This document discusses infective endocarditis, including its prevalence, mortality rate, prevention, diagnosis, treatment, and timing of intervention. It provides an overview of antibiotic prophylaxis guidelines and limitations. Case examples are presented to demonstrate diagnostic imaging modalities like CT and PET-CT. The importance of an infective endocarditis team approach involving multiple specialties is highlighted. Specific clinical situations that require emergent versus urgent versus elective surgery are also examined.

1. Victoria Delgado, MD, PhD
Leiden University Medical Center
The department of cardiology of the Leiden University Medical
Center received unrestricted research grants from Biotronik,
Medtronic, Edwards Lifesciences and Boston Scientific

2. Infective endocarditis: prevalence
Selton-Suty et al. Clin Infect Dis 2012
N = 497

3. Infective endocarditis
• Deadly disease:
• 14-22% 1-year mortality
• Prevention
• Randomized clinical trial on timing of intervention
• Imaging advances
• Endocarditis team: primary care physicians, cardiologists,
surgeons, microbiologists, infectious disease specialists and others

4. Prevention
• Antibiotic prophylaxis limited to highest risk patients
undergoing highest risk dental procedures
• Good oral hygiene and regular dental review
• Aseptic measures mandatory during cardiac devices
implantation

5. Antibiotic prophylaxis
• 2008 NICE guidelines: stop antibiotic prophylaxis
• 2007 AHA/ACC and 2009 ESC guidelines: stop in patients at
moderate risk
Dayer et al. Lancet 2015 Mar 28;385(9974):1219-28

6. Antibiotic prophylaxis
Dayer et al. Lancet 2015 Mar 28;385(9974):1219-28

10. Prevention
• Antibiotic prophylaxis limited to highest risk patients
undergoing highest risk dental procedures
• Good oral hygiene and regular dental review
• Aseptic measures mandatory during cardiac devices
implantation

12. Diagnosis - Case
• 46 year old man
• Known bicuspid aortic valve since 5 years ago:
• Systolic murmur in regular check-up at work
• Mild aortic stenosis
• Had a bike accident and underwent dental implants
• 1 week later consults the GP because of fever, shivers,
feeling unwell and pale.
• HR 95 bpm, T 39°C, BP 130/40 mmHg
• Aortic diastolic murmur

15. Diagnosis
• Lab: CRP 300, Leucos 22.000, Ht 42%, Hb 8.9, Thrombo 450
• Blood cultures: S. viridans (4/4)

16. Diagnosis

17. Diagnosis
Vegetation size 18 mm

19. Diagnosis

23. Additional imaging modalities
• 78 year old man. AVR 1 year ago with sutureless valve
• Diagnosed with colon carcinoma
• Fever, loss of weight
• TTE -, blood cultures -

24. Additional imaging modalities - CT

25. Additional imaging modalities
• 81 year old man. TAVI 2 years ago
• Peripheral artery disease, amputation of left inferior limb
• Fever despite antibiotic treatment
• TTE -, blood cultures -

26. Additional imaging modalities – PET-CT

27. Additional imaging modalities – PET-CT

28. Treatment - Endocarditis team
Cardiologist
Cardiac imaging
Infectious
disease
Cardiac surgeon
Microbiologist

29. Timing for intervention
Kang et al N Engl J Med 2012;366:2466-73

30. Emergency = within 24h
Urgent = within a few days
Elective = 1-2 weeks

31. Specific situations
• 69 year old female
• Hypertension, diabetes
• Chronic atrial fibrillation
• Admitted with neurologic symptoms: disoriented, confused,
inappropriate reactions to normal requests since 2 days
• HR 89 bpm, BP 130/70 mmHg, T 39°C
• Systolic murmur
• Blood test: CRP 346, Leucocytosis, Hb 7.6, INR 2.5,
Thrombocytes 478, Na 142, K 3.7, eGFR 78

32. Specific situations

33. Specific situations

34. What to do?
1. Medical therapy: starting with antibiotics, wait for the
results of the blood cultures and elective surgery
2. Emergent surgery
3. Start antibiotic treatment and urgent surgery