Risk of embolic events before and after antibiotic treatment initiation among patients with left-side infective endocarditis.

PURPOSE: Embolic events (EEs) are a common complication of left-side infective endocarditis (IE). The aim of the present study was to identify risk factors for the occurrence of EEs before or after antibiotic treatment instauration among patients with definite or possible IE. METHODS: This retro-prospective study was conducted at the Lausanne University Hospital, Lausanne, Switzerland, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria. RESULTS: A total of 441 left-side IE episodes were included (334: 76% were definite and 107; 24% possible IE). EE were diagnosed in 260 (59%) episodes; in 190 (43%) before antibiotic treatment initiation and 148 (34%) after. Central nervous system (184; 42%) was the most common site of EE. Multivariable analysis identified S. aureus (P 0.022), immunological phenomena (P < 0.001), sepsis (P 0.027), vegetation size ≥ 10 mm (P 0.003) and intracardiac abscess (P 0.022) as predictors of EEs before antibiotic treatment initiation. For EEs after antibiotic treatment initiation, multivariable analysis revealed vegetation size ≥ 10 mm (P < 0.001), intracardiac abscess (P 0.035) and prior EE (P 0.042), as independent predictors of EEs, while valve surgery (P < 0.001) was associated with lower risk for EEs. CONCLUSIONS: We reported a high percentage of EEs among patients with left-side IE; vegetation size, intracardiac abscess, S. aureus and sepsis were independently associated with the occurrence of EEs. In addition to antibiotic treatment, early surgery led to further decrease in EEs incidence.

Impact of thoracoabdominal imaging on diagnosis and management in patients with suspected infective endocarditis.

BACKGROUND: Embolic events (EEs) are a common complication of infective endocarditis (IE) and their presence can impact diagnosis and modify the therapeutic plan. The present study aimed to describe the role of thoracoabdominal imaging, either thoracoabdominal-pelvic Computed Tomography or 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography, on diagnosis and management of patients with suspected IE. METHODS: This study was conducted at a university hospital, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria. RESULTS: Among 966 episodes with suspected IE and thoracoabdominal imaging, 528 (55%) patients were asymptomatic. At least one EE was found in 205 (21%) episodes. Based on thoracoabdominal imaging findings, the diagnosis was reclassified from rejected to possible or from possible to definite IE in 6 (1%) and 10 (1%) episodes, respectively. Among the 413 patients with IE, at least one EE was found on thoracoabdominal imaging in 143 (35%) episodes. Together with the presence of left-side valvular vegetation >10 mm, the results of thoracoabdominal imaging established a surgical indication (prevention of embolism) in 15 (4%) episodes, 7 of which were asymptomatic. CONCLUSIONS: Thoracoabdominal imaging performed in asymptomatic patients with suspected IE improved the diagnosis in only a small proportion of patients. Thoracoabdominal imaging led to a new surgical indication (in association with left-side valvular vegetation >10 mm) in only a small percentage of patients.

The role of early defervescence in ruling out infective endocarditis: a cohort study.

OBJECTIVES: To evaluate the role of defervescence within 4 days from antibiotic treatment initiation in ruling out infective endocarditis (IE) among patients suspected of such diagnosis. METHODS: This study was conducted at the Lausanne University Hospital, Switzerland (January 2014 to May 2022). All patients with suspected IE being febrile upon presentation were included. IE was classified according to the modified Duke criteria proposed by the 2015 European Society of Cardiology guidelines, before or after applying the criterion 'resolution of symptoms suggesting IE within 4 days of the introduction of antibiotic therapy' based solely on early defervescence. RESULTS: Among 1022 episodes with suspected IE, 332 (37%) had IE according to Endocarditis-Team evaluation; 248 were classified by clinical Duke criteria as definite and 84 as possible IE. The rate of defervescence within 4 days from antibiotic treatment initiation was similar (p 0.547) among episodes without (606/690; 88%) and those with IE (287/332; 86%); among episodes classified as definite and possible IE by clinical Duke criteria, 211 of 248 (85%) and 76 of 84 (90%), respectively, defervesced within 4 days from antibiotic treatment initiation. By using early defervescence as a rejection criterion, the 76 episodes with final IE diagnosis classified as possible by clinical criteria could be reclassified as rejected. DISCUSSION: The majority of IE episodes defervesced within 4 days from antibiotic treatment initiation; thus, early defervescence should not be used to rule out the diagnosis of IE.

Role of Cerebral Imaging on Diagnosis and Management in Patients With Suspected Infective Endocarditis.

BACKGROUND: Cerebral embolic events (CEEs) are common complications of infective endocarditis (IE), and their presence can modify diagnosis and therapeutic plans. The aim of the present study was to assess the role of cerebral imaging (Cer-Im) on diagnosis and management of patients with suspected IE. METHODS: This study was conducted at the Lausanne University Hospital, Lausanne, Switzerland, from January 2014 to June 2022. CEEs and IE were defined according to modified Duke criteria of the European Society of Cardiology (ESC) guidelines. RESULTS: Among 573 patients with IE suspicion and Cer-Im, 239 (42%) patients had neurological symptoms. At least 1 CEE was found in 254 (44%) episodes. Based on Cer-Im findings, episodes were reclassified from rejected to possible or from possible to definite IE in 3 (1%) and 25 (4%) patients, respectively (0% and 2% in asymptomatic patients, respectively). Among the 330 patients with possible or definite IE, at least 1 CEE was found in 187 (57%) episodes. A new surgical indication (in association with left-side vegetation >10 mm) was established in 74/330 (22%) IE patients and 30/155 (19%) asymptomatic IE patients, respectively. CONCLUSIONS: Cer-Im in asymptomatic patients with IE suspicion showed limited potential for improving the diagnosis of IE. In contrast, performing Cer-Im in asymptomatic patients with IE may be useful for decision making, because Cer-Im findings led to the establishment of new operative indication for valvular surgery in one fifth of patients according to ESC guidelines.