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Risk stratification score screening for infective endocarditis in patients with Gram-positive bacteraemia
Helena Lindberg1, Emma Löfström2, Magnus Rasmussen3
1Department of Infectious Diseases, Hospital of Halland, Halmstad, Sweden.
Insights
Six risk stratification scores for Gram-positive bacteraemia show high accuracy in predicting infective endocarditis. These tools can help clinicians identify patients needing further investigation, like echocardiography, to diagnose this serious condition.
Area of Science:
- Infectious Diseases
- Cardiology
- Medical Informatics
Background:
- Infective endocarditis is a serious complication of Gram-positive bacteraemia.
- Risk stratification scores can assist clinicians in identifying patients at high risk.
- Six scores were evaluated for predicting endocarditis in specific Gram-positive bacteraemia contexts.
Purpose of the Study:
- To validate the predictive ability of six established risk stratification scores for infective endocarditis.
- To assess the impact of these scores on the utilization of echocardiography.
- To determine the effectiveness of these scores in different Gram-positive bacteraemia scenarios.
Main Methods:
- Retrospective evaluation of hospitalized adult patients with Gram-positive bacteraemia (2017-2019).
- Data collection included baseline characteristics, score-specific data, endocarditis diagnosis, and echocardiography records.
- Analysis focused on sensitivity, specificity, and predictive values of six scores (PREDICT, VIRSTA, POSITIVE, HANDOC, NOVA, DENOVA).
Main Results:
- Definite endocarditis was diagnosed in 7.5% (S. aureus), 6.6% (non-β-haemolytic streptococci), and 3.2% (E. faecalis) of patients.
- Score sensitivities ranged from 80-100%, with negative predictive values of 98-100%.
- VIRSTA, HANDOC, NOVA, and DENOVA identified all cases; PREDICT5 missed one, and POSITIVE missed four cases. Echocardiography use increased by 7-77% with score implementation.
Conclusions:
- All evaluated risk stratification scores demonstrated high negative predictive values (>98%) for endocarditis.
- PREDICT5, VIRSTA, POSITIVE, HANDOC, and DENOVA are considered effective early screening tools for Gram-positive bacteraemia.
- The application of these scores is likely to increase the number of echocardiography investigations performed.
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.
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