Recommendations for Preventing the Spread of Vancomycin Resistance Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). Size of Treatment Effect : CLASS I Benefit >>> Risk Procedure/Treatment SHOULD be performed/ administered: CLASS IIa Benefit >> Risk Additional studies with focused. Early Surgery in Infective Endocarditis n engl j med 366;26 nejm.org june 28, 2012 Conventional treatment treatment Group.
The diagnosis of infective endocarditis (IE) is a clinical challenge because of its varying clinical presentation, the different microorganisms involved.
Infective Endocarditis . The continuing evolution of antimicrobial resistance among common pathogens that cause infective endocarditis creates additional therapeutic issues for physicians to manage in this potentially life- threatening illness.
Methods and Results— This work represents the third iteration of an infective endocarditis “treatment” document developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It updates recommendations for diagnosis, treatment, and management of complications of infective endocarditis.
A multidisciplinary committee of experts drafted this document to assist physicians in the evolving care of patients with infective endocarditis in the new millennium. This extensive document is accompanied by an executive summary that covers the key points of the diagnosis, antimicrobial therapy, and management of infective endocarditis. For the first time, an evidence- based scoring system that is used by the American College of Cardiology and the American Heart Association was applied to treatment recommendations. Tables also have been included that provide input on the use of echocardiography during diagnosis and treatment of infective endocarditis, evaluation and treatment of culture- negative endocarditis, and short- term and long- term management of patients during and after completion of antimicrobial treatment.
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To assist physicians who care for children, pediatric dosing was added to each treatment regimen. Conclusions— The recommendations outlined in this update should assist physicians in all aspects of patient care in the diagnosis, medical and surgical treatment, and follow- up of infective endocarditis, as well as management of associated complications. Clinical variability and complexity in infective endocarditis, however, dictate that these guidelines be used to support and not supplant physician- directed decisions in individual patient management. Introduction. Since the most recent version of the American Heart Association (AHA) statement addressing treatment of IE was published in 1. IE: streptococci, staphylococci, and enterococci. Reports from different patient populations indicate that multidrug resistance among viridans group streptococci is now characteristic of many colonizing and infecting strains.
Oxacillin resistance among Staphylococcus aureus (ORSA) isolates is at an all- time high at many tertiary care institutions. In addition, reports. United States indicate that community- acquired infection resulting from ORSA is frequently seen. Perhaps the most alarming event for S aureus is the development of intermediate- and high- level resistance to vancomycin, which was first described in Japan in 1. United States. 9–1. Vancomycin resistance among enterococci is characteristic of many of the nosocomial isolates. Increasing aminoglycoside resistance among enterococci has been reported.
IE. Coupled with the recent deterioration of antibiotic susceptibility among these groups of Gram- positive cocci is the observation that S aureus has surpassed viridans group streptococci as the leading cause of IE in several recent case series. This has resulted in an overall worsening of the average clinical course of patients with endocarditis and has been associated with an increased number of serious complications and higher mortality rates. The AHA’s recommendations for the treatment of IE have therefore been updated in this statement to better address these microbiological changes. The present Writing Committee conducted a comprehensive review of the literature published between 1. Literature searches of the Pub. Med/MEDLINE databases were undertaken to identify pertinent articles. Searches were limited to the English language.
The major search terms included endocarditis, infective endocarditis, infectious endocarditis, intracardiac, valvular, mural, infection, diagnosis, bacteremia, case definition, epidemiology, risks, demographics, injection drug use, echocardiography, microbiology, culture- negative, therapy, antibiotic, antifungal, antimicrobial, antimicrobial resistance, adverse drug effects, drug monitoring, outcome, meta- analysis, complications, abscess, congestive heart failure, emboli, stroke, conduction abnormalities, survival, pathogens, organisms, treatment, surgery, indications, valve replacement, valve repair, ambulatory care, trials, and prevention. In addition, the present statement includes and updates sections of a separate statement. This work primarily addresses IE in adults; a more detailed review of the unique features of IE in children is available in another statement. AHA Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease. The Committee has also published a statement.
Evidence- Based Scoring System. This is the first time that the American College of Cardiology/American Heart Association evidence- based scoring system (see http: //circ. The purpose of the scoring system is to assist the clinician in interpreting these recommendations and formulating treatment decisions. The system is based on both a classification of recommendations and the level of evidence.
Each treatment recommendation has been assigned a class and a level of evidence. The use of this system should support but not supplant the clinician’s decision making in the management of individual patients’ cases. Classification of Recommendations.
Class I: Conditions for which there is evidence, general agreement, or both that a given procedure or treatment is useful and effective. Class II: Conditions for which there is conflicting evidence, a divergence of opinion, or both about the usefulness/efficacy of a procedure or treatment. In other patients, however, the classic peripheral stigmata may be few or absent. This may occur during acute courses of IE, particularly among patients who are injection drug users (IDUs), in whom IE is often the result of S aureus infection of right- sided heart valves.
Acute IE may evolve too quickly for the development of immunologic vascular phenomena, which are more characteristic of subacute IE. In addition, valve lesions in acute right- sided IE usually do not create the peripheral emboli and immunologic vascular phenomena that can result from left- sided valvular involvement.
Right- sided IE can cause septic pulmonary emboli, however. The variability in clinical presentation of IE requires a diagnostic strategy that is both sensitive for disease detection and specific for its exclusion across all forms of the disease. In 1. 99. 4, Durack and colleagues. Duke University Medical Center proposed a diagnostic schema termed the Duke criteria, which stratified patients with suspected IE into 3 categories: “definite” cases, identified either clinically or pathologically (IE proved at surgery or autopsy); “possible” cases (not meeting the criteria for definite IE); and “rejected” cases (no pathological evidence of IE at autopsy or surgery, rapid resolution of the clinical syndrome with either no treatment or short- term antibiotic therapy, or a firm alternative diagnosis).
A diagnosis of IE is based on the presence of either major or minor clinical criteria. Major criteria in the Duke strategy included IE documented by data obtained at the time of open heart surgery or autopsy (pathologically definite) or by well- defined microbiological criteria (high- grade bacteremia or fungemia) plus echocardiographic data (clinically definite). To maintain the high specificity of blood culture results for IE, the Duke criteria required that some patients with high- grade bacteremia with common IE pathogens also fulfill secondary criteria.
For example, bacteremia resulting from viridans streptococci and members of the HACEK group of fastidious Gram- negative rods, which are classic IE pathogens but uncommonly seen in patients without IE, are given primary diagnostic weight. In contrast, S aureus and Enterococcus faecalis commonly cause both IE and non- IE bacteremias. The Duke criteria therefore gave diagnostic weight to bacteremia with staphylococci or enterococci only when they were community acquired and without an apparent primary focus; these latter types of bacteremia have the highest risk of being associated with IE. The Duke criteria incorporated echocardiographic findings in the diagnostic strategy. Major diagnostic weight was given to only 3 typical echocardiographic findings: mobile, echodense masses attached to valvular leaflets or mural endocardium; periannular abscesses; or new dehiscence of a valvular prosthesis (see Echocardiography).
Six common but less specific findings of IE also were included as minor criteria in the original Duke schema: intermittent bacteremia or fungemia, fever, major embolic events, nonembolic vascular phenomena, underlying valvular disease or injection drug use, and echocardiographic abnormalities that fell short of typical valvular vegetations, abscesses, or dehiscence. Clinically definite IE by the Duke criteria required the presence of 2 major criteria, 1 major criterion and 3 minor criteria, or 5 minor criteria. In the mid- to late 1. Duke criteria were made in 1. These studies. 21–3.
Duke criteria and the diagnostic utility of echocardiography in identifying clinically definite cases. Moreover, a retrospective study of 4. Duke criteria and clinical assessment by infectious disease experts blinded to underlying IE risk factors. Several refinements have been made recently to both the major and minor Duke criteria.
As noted above, in the original Duke criteria, bacteremia resulting from S aureus was considered to fulfill a major criterion only if it was community acquired because ample literature has suggested that this parameter is an important surrogate marker for underlying IE. An increasing number of contemporary studies, however, have documented IE in patients experiencing nosocomial staphylococcal bacteremia. For example, of 5. S aureus IE, 4. 5.