Prosthetic Valve Endocarditis - Guideline for Management of
|Last review: 22/02/2017|
|Next review: 01/02/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the Management of Prosthetic Valve Endocarditis
Prosthetic Valve Endocarditis
This guideline applies to patients with suspected or confirmed prosthetic valve endocarditis (PVE)
1. fever, sweats, general malaise, weight loss, anorexia, leukocytosis or raised C-reactive protein
NB not every patient with PVE has a murmur or a fever.
3 sets of Blood cultures taken at different times during the first 24 hours.
If there are concerns about renal function: Vancomycin can be replaced with Daptomycin or teicoplanin and Gentamicin can be replaced with ciprofloxacin
With an appropriate choice and duration of antimicrobial therapy a significant proportion of cases can be cured. If a cure can be achieved with antimicrobial therapy this avoids the risks associated with open cardiac surgery for a re-do valve replacement. The risks of attempted medical therapy (see below) need to be balanced against the risks of device removal on a case-by-case basis.
Clinical findings that indicate failure of medical therapy in a patient who has had at least 10 days of appropriate antimicrobials include:
1. failure of a raised temperature to settle
A continuing picture of severe sepsis warrants review at an earlier stage.
Indications for Surgery in PVE
1. evidence of uncontrolled infection (see above)
|Empirical Antimicrobial Treatment|
*dose adjustments may be necessary in patients with renal impairment. Low-dose Gentamicin is for synergistic activity: pre-dose levels should be maintained <1mg/l and 1 hour post-dose levels 3-5mg/l.
In patients with acute kidney injury teicoplanin (Initially 10mg /kg dosing) or Daptomycin (8mg/kg, interval adjusted according to renal function) can be used in place of Vancomycin . Ciprofloxacin can be used in place of Gentamicin.2
Therapy will be altered depending on the need for prosthetic valve removal. In the absence of clear indications for surgery (see above), a trial of six weeks antimicrobial therapy should be given.
A wide range of pathogens with varying antimicrobial susceptibilities can cause prosthetic valve endocarditis or pacing lead infection. Empirical therapy may be needed in two clinical situations:
1. A patient with severe sepsis or septic shock in whom it would be inappropriate to wait for blood culture results before starting antimicrobial therapy.
|Directed Antimicrobial Treatment (when microbiology results are known)|
For methicillin-resistant staphylococci a combination of intravenous Vancomycin * see dosing guidelines in combination with oral Rifampicin * 600mg 12-hourly and intravenous Gentamicin* 1mg/kg 8-12 hourly is recommended. Gentamicin should ideally be given for at least 2 weeks.
For patients intolerant of Vancomycin (or risk of nephrotoxicity) or with vancomycin-resistant staphylococci, Daptomycin (link to LTHT daptomycin guideline)can be used instead of vancomycin at a dose of 8mg/Kg every 24 hours.
Daptomycin requires creatinine kinase (CK) levels at baseline and then weekly throughout treatment (or every three days if patient is at a high risk of developing myopathy). Daptomycin is eliminated primarily by the kidneys, therefore baseline creatinine clearance and regular monitoring of renal function is advised.
Use regimen for meticillin-resistant staphylococci in patients with a genuine penicillin allergy and consider desensitization.
*Low-dose Gentamicin is for synergistic activity: pre-dose levels should be maintained <1mg/l and 1 hour post-dose levels 3-5mg/l.
NB. Synergy may be lost in isolates with high-level resistance to Gentamicin.
Other regimens may be required where isolates are resistant to these regimens or toxicity /poor clinical response to therapy occurs.
For streptococci with reduced susceptibility to penicillin (MIC 0.125-≤0.5mg/L) a combination of intravenous Benzyl penicillin 2.4g 4-hourly with Gentamicin* 1mg/kg 12 hourly for the first 2 weeks of therapy is recommended.
For penicillin-resistant streptococci (>MIC 0.5mg/L) see enterococcal regimens.
|Duration of Treatment|
In most instances, uncomplicated prosthetic valve endocarditis should be treated with six weeks with intravenous antimicrobials. If the patient’s symptoms of infection have resolved; they are afebrile; and CRP is returning to normal (<30mg /L) after six weeks treatment, antimicrobials can be stopped.
The presence of a brain abscess, intracardiac abscesses or vertebral osteomyelitis usually requires treatment with six weeks antimicrobials.
|Switch to oral agent(s)|
Adjunctive therapy with agents with good bioavailability such as Rifampicin can be given orally otherwise standard therapy for endocarditis requires intravenous therapy for the duration.
Please contact Microbiology if the patient is not responding to the recommended antimicrobial regimens.
Prosthetic valve endocarditis
|Target patient group:||Adults|
|Target professional group(s):||Secondary Care Doctors
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT consensus.
- Horstkotte D, Piper C, Niehues R, Wiemer M, Schultheiss HP. Late prosthetic valve endocarditis. Eur Heart J 1995; 16 Suppl B: 39-47.
- Gould FK, Denning DW, Elliott TS, et al. Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2012; 67(2): 269-89.
- Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 1994; 96(3): 200-9.
- Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30(4): 633-8.
- Lamas CC, Eykyn SJ. Suggested modifications to the Duke criteria for the clinical diagnosis of native valve and prosthetic valve endocarditis: analysis of 118 pathologically proven cases. Clin Infect Dis 1997; 25(3): 713-9.
- Olaison L, Hogevik H, Alestig K. Fever, C-reactive protein, and other acute-phase reactants during treatment of infective endocarditis. Arch Int Med 1997; 157(8): 885-92.
- McCartney AC, Orange GV, Pringle SD, Wills G, Reece IJ. Serum C reactive protein in infective endocarditis. Journal of Clinical Pathology 1988; 41(1): 44-8.
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