Table 3. Surgical indications: uncontrolled infection.
| Guidelines | Recommendation | Level/class of evidence |
|---|---|---|
| ESC guidelines | Locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation)—timing of surgery: urgent | I/B |
| Infection caused by fungi or multi-resistant organisms—timing of surgery: urgent/elective | I/C | |
| Persisting positive blood cultures despite appropriate antibiotic therapy and adequate control of septic metastatic foci—timing of surgery: urgent/elective | IIa/B | |
| PVE caused by staphylococci or non-HACEK gram-negative bacteria—timing of surgery: urgent/elective | IIa/C | |
| Right-sided IE: Microorganisms difficult to eradicate (e.g., persistent fungi) or bacteremia for >7 days (e.g., S. aureus, P. aeruginosa) despite adequate antimicrobial therapy | IIa/C | |
| AHA/ACC guidelines | Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms | I/B |
| Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy | I/B | |
| Surgery is recommended for patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection | I/C |
ESC guidelines show greater stratification in choosing the correct intervention timing. The AHA/ACC guidelines show greater attention to the onset of symptoms and contemplate a specific indication for IE arisen on a prosthetic valve. Both identify infections refractory to antibiotic therapy or infections caused by microorganisms that are difficult to eradicate as an indication for surgery. IE, Infective endocarditis; ESC, European Society of Cardiology; AHA, American Heart Association; ACC, American College of Cardiology.