2023 ESC Clinical Practice Guidelines for the management of endocarditis
26 Aug 2023
Four new ESC Clinical Practice Guidelines and a focused update are being presented at ESC Congress 2023 to help shape clinical practice and improve patient care based on the latest evidence.
The first of these new guidelines, the 2023 ESC Guidelines on endocarditis,1 was unveiled yesterday by Professor Victoria Delgado (Hospital University Germans Trias i Pujol and Institute for Health Science Research Germans Trias i Pujol - Badalona, Spain) and Professor Michael A. Borger (Leipzig Heart Center - Leipzig, Germany), Chairs of the Guidelines Task Force.
With an increased population at risk of infective endocarditis (IE), the Task Force has created several new recommendations on prevention. “We carefully considered all the new studies published after 2015 and have revised and updated the risk categories for IE, strengthening the recommendation for antibiotic prophylaxis, clarifying the definition of the population at risk and considering the advances in transcatheter valve interventions,” says Prof. Delgado.
Populations at high risk for IE include patients with previous IE, patients with surgical or transcatheter prosthetic valves or post-cardiac valve repair, and patients with untreated congenital heart disease (CHD) and surgically corrected CHD. Prevention of IE should comprise hygienic measures (including oral hygiene) for all individuals and antibiotic prophylaxis for patients at high risk of IE undergoing oro-dental procedures.
Data on the contemporary characterisation of patients with IE have been taken into consideration when updating recommendations on the diagnosis and management of patients with IE. Diagnosis is based on major criteria such as positive blood cultures and valvular and perivalvular/periprosthetic anatomic and metabolic lesions detected on imaging, and also on minor criteria, which have been revised to include frequent embolic vascular dissemination considering asymptomatic lesions detected by imaging only. There are new recommendations on the role of computed tomography, nuclear imaging and magnetic resonance in IE. Furthermore, clear diagnostic algorithms are given to diagnose native valve IE, prosthetic valve IE and cardiac device-related IE.
Recommendations on antibiotic therapy have been updated based on the susceptibility categories defined by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoints (www.eucast.org). Recommendations on outpatient parenteral antibiotic therapy or oral antibiotic treatment are also included based on the results of POET and other trials.
The main indications and timing of surgery to prevent embolism in native valve and prosthetic valve endocarditis have been revised and there is now a Class I recommendation for urgent surgery (within 3–5 days) in IE with vegetation ≥10 mm and other indications for surgery (level of evidence C), as well as a new indication for urgent surgery in patients with early prosthetic valve endocarditis (Class I, level of evidence C). There are several new and revised recommendations in the section dealing with other complications. For instance, mechanical thrombectomy may be considered in select cases of embolic stroke if the expertise is available in a timely manner. It is recommended against using thrombolytic therapy for embolic stroke due to IE.
New recommendations are given in the section on post-discharge follow-up, including a Class I recommendation for patient education on the risk of recurrence and preventive measures, with emphasis on dental health, and based on the individual risk profile (level of evidence C).
Patients must be at the centre of care to achieve the best physical and mental outcomes.
A new section is devoted to patient-centred care and shared decision-making. Prof. Borger highlights, “The severity of IE, the complex and comprehensive diagnostics and treatment, as well as the long illness trajectory, put special emphasis on patient-centred care and shared decision-making in IE. Patients report slow physical and mental recovery after IE, often extending their recuperation longer than anticipated, and all IE patients remain at risk for future recurrent IE. It is therefore important that patient-centred care extends further than hospital treatment to ensure a good outcome after discharge.”
Want to know more about what’s new? The 2023 ESC Guidelines for the management of endocarditis are now published in the European Heart Journal and are available on the ESC Pocket Guidelines app.
- Delgado V, et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J. 2023. doi:10.1093/eurheartj/ehad193.