Inclusion of PET/CT and SPECT/CT in Modified Duke Criteria.

2.  Boosted the role of imaging in diagnosis
 While the 2009 guidelines focused on echo, the 2015
guidelines show the important role of PET-CT and
SPECT/CT.
 Guidelines recommend that an Endocarditis Team
operating in a reference centre is crucial for the
management of IE
 Reference centres should have immediate access to
diagnostic procedures and cardiac surgery.
 A multidisciplinary approach is mandatory

3.  Management by an Endocarditis Team in a reference centre is
one of the most important new recommendations.
 Also new are recommendations for specific situations including
IE in the ICU, IE associated with cancer, and marantic (non-
bacterial) IE.
 Important recommendations are given for the combination of
early diagnosis, early antibiotic therapy and early surgery
 The 2009 guidelines were the first to introduce the concept of
optimal timing of surgery in patients with IE and this is
highlighted again in 2015."

4.  Focus on prevention rather than prophylaxis to
reduce the incidence of IE, particularly in the field of
nosocomial (hospital-acquired) endocarditis
 Because there was no real scientific proof of its
efficacy and it may be potentially dangerous.
 Thus, antibiotic prophylaxis was recommended only
for patients with the highest risk of IE undergoing
the highest risk dental procedures.

5.  The risk of IE related more to low-grade bacteraemia
during daily life rather than sporadic high-grade
bacteraemia after dental procedures.
 Most case–control studies did not report an association
between invasive dental procedures and the occurrence of
IE.
 Avoid 1 case of IE per 150 000 dental procedures and 1
per 46 000 for procedures unprotected by antibiotics.
 Small risk of anaphylaxis

6.  Emergence of resistant microorganisms.
 The effect of bacteraemia in humans is
controversial. (Proven in animals only)
 No prospective RCT has investigated the
efficacy of antibiotic prophylaxis on the
occurrence of IE.

13.  No single practitioner will be able to manage full
spectrum of IE.
 A very high level of expertise is needed from
several specialties, including cardiologists, cardiac
surgeons, ID specialists, microbiologists,
neurologists, neurosurgeons, experts in CHD and
others.
 About 50% patients with IE undergo surgery during
the hospital course. Early discussion with the
surgical team is important and is considered
mandatory in all cases of complicated IE.

14.  Such a team approach has been
recommended recently as class IB in the
2014 AHA/ACC guideline for the
management of patients with VHD.

15. When to refer a patient with IE to an
‘Endocarditis Team’ in a reference centre:
 1. Patients with complicated IE should be referred
early.
 2. Patients with non-complicated IE can be initially
managed in a nonreference centre, but with regular
communication with the reference centre,
consultations with the multidisciplinary ‘Endocarditis
Team’, and, when needed, with external visit to the
reference centre.

16. Characteristics of the reference centre
 1. Immediate access to diagnostic procedures, including
TTE, TOE, multislice CT, MRI, and nuclear imaging.
 2. Immediate access to cardiac surgery.
 3. Several specialists should be present on site (the
‘Endocarditis Team’), including cardiac surgeons,
cardiologists, anaesthesiologists, ID specialists,
microbiologists and, when available, specialists in valve
diseases, CHD, pacemaker extraction, echocardiography
and other cardiac imaging techniques, neurologists, and
facilities for neurosurgery and interventional
neuroradiology .

17. Role of the ‘Endocarditis Team’
 1. It should have meetings on a regular basis in order to discuss
cases, take surgical decisions, and define the type of follow-up.
 2. They chooses the type, duration, and mode of follow up of
antibiotic therapy, according to a standardized protocol, following
the current guidelines.
 3. They should participate in national or international registries,
publicly report the mortality and morbidity of their centre,
and be involved in a quality improvement programme, as well as in
a patient education programme.
 4. The follow-up should be organized on an outpatient visit basis at
a frequency depending on the patient’s clinical status (ideally at 1,
3, 6, and 12 months after hospital discharge, since the majority of
events occur during this period).

38. Antibiotic Treatment Of Blood Culture
Negative Infective Endocarditis
(BCNIE)

42. SURGICAL
MANAGEMENT

48. Cardiac device related
infective endocarditis
(CDRIE)

55.  The incidence of nosocomial infection is increasing and patients
may develop IE
 Admitted to the ICU due to haemodynamic instability related to
severe sepsis, overt HF and/or severe valvular pathology or
organ failure from IE-related complications
 Staph is M.C. f/b streptococcus f/b fungal
 There should be a relatively low threshold for TOE in critically ill
patients with S. Aureus
 multidisciplinary Endocarditis Team environment should be
created.

56.  Incidence – 0.006%.
 Higher inpatients with cardiac disease and further
more in pt with prosthetic valves.
 Maternal mortality ~33%.
 Foetal mortality ~29%.
 Rapid detection and appropriate treatment is
important.
 Despite the high foetal mortality , urgent surgery
should be performed in pt who present with HF due
to acute regurgitation.

57.  Fewer systematic studies.
 Incidence is lower in children(o.o4% per year ) than in
adult(0.1%)
 CHD with multiple lesion is at higher risk than simple lesion.
 Mortality of 4-10 %. Prognosis is better than other forms.
 Surgical repair of CHD reduces the risk, provided there is no
residual shunt.
 Artificial valve substrate may increase the risk.

58.  Sterile vegetations consisting of fibrin and
platelet aggregates on cardiac valves
 Neither bacteraemia nor with destructive
changes of the underlying valve
 Associated with CTD, autoimmune
disorders, hypercoagulable states,
septicaemia, severe burns, tuberculosis,
uraemia or AIDS
 A potentially life-threatening source of
thromboembolism,

59.  Initial diagnostic workup- same
 Strong suspicion if- presence of a heart murmur, the presence of
vegetations not responding to antibiotic and evidence of multiple
systemic emboli
 Small, broad based and irregularly shaped.
 TOE should be ordered when there is a high suspicion
 Immunological assays for APLA syndrome (i.E. Lupus
anticoagulant, anticardiolipin antibodies, and anti-b2-
glycoprotein 1 antibodies; at least one must be positive for the
diagnosis of APLA on at least two occasions 12 weeks apart)

60.  Anticoagulated with UFH or LMWH or warfarin,
although there is little evidence to support this
strategy
 Surgery, valve debridement and/or
reconstruction are often not recommended
unless the patient presents with recurrent
thromboembolism despite well-controlled
anticoagulation.
 Other indications for valve surgery are the same
as for IE

61.  IE may be a potential marker of occult cancers.
 In a large, Danish,nationwide, population-based cohort study,
997 cancers were identified among 8445 IE patients with a
median follow-up of 3.5 years.
 Risk of abdominal and haematological cancers was high (within
the first 3 months)
 S. bovis infection, specifically S. gallolyticus subspecies--
colonic adenoma or carcinoma.
 it is recommended to rule out occult colon cancer during
hospitalization and annual colonoscopy.