Imaging REASSESSment of embolic events before antibiotic discontinuation in infective endocarditis: REASSESS-IE study

Embolic events (EEs) in infective endocarditis (IE) are frequent and associated with poor prognosis. Follow-up imaging is not standardized despite the risk of persistent extracardiac foci. We aimed to assess the therapeutic impact of imaging reassessment before antibiotic discontinuation.

Prospective multicentre study including patients with definite or possible IE complicated by EEs (2013-2022). Asymptomatic or clinically stable patients who underwent follow-up imaging before antibiotic discontinuation to reassess IE-related EEs were included, whereas those imaged for clinical reasons were excluded. The primary endpoint was therapeutic impact: antibiotic modification and/or intervention. Secondary endpoints included all-cause mortality. Overall, 54% (n = 700/1300) of the entire cohort had IE-related EEs. Among them, 554 patients (mean age 65.7 years, 76% male) under antibiotic therapy were included: 49% with cerebral and 79% with extracerebral EEs, mainly ischaemic stroke (42%) and splenic embolism (40%). Follow-up imaging before antibiotic discontinuation (median, 6 weeks) was performed in 51% (n = 281/554), leading treatment modification in 5.7% (16/281), mainly in patients with Staphylococcus aureus IE complicated by abscess. In-hospital and 5-year mortality were 9.4% and 30.8%, respectively. Haemodynamic instability and comorbidities were associated with long-term mortality, whereas only cardiac surgery was associated with improved survival.

Imaging reassessment of IE-related EEs before stopping antibiotics may lead to therapeutic modification in asymptomatic or clinically stable patients using a risk-stratified individualized imaging strategy guided by the endocarditis teams, rather than a uniform approach. Prospective studies are needed to define standardized imaging algorithms.