the highest risk of IE undergoing the highest risk dental procedures. Prophylaxis is no longer recommended in the majority of acquired valvular valve disease. Good oral hygiene and regular dental review have a very important role in reducing the risk of IE. Considerations for antibiotic therapy (C Naber, Essen, DE) Successful treatment of IE relies on microbial eradication by antimicrobial drugs. Surgery contributes by removing infected material and draining abscesses. Bactericidal regimens are more effective than bacteriostatic therapy, both in animal experiments and in humans. Bactericidal drug combinations are preferred to monotherapy against tolerant organisms. Drug treatment of prosthetic valve endocarditis should last longer (at least 6 weeks) than that of native valve endocarditis (2-6 weeks). Outpatient parenteral antibiotic therapy should be used to consolidate antimicrobial therapy once critical infection-related complications are under control (e.g. peri-valvular abscesses, acute heart failure, septic emboli, and stroke). When to operate and how (MJ Antunes, Coimbra, PT) The treatment of IE relies on the combination of prolonged antimicrobial therapy and - in about half of patients - surgical eradication of the infected tissues. The new guidelines focus on these 3 main indications of surgery- heart failure (HF), uncontrolled infection, and prevention of embolic events. Moreover, the guidelines gave for the first time indications concerning the optimal timing of surgery. Neurological problems in patients with endocarditis (JA San Roman Calvar, Valladolid, ES) Neurological events develop in 20-40% of all patients with IE and are mainly the consequence of embolism. Stroke is associated with excess mortality. Rapid diagnosis and initiation of appropriate antibiotics are of major importance to prevent a first or recurrent neurological complication. After a first neurological event, most patients still have an indication for surgery. After an ischaemic stroke, cardiac surgery is not contraindicated unless the neurological prognosis is judged to poor. If cerebral haemorrhage has been excluded by cranial CT and neurological damage is not severe, surgery should not be delayed and can be performed with a relatively low neurological risk. Close cooperation with the neurosurgical team is mandatory.
Endocarditis: what's new in the guidelines?
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