Optimal surgical timing for non-urgent surgery patients with active infective endocarditis

While preoperative antibiotic therapy is generally recommended in non-emergency surgery cases of infective endocarditis, delaying surgery may lead to a deterioration in patient condition. This study examined deterioration of condition during preoperative antibiotic therapy and associated clinical characteristics to clarify the optimal timing for non-emergent infective endocarditis surgery. We retrospectively analyzed 65 patients (mean age 57.1 ± 16.9 years) with active left-sided infective endocarditis (57 with native valves, 8 with prosthetic valves) initially considered suitable for combined antibiotic therapy and non-emergent surgical treatment. Causative organisms were Streptococcus spp. (n=31), Staphylococcus spp. (n=15, including 5 resistant strains), and Gram-negative bacteria (n=4). Twelve patients (18%) required unexpected urgent operations shortly after starting antibiotics (median 5.5 days, interquartile range 3-8 days). Another 12 patients (18%) experienced deterioration of condition 20-30 days after starting antibiotics, including worsening heart failure (n=5), new embolic events (n=3), new perivalvular extension of infection (n=3), and worsening infection parameters (n=1). A leukocyte count >7900/μL one week after starting antibiotics predicted late deterioration (sensitivity 91%, specificity 76%, area under the receiver operating characteristic curve 0.866). Among patients with active infective endocarditis who initially received maximal antibiotic therapy and were considered for non-emergent surgery, 18% required urgent operation and another 18% experienced late deterioration. A high leukocyte count despite one week of antibiotic therapy was associated with late deterioration. For these patients, earlier surgical intervention might be beneficial to avoid a deterioration in conditions.