Risk stratification score screening for infective endocarditis in patients with Gram-positive bacteraemia

Abstract

Background

A feared cause of bacteraemia with Gram-positives is infective endocarditis. Risk stratification scores can aid clinicians in determining the risk of endocarditis. Six proposed scores for the use in bacteraemia; Staphylococcus aureus (PREDICT, VIRSTA, POSITIVE), non-β-haemolytic streptococci (HANDOC) and Enterococcus faecalis (NOVA, DENOVA) were validated for predictive ability and the utilization of echocardiography was investigated.

Methods

Hospitalized adult patients with Gram-positive bacteraemia during 2017–2019 were evaluated retrospectively through medical records and the Swedish Death Registry. Baseline and score-specific data, definite endocarditis and echocardiographies performed were recorded. Sensitivity, specificity, negative and positive predictive values and echocardiography utilization were determined.

Results

480 patients with bacteraemia were included and definite endocarditis was diagnosed in 20 (7.5%), 10 (6.6%), and 2 (3.2%) patients with S. aureus, non-β-haemolytic streptococci and E. faecalis, respectively. The sensitivities of the scores were 80–100% and specificities 8–77%. Negative predictive values of the six scores were 98–100%. VIRSTA, HANDOC, NOVA and DENOVA identified all, the PREDICT5 score missed 1/20 and the POSITIVE score missed 4/20 cases of endocarditis. Transoesophageal echocardiography was performed in 141 patients (29%). Thus, the risk stratification scores suggested an increase of 3–63 (7–77%) investigations with echocardiography.

Conclusions

All scores had negative-predictive values over 98%, therefore it can be concluded that PREDICT5, VIRSTA, POSITIVE, HANDOC and DENOVA are reasonable screening tools for endocarditis early on in Gram-positive bacteraemia. The use of risk stratification scores will lead to more echocardiographies.

Keywords:

• Infective endocarditis
• Staphylococcus aureus
• Enterococcus faecalis
• non-β-haemolytic Streptococcus
• risk stratification score
• transoesophageal echocardiography (TEE)

Acknowledgement

The authors thank Erik Gunnarsson and Christoffer Lindsten at the Department of Microbiology, Halmstad, for their work with the microbiological data extraction in this study, Anders Holmén for the support in SPSS-files, Ingrid Larsson for important discussions, and Sienna Linden for generous help proofreading the text.

Disclosure statement

The authors report no conflict of interest.

Additional information

Funding

This work was supported by The Region Halland Research Council and The Foundation of Sparbanken Varberg to H. L. and the Swedish Government Funds for Clinical Research (ALF) to M. R.