Infective Endocarditis (IE)

NICE clinical guideline [CG64] Prophylaxis against infective endocarditis. Last updated: Jul 2016 BNF treatment summary: cardiovascular system infections, antibacterial therapy

IE Prophylaxis Guidelines

NICE states that the following cardiac conditions put patients at higher risk of IE:
  • Previous IE
  • Valve replacement 
  • Acquired valvular stenosis / regurgitation 
  • Hypertrophic cardiomyopathy
  • Congenital structural heart diseaseESC defines structural heart disease as an abnormality in the heart structure - valve / wall / chamber / great vessel. Note that coronary artery disease itself does not fall under the category of structural heart disease. Common congenital structural heart diseases: ⦁ ASD ⦁ VSD ⦁ Tetralogy of Fallot ⦁ Bicuspid aortic valve

Selected points from NICE, ESC, AHA guidelines to prevent IE:
  • Maintain good oral hygiene
  • Avoid non-essential invasive procedures (e.g. skin piercing, tattooing)
  • Avoid IVDU
  • Patient education

Antibiotic prophylaxis is NOT recommended routinely.

NICE specifically states that in the following scenarios, routine antibiotic prophylaxis against IE is not recommended:
  • Dental procedures
    • Chlorhexidine mouthwash shouldn’t be offered as prophylaxis for dental procedures
  • Non-dental procedures at the following sites:
    • Upper and lower GI tract
    • Upper and lower respiratory tract (including ENT procedures and bronchoscopy)
    • Genitourinary tract (including urological, O&G procedures, childbirth)
NICE acknowledges that the evidence reviews for this guideline covered only procedures at the sites listed in this recommendation. Procedures at other sites are outside the scope of the guideline.

NICE recommends that if a person is at risk of IE and is receiving antimicrobial therapy due to a GI /GU procedure for suspected infection → give antibiotics that cover IE organisms. 

IE Management Guidelines

BNF recommends antibiotic therapy depending on native or prosthetic valve IE:
  • Native valve
    • 1st line: amoxicillin / ampicillin +/- gentamicin
    • Penicillin allergic / MRSA suspected / severe sepsis: vancomycin + gentamicin
    •  Severe sepsis with RF for gram -ve infection: vancomycin + meropenem
  • Prosthetic valve
    • 1st line: vancomycin + rifampicin + gentamicin (low-dose)

Duration of antibiotic therapy: generally 4-6 weeks
 
Organism 1st line antibiotic MRSA / penicillin allergic
Staphylococci Native valve → flucloxacillin Native valve → vancomycin + rifampicin
Prosthetic valve → flucloxacillin + rifampicin + gentamicin Prosthetic valve → vancomycin + rifampicin + gentamicin
Streptococci Benzypenicillin Vancomycin / teicoplanin + gentamicin 
Enterococci Amoxicillin / ampicillin + gentamicin / benzylpenicillin  Vancomycin / teicoplanin + gentamicin 
HACEK microorganisms Gram -ve organisms that are typically oropharyngeal commensals ⦁ Haemophilus species ⦁ Aggregatibacter actinomycetemcomitans ⦁ Cardiobacterium hominis ⦁ Eikenella corrodens ⦁ Kingella kingae Amoxicillin / ampicillin + gentamicin  Ceftriaxone / cefotaxime + gentamicin 
Author: Hamza M
Editor: Adams Lau
Last Edited: 25/12/2024