New indications in antibiotic therapy in ACS

Aug 25, 2023
Emil L Fosbøl
New indications in
antibiotic therapy
2023 ESC Guidelines for the management of
endocarditis

www.escardio.org/guidelines
©ESC

©ESC
2023 ESC Guidelines for the management of endocarditis
(European Heart Journal; 2023 – doi: 10.1093/eurheartj/ehad193)
2023 ESC Guidelines on Endocarditis
Agenda
• Novel aspects of antibiotic treatment in 2023 guidelines
• Per oral + out-patient parental treatment (OPAT) and underlying data
• A new paradigm in endocarditis treatment

©ESC
Changes/trends in the new guidelines and novel aspects
• Reinforced: The endocarditis team is at the centre of treatment
decisions
• Similar: Prophylactic, empirical and targeted antibiotic therapy
similar to 2015 ESC guidelines
• Novel: The introduction of oral antibiotic therapy or OPAT

©ESC
Reinforced:
• The endocarditis team is at
the centre
• Managing expert team
• Cardiologist
• Surgeons
• Microbiologists
• Infectious diseases
experts…

©ESC
2015 Class Level 2023 Class Level
Recommendations for antibiotic prophylaxis in patients with cardiovascular diseases
undergoing oro-dental procedures at increased risk for infective endocarditis
Antibiotic prophylaxis should be
considered for patients at highest
risk for IE:
1. Patients with any prosthetic
valve, including a transcatheter
valve, or those in whom any
prosthetic material was used for
cardiac valve repair.
IIa C
Antibiotic prophylaxis is
recommended in patients with
previous IE.
I B
Antibiotic prophylaxis is
recommended in patients with
surgically implanted prosthetic
valves and with any material used
for surgical cardiac valve repair.
I C
Similar

©ESC
Similar
• Antibiotic regimens are similar
• No new randomized data (Most are I-B/C recommendations)
• Oral regimens are new: dual oral coverage

©ESC
Novel: a new outpatient paradigm for antibiotic therapy
Recommendations Class Level
Outpatient parenteral or oral antibiotic treatment should be considered in patients
with left-sided IE caused by Streptococcus spp., E. faecalis, S. aureus, or CoNS who
were receiving appropriate i.v. antibiotic treatment for at least 10 days (or at least 7
days after cardiac surgery), are clinically stable, and who do not show signs of abscess
formation or valve abnormalities requiring surgery on TOE.
IIa A
Outpatient parenteral antibiotic treatment is not recommended in patients with IE
caused by highly difficult-to-treat microorganisms, liver cirrhosis (Child-Pugh B or C),
severe cerebral nervous system emboli, untreated large extracardiac abscesses, heart
valve complications, or other severe conditions requiring surgery, severe post-surgical
complications, and PWID-related IE.
III C

©ESC
Novel:
• Randomized data
• Formalizing treatment phases
• Introducing “stability”

©ESC
Novel:
• Defining stability
• Stability  oral therapy
• Shorter hospitalizations and
better outcomes

©ESC
Novel per oral paradigm based on the POET trial:

©ESC
POET: Baseline characteristics

©ESC
POET primary outcome data: death, emboli, unplanned surgery, relapse
Oral group
discharged 17
days earlier
5-years FU: Oral superior to iv, HR 0.65 (0.47-0.90)

©ESC
Novel per oral treatment
• Stabilization is key
• Patients may be discharged much
earlier
• Monitoring, adherence and out-
patient care is important

©ESC
Case for illustration
• 63yo man
• Medical history:
• Diabetes
• Atrial fibrillation
Strep agalactiae, CRP 154, no
emboli

©ESC
• After 17 days iv AB:
• CRP 23
• No fever
• TEE is performed and
vegetation is only 4mm now
and valve is doing well

©ESC
• After 17 days iv AB: Patient is stable
2023 ESC Guidelines
2015 ESC Guidelines
4–6 weeks iv treatment
in-hospital
Switched after 17 days to double
oral antibiotic treatment,
discharged and seen twice per
week. Total of 4–6 weeks therapy

©ESC
Take home messages
• The 2023 ESC guidelines reinforce use of antibiotic prophylaxis and
empirical + targeted antibiotic therapy
• The 2023 ESC guidelines introduce a novel treatment paradigm for
endocarditis: oral/out-patient treatment after stabilization

New indications in antibiotic therapy in ACS

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