Avoidable delays in the care of infective endocarditis patients: a priority issue

Guidelines recommend prompt diagnosis and timely surgical intervention for infective endocarditis (IE); however, adherence in clinical practice remains inconsistent. We quantified delays throughout the IE care pathway and evaluated their association with mortality after adjusting for baseline severity.

We conducted a retrospective single-centre cohort study of consecutive patients with definite IE and a guideline-based surgical indication who were admitted to Misericordia Hospital, Grosseto (Italy), between 1 January 1998 and 31 December 2023. Time intervals from the first symptom to hospital admission, to transthoracic (TTE), transoesophageal (TOE) echocardiography, and surgery were recorded. Patients were classified as In-Time if surgery was performed within the guideline-recommended timeframe (emergency: <24 h; urgent: <5 days; elective: otherwise) or Delayed. A prespecified subgroup analysis within the Delayed group distinguished Delayed-operated from Delayed-never-operated patients. Univariable and multivariable logistic regression estimated the association between delay and in-hospital mortality, adjusting for age, Sequential Organ Failure Assessment (SOFA) score, Staphylococcus aureus aetiology, acute heart failure, embolization, and abscess.

The analytic cohort comprised 198 patients with a surgical indication: 62 (31.3%) in the In-Time group and 136 (68.7%) in the Delayed group (78 Delayed-operated and 58 Delayed-never-operated). The interval from symptom onset to hospital admission was the largest single contributor to the total time to surgery (∼50% of the total). Crude in-hospital mortality was 9.7% in the In-Time group and 40.4% in the Delayed group (p < 0.001). Within the Delayed group, in-hospital mortality was 20.5% in Delayed-operated patients and 67.2% in Delayed-never-operated patients. In the multivariable model (n = 193, events = 60), delayed treatment remained independently associated with in-hospital mortality [adjusted OR 3.37, 95% confidence interval (CI) 1.19-9.56; p = 0.022]; SOFA score [adjusted odds ratio (aOR) 1.43 per point, 1.23-1.66; p < 0.001] and the presence of any embolization (aOR 2.42, 1.09-5.38; p = 0.030) were also independently significant.

Delays are common along the IE care pathway and concentrated in the pre-admission and indication-to-surgery phases. Patients with delayed management have substantially higher crude and adjusted in-hospital mortality, with the worst outcomes in patients who never reach the operating room. These observations support modifiable system-level priorities: educating general practitioners and high-risk patients about suspicious symptoms; faster in-hospital access to TOE and PET/CT; and implementing a structured endocarditis Heart Team with protected operating slots.