Francisco Nacinovich

Health care-associated native valve endocarditis: importance of non-nosocomial acquisition.

BACKGROUND The clinical profile and outcome of nosocomial and non-nosocomial health care-associated native valve endocarditis are not well defined. OBJECTIVE To compare the characteristics and outcomes of community-associated and nosocomial and non-nosocomial health care-associated native valve endocarditis. DESIGN Prospective cohort study. SETTING 61 hospitals in 28 countries. PATIENTS Patients with definite native valve endocarditis and no history of injection drug use who were enrolled in the ICE-PCS (International Collaboration on Endocarditis Prospective Cohort Study) from June 2000 to August 2005. MEASUREMENTS Clinical and echocardiographic findings, microbiology, complications, and mortality. RESULTS Health care-associated native valve endocarditis was present in 557 (34%) of 1622 patients (303 with nosocomial infection [54%] and 254 with non-nosocomial infection [46%]). Staphylococcus aureus was the most common cause of health care-associated infection (nosocomial, 47%; non-nosocomial, 42%; P = 0.30); a high proportion of patients had methicillin-resistant S. aureus (nosocomial, 57%; non-nosocomial, 41%; P = 0.014). Fewer patients with health care-associated native valve endocarditis had cardiac surgery (41% vs. 51% of community-associated cases; P < 0.001), but more of the former patients died (25% vs. 13%; P < 0.001). Multivariable analysis confirmed greater mortality associated with health care-associated native valve endocarditis (incidence risk ratio, 1.28 [95% CI, 1.02 to 1.59]). LIMITATIONS Patients were treated at hospitals with cardiac surgery programs. The results may not be generalizable to patients receiving care in other types of facilities or to those with prosthetic valves or past injection drug use. CONCLUSION More than one third of cases of native valve endocarditis in non-injection drug users involve contact with health care, and non-nosocomial infection is common, especially in the United States. Clinicians should recognize that outpatients with extensive out-of-hospital health care contacts who develop endocarditis have clinical characteristics and outcomes similar to those of patients with nosocomial infection. PRIMARY FUNDING SOURCE None.

Emergence of Coagulase-Negative Staphylococci as a Cause of Native Valve Endocarditis

BACKGROUND Coagulase-negative staphylococci (CoNS) are an infrequent cause of native valve endocarditis (NVE), and our understanding of NVE caused by CoNS is incomplete. METHOD The International Collaboration on Endocarditis-Prospective Cohort Study includes patients with endocarditis from 61 centers in 28 countries. Patients with definite cases of NVE caused by CoNS who were enrolled during the period June 2000-August 2006 were compared with patients with definite cases of NVE caused by Staphylococcus aureus and patients with NVE caused by viridans group streptococci. Multivariable logistic regression was used to determine factors associated with death in patients with NVE caused by CoNS. RESULTS Of 1635 patients with definite NVE and no history of injection drug use, 128 (7.8%) had NVE due to CoNS. Health care-associated infection occurred in 63 patients (49%) with NVE caused by CoNS. Comorbidities, long-term intravascular catheter use, and history of recent invasive procedures were similar among patients with NVE caused by CoNS and among patients with NVE caused by S. aureus. Surgical treatment for endocarditis occurred more frequently in patients with NVE due to CoNS (76 patients [60%]) than in patients with NVE due to S. aureus (150 [33%]; P=.01) or in patients with NVE due to viridans group streptococci (149 [44%]; P=.01). Despite the high rate of surgical procedures among patients with NVE due to CoNS, the mortality rates among patients with NVE due to CoNS and among patients with NVE due to S. aureus were similar (32 patients [25%] and 124 patients [27%], respectively; P=.44); the mortality rate among patients with NVE due to CoNS was higher than that among patients with NVE due to viridans group streptococci (24 [7.0%]; P=.01). Persistent bacteremia (odds ratio, 2.65; 95% confidence interval, 1.08-6.51), congestive heart failure (odds ratio, 3.35; 95% confidence interval, 1.57-7.12), and chronic illness (odds ratio, 2.86; 95% confidence interval, 1.34-6.06) were independently associated with death in patients with NVE due to CoNS (c index, 0.73). CONCLUSIONS CoNS have emerged as an important cause of NVE in both community and health care settings. Despite high rates of surgical therapy, NVE caused by CoNS is associated with poor outcomes.

Non-HACEK Gram-Negative Bacillus Endocarditis

Context Infective endocarditis due to non-HACEK organisms has been considered to be associated with injection drug use. Contribution Analysis of 2761 cases of patients with infective endocarditis from an international collaborative of 61 hospitals found that non-HACEK organisms account for fewer than 2% of the cases, and that most patients with non-HACEK endocarditis had infections associated with health care. Of patients with non-HACEK infections, 59% had implanted endovascular devices or prosthetic valves, but only 4% had injection drug use. More than one half of patients with non-HACEK infections required cardiac surgery and 24% died. Implication Infective endocarditis due to non-HACEK organisms is a rare but frequently fatal condition. It is much more frequently associated with implanted endovascular devices than with injection drug use. The Editors Infective endocarditis caused by non-HACEK (species other than Haemophilus species, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella species) gram-negative bacilli is a rare and poorly characterized disease. The literature describing non-HACEK gram-negative bacillus endocarditis primarily consists of several small case series from the 1970s and 1980s of outbreaks in injection drug users in large urban areas, such as Detroit (1, 2), Cleveland (3), and San Francisco (4, 5). As a result, endocarditis due to non-HACEK gram-negative bacilli has been considered to be almost exclusively associated with injection drug use (6, 7). In contrast to this reporting bias, however, non-HACEK gram-negative bacillus endocarditis has been occasionally reported to be a nosocomial problem, particularly in patients with early endocarditis after cardiac surgery (811). The International Collaboration on Endocarditis Prospective Cohort Study (ICE-PCS) database was created in 1999. From 1 January 2000 to 31 August 2005, 2761 patients with definite endocarditis from 61 centers in 28 countries were prospectively enrolled. This resource offers a unique opportunity to evaluate the epidemiology, characteristics, and outcome of endocarditis due to non-HACEK gram-negative bacilli in a large, contemporary, and international cohort of well-characterized patients with endocarditis. Methods The International Collaboration on Endocarditis Prospective Cohort Study Hospitalized patients with endocarditis (12) were identified prospectively by using site-specific procedures to ensure consecutive enrollment. Informed consent (oral or written) was obtained from all patients according to local institutional review board or ethics committee instructions. A standard case report form containing 275 variables was completed for each patient on enrollment at the participating site. The ICE-PCS database is maintained at the Duke Clinical Research Institute, Durham, North Carolina, which serves as the coordinating center for the ICE studies, with approval from the institutional review board. We included all patients with endocarditis from sites that met performance criteria for participation. These site criteria included 1) minimum enrollment of 12 cases per year in a center with access to cardiac surgery, 2) the presence of patient identification procedures to ensure consecutive enrollment and to minimize ascertainment bias (as described elsewhere) (13, 14), 3) high-quality data with query resolution, and 4) institutional review board or ethics committee approval or waiver based on local standards. All patients from sites that did not meet these criteria (totaling 494 case-patients from 14 sites) were excluded. Sample We included patients who had both definite endocarditis according to the modified Duke criteria (12) and isolation of a pure culture of an aerobic gram-negative bacillus from the bloodstream or valve. To ensure that the diagnosis of gram-negative endocarditis was accurate, the following additional criteria were applied when interpreting the blood culture results: 1) the patients bacteremia had to meet the definition for persistently positive blood cultures when applying the modified Duke criteria; 2) a single blood culture positive for a gram-negative organism was not considered to constitute a minor microbiological criterion when applying the modified Duke criteria; and 3) patients with endocarditis due to anaerobes, Brucella species, HACEK organisms, or other fastidious gram-negative pathogens (for example, Pasteurella species) or polymicrobial infections were excluded. Definitions We used published definitions of health carerelated variables (15, 16). Nonnosocomial health careassociated infection was defined as a health careassociated infection that was not acquired as a hospital inpatient (for example, hemodialysis, outpatient cancer chemotherapy, or receipt of intravenous antibiotics at home) (16). A nosocomial infection was defined as a health careassociated infection that was acquired after at least 48 hours as a hospital inpatient. Prosthetic endocarditis was defined as endocarditis involving a prosthetic heart valve or implanted endovascular device, such as a permanent cardiac pacemaker, cardioverter defibrillator, or aortic stent. Statistical Analysis Patients with definite non-HACEK gram-negative bacillus endocarditis were compared with all other patients with definite endocarditis in the ICE-PCS database. Continuous variables are presented as medians and 25th and 75th percentiles. Categorical variables are presented as frequencies and percentages of the specified group. Univariable comparisons were made by using the Wilcoxon rank-sum test or the chi-square test as appropriate. For all tests, a P value of 0.05 or less was considered statistically significant. Missing data for each variable were excluded from the denominator as indicated in Table 1. All statistical analyses were performed by using SAS software (version 8.2, SAS Institute, Cary, North Carolina). Table 1. Frequency of Individual Duke Criteria among 49 Patients with Non-HACEK Gram-Negative Bacillus Endocarditis* Role of the Funding Source The study did not receive funding. Results Of the 2761 patients with definite endocarditis, 49 (1.8%) had endocarditis due to non-HACEK gram-negative bacilli. Twenty-six of these patients (53%) were enrolled from Europe; 11 (22%) from North America; and the remainder from South America, New Zealand, Australia, the Middle East, and Asia. Patient enrollment was constant throughout the study period. Characteristics of Non-HACEK Gram-Negative Bacillus Endocarditis Patients with non-HACEK gram-negative bacillus endocarditis were more likely to have had symptoms for more than 1 month than were patients infected with other pathogens (90% [95% CI, 82% to 98%] vs. 77% [CI, 75% to 79%], respectively; P= 0.035) (Table 2). Injection drug use was uncommon in patients with non-HACEK gram-negative bacillus endocarditis and in patients with endocarditis due to other organisms (4% [CI, 0% to 9%] vs. 10% [CI, 9% to 11%]; P= 0.20). In contrast, health care contact was a statistically significant risk factor for non-HACEK gram-negative bacillus endocarditis (57% [CI, 43% to 71%] vs. 30% [CI, 28% to 32%]; P< 0.001), largely because the proportion of nosocomial infections was higher in the non-HACEK gram-negative bacillus endocarditis group (39% [CI, 25% to 53%] vs. 14% [CI, 13% to 15%]; P< 0.001). The Figure shows the routes of acquisition of non-HACEK gram-negative bacillus endocarditis compared with Staphylococcus aureus endocarditis (15) and all other causes of endocarditis in the ICE-PCS database. Table 2. Characteristics of Patients with Non-HACEK Gram-Negative Bacillus Infective Endocarditis and Those with Other Causes of Endocarditis* Figure. Routes of acquisition among patients with definite endocarditis due to non-HACEK gram-negative bacilli, Staphylococcus aureus , and other pathogens. HACEK = Haemophilus species, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella species. Implanted endovascular devices were more common in patients with non-HACEK gram-negative bacillus endocarditis than in patients with other pathogens (29% [CI, 16% to 42%] vs. 11% [CI, 10% to 12%]; P< 0.001). Patients with non-HACEK gram-negative bacillus endocarditis were also statistically significantly more likely than patients with other causes of endocarditis to have a presumed source of infection involving the genitourinary or nonoral gastrointestinal tract (35% [CI, 22% to 48%] vs. 12% [CI, 11% to 13%]; P< 0.001). A nondental invasive procedure within 60 days before symptom onset was more likely in patients with non-HACEK gram-negative bacillus endocarditis than in patients with other causes of endocarditis (38% [CI, 24% to 52%] vs. 19% [CI, 18% to 20%]; P= 0.002). Intracardiac abscesses were statistically significantly more common in patients with non-HACEK gram-negative bacillus endocarditis than in patients with endocarditis due to other organisms (25% [CI, 13% to 37%] vs. 14% [CI, 13% to 15%]; P= 0.034). The in-hospital mortality rate was 24% (CI, 12% to 36%) for patients with non-HACEK gram-negative bacillus endocarditis and 17% (CI, 16% to 18%) for patients with other causes of endocarditis (P= 0.190). Of the 49 patients with non-HACEK gram-negative bacillus endocarditis, 20 (41%) had native-valve endocarditis and 29 (59%) had prosthetic endocarditis. All 49 cases were confirmed as definite endocarditis by the modified Duke criteria: 22 (45%) were histopathologically (16 patients [33%]) or macroscopically (at surgery in 6 patients [12%]) confirmed (Table 1). Of the 16 patients with pathologic confirmation, 8 had valve cultures, 2 had device cultures, and 1 had an aortic aneurysm culture. Microbiology of Non-HACEK Gram-Negative Bacillus Endocarditis The most common pathogens in patients with non-HACEK gram-negative bacillus endocarditis were Escherichia coli (14 patients [29%]) and Pseudomonas aeruginosa (11 patients [22%]). Othe

Association Between Surgical Indications, Operative Risk, and Clinical Outcome in Infective Endocarditis: A Prospective Study From the International Collaboration on Endocarditis

Background— Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined. Methods and Results— The International Collaboration on Endocarditis–PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non–cardiac device–related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE. Conclusions— Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management.Background— Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined. Methods and Results— The International Collaboration on Endocarditis–PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non–cardiac device–related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE. Conclusions— Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management. # CLINICAL PERSPECTIVE {#article-title-40}

High-Dose Daptomycin Therapy for Left-Sided Infective Endocarditis: a Prospective Study from the International Collaboration on Endocarditis

ABSTRACT The use of daptomycin in Gram-positive left-sided infective endocarditis (IE) has significantly increased. The purpose of this study was to assess the influence of high-dose daptomycin on the outcome of left-sided IE due to Gram-positive pathogens. This was a prospective cohort study based on 1,112 cases from the International Collaboration on Endocarditis (ICE)-Plus database and the ICE-Daptomycin Substudy database from 2008 to 2010. Among patients with left-sided IE due to Staphylococcus aureus, coagulase-negative staphylococci, and Enterococcus faecalis, we compared those treated with daptomycin (cohort A) to those treated with standard-of-care (SOC) antibiotics (cohort B). The primary outcome was in-hospital mortality. Time to clearance of bacteremia, 6-month mortality, and adverse events (AEs) ascribable to daptomycin were also assessed. There were 29 and 149 patients included in cohort A and cohort B, respectively. Baseline comorbidities did not differ between the two cohorts, except for a significantly higher prevalence of diabetes and previous episodes of IE among patients treated with daptomycin. The median daptomycin dose was 9.2 mg/kg of body weight/day. Two-thirds of the patients treated with daptomycin had failed a previous antibiotic regimen. In-hospital and 6-month mortalities were similar in the two cohorts. In cohort A, median time to clearance of methicillin-resistant S. aureus (MRSA) bacteremia was 1.0 day, irrespective of daptomycin dose, representing a significantly faster bacteremia clearance compared to SOC (1.0 versus 5.0 days; P < 0.01). Regimens with higher daptomycin doses were not associated with increased incidence of AEs. In conclusion, higher-dose daptomycin may be an effective and safe alternative to SOC in the treatment of left-sided IE due to common Gram-positive pathogens.

Candida Infective Endocarditis: an Observational Cohort Study with a Focus on Therapy

ABSTRACT Candida infective endocarditis is a rare disease with a high mortality rate. Our understanding of this infection is derived from case series, case reports, and small prospective cohorts. The purpose of this study was to evaluate the clinical features and use of different antifungal treatment regimens for Candida infective endocarditis. This prospective cohort study was based on 70 cases of Candida infective endocarditis from the International Collaboration on Endocarditis (ICE)-Prospective Cohort Study and ICE-Plus databases collected between 2000 and 2010. The majority of infections were acquired nosocomially (67%). Congestive heart failure (24%), prosthetic heart valve (46%), and previous infective endocarditis (26%) were common comorbidities. Overall mortality was high, with 36% mortality in the hospital and 59% at 1 year. On univariate analysis, older age, heart failure at baseline, persistent candidemia, nosocomial acquisition, heart failure as a complication, and intracardiac abscess were associated with higher mortality. Mortality was not affected by use of surgical therapy or choice of antifungal agent. A subgroup analysis was performed on 33 patients for whom specific antifungal therapy information was available. In this subgroup, 11 patients received amphotericin B-based therapy and 14 received echinocandin-based therapy. Despite a higher percentage of older patients and nosocomial infection in the echinocandin group, mortality rates were similar between the two groups. In conclusion, Candida infective endocarditis is associated with a high mortality rate that was not impacted by choice of antifungal therapy or by adjunctive surgical intervention. Additionally, echinocandin therapy was as effective as amphotericin B-based therapy in the small subgroup analysis.

Repeat endocarditis: analysis of risk factors based on the International Collaboration on Endocarditis - Prospective Cohort Study.

Repeat episodes of infective endocarditis (IE) can occur in patients who survive an initial episode. We analysed risk factors and 1-year mortality of patients with repeat IE. We considered 1874 patients enrolled in the International Collaboration on Endocarditis - Prospective Cohort Study between January 2000 and December 2006 (ICE-PCS) who had definite native or prosthetic valve IE and 1-year follow-up. Multivariable analysis was used to determine risk factors for repeat IE and 1-year mortality. Of 1874 patients, 1783 (95.2%) had single-episode IE and 91 (4.8%) had repeat IE: 74/91 (81%) with new infection and 17/91 (19%) with presumed relapse. On bivariate analysis, repeat IE was associated with haemodialysis (p 0.002), HIV (p 0.009), injection drug use (IDU) (p < 0.001), Staphylococcus aureus IE (p 0.003), healthcare acquisition (p 0.006) and previous IE before ICE enrolment (p 0.001). On adjusted analysis, independent risk factors were haemodialysis (OR, 2.5; 95% CI, 1.2-5.3), IDU (OR, 2.9; 95% CI, 1.6-5.4), previous IE (OR, 2.8; 95% CI, 1.5-5.1) and living in the North American region (OR, 1.9; 95% CI, 1.1-3.4). Patients with repeat IE had higher 1-year mortality than those with single-episode IE (p 0.003). Repeat IE is associated with IDU, previous IE and haemodialysis. Clinicians should be aware of these risk factors in order to recognize patients who are at risk of repeat IE.

Response to Letter Regarding Article, "Association Between Surgical Indications, Operative Risk, and Clinical Outcome in Infective Endocarditis: A Prospective Study From the International Collaboration on Endocarditis".

We appreciate the thoughtful comments of Drs Almonedro-Delia, Galvez-Acebal, and Rodriguez-Bano regarding our recent publication, “Association Between Surgical Indications, Operative Risk, and Clinical Outcome in Infective Endocarditis: a Prospective Study From the International Collaboration on Endocarditis.”1 These authors raise important issues for evaluating the impact of surgery on patient outcomes, particularly survival. We strongly agree that treatment selection bias and survivor bias are major issues when evaluating the impact of surgery on mortality and that the use of appropriate statistical methodologies is necessary to quantify an unbiased and causal association of the effect of surgical treatment on outcome. In our previous studies on …

Association Between Surgical Indications, Operative Risk, and Clinical Outcome in Infective Endocarditis

Background— Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined. Methods and Results— The International Collaboration on Endocarditis–PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non–cardiac device–related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE. Conclusions— Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management.Background— Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined. Methods and Results— The International Collaboration on Endocarditis–PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non–cardiac device–related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE. Conclusions— Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management. # CLINICAL PERSPECTIVE {#article-title-40}

Association Between Surgical Indications, Operative Risk, and Clinical Outcome in Infective EndocarditisCLINICAL PERSPECTIVE

Background— Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined. Methods and Results— The International Collaboration on Endocarditis–PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non–cardiac device–related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE. Conclusions— Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management.Background— Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined. Methods and Results— The International Collaboration on Endocarditis–PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non–cardiac device–related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE. Conclusions— Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management. # CLINICAL PERSPECTIVE {#article-title-40}