Risk of embolization after institution of antibiotic therapy for infective endocarditis
Open accessAbstract
Objectives This study was designed to assess the risk of systemic embolization in patients with left-sided infective endocarditis, once adequate antibiotic treatment had been initiated, on the basis of prospective clinical follow-up.Background As one of the complications of infective endocarditis, embolization has a great impact on prognosis. Prediction of an individual patient's risk of embolization is very difficult.Methods We studied 217 episodes of left-sided endocarditis that were experienced among a cohort of 211 prospectively recruited patients. According to the Duke criteria, 91% of the episodes were definite infective endocarditis. Seventy-two episodes involved infections located on prosthetic valves. All patients were studied by transthoracic and transesophageal echocardiography. Clinical, echocardiographic and microbiologic data were entered in a data base. The mean follow-up interval was 151 days.Results Twenty-eight episodes (12.9%; group I) of endocarditis had embolic events after the initiation of antibiotic therapy. The remaining 189 episodes did not embolize (group II). Most emboli (52%) affected the central nervous system, and 65% of the embolic events occurred during the first two weeks after initiation of antibiotic therapy. Previous embolism was associated with new embolism (relative risk [RR] 1.73, 95% confidence interval [CI] 1.02 to 2.93; p = 0.05). There was an increase in the risk of embolization with increasing vegetation size (RR 3.77, 95% CI 0.97 to 12.57; p = 0.07). Vegetation size had no impact on the risk of embolization in streptococcal endocarditis or aortic infection. By contrast, large (> or = 10 mm) vegetations had a higher incidence of embolism when the microorganism was staphylococcus (p = 0.04) and the mitral valve was infected (p = 0.03). The increase in vegetation size at follow-up showed a higher risk for embolization (RR 2.64, 95% CI 0.98 to 7.16; p = 0.02).Conclusions Embolism before antimicrobial therapy is a risk factor for new emboli. The risk of embolization seems to increase with increasing vegetation size, and this is particularly significant in mitral endocarditis and staphylococcal endocarditis. An increase in vegetation size, despite antimicrobial treatment, may predict later embolism.
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Staphylococcal or fungal infective endocarditis appears to carry a high incidence rate of embolization independently of vegetation size.
“In contrast, as confirmed above by Vilacosta et al, 278 staphylococcal or fungal IE appears to carry a high incidence rate of embolization independently of vegetation size.”
From Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association (2015) · cites this paper as [278]
The Discussion says earlier reports suggested increased embolization risk with Staphylococcus and fungi, but this study found no significant difference by microorganism. It also reports that, in staphylococcal endocarditis, large vegetations had a higher incidence of embolism. The Clinical and microbiologic data section identifies vegetation size—not microorganism—as the only independent predictor in its multivariate analysis. (LLM, conf=0.88)
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Experimental — accuracy not yet measuredVilacosta et al confirmed the reduced frequency of embolization after 2 weeks of therapy and reemphasized the increased risk of embolization with increasing vegetation size during therapy, mitral valve involvement, and staphylococcal pathogenesis.
“Vilacosta et al 278 confirmed the reduced frequency of embolization after 2 weeks of therapy.Moreover, the latter study reemphasized the increased risk of embolization with increasing vegetation size during therapy, mitral valve involvement, and staphylococcal pathogenesis.”
From Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association (2015) · cites this paper as [278]
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Experimental — accuracy not yet measuredEmboli can occur before diagnosis, during therapy, or after therapy is completed, although most emboli occur within the first 2 to 4 weeks of antimicrobial therapy.
“Emboli can occur before diagnosis, during therapy, or after therapy is completed, although most emboli occur within the first 2 to 4 weeks of antimicrobial therapy.58,278”
Two independent studies have confirmed that the rate of embolic events decreases dramatically during and after the first 2 to 3 weeks of successful antibiotic therapy.
“Of note, 2 independent studies have confirmed that the rate of embolic events decreases dramatically during and after the first 2 to 3 weeks of successful antibiotic therapy.”
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- Authors
- Vilacosta, I., Graupner, C., SanRomán, J., Sarriá, C., Ronderos, R., Fernández, C., Mancini, L., Sanz, O., Sanmartín, J., & Stoermann, W.
- Affiliations
- Hospital Clínico San Carlos (ES)
- Hospital Clínico Universitario de Valladolid (ES)
- Hospital Universitario de La Princesa (ES)
- Corresponding author
- Vilacosta, Isidre
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2002-05
- Volume
- 39
- Issue
- 9
- Pages
- 1489-1495
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2135673803
- Semantic Scholar
- 660cb98d36a03cc4f99e4df529de3fbfe95ce150
- Cited by
- 468
- References
- 21
- Citations by year
- 2026: 14 · 2025: 17 · 2024: 23 · 2023: 19 · 2022: 28 · 2021: 33 · 2020: 21 · 2019: 29 · 2018: 18 · 2017: 15 · 2016: 23 · 2015: 18 · 2014: 30 · 2013: 26 · 2012: 11
- FWCI
- 10.30
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Infective Endocarditis Diagnosis and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Valve Diseases and Treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Streptococcal Infections and Treatments
- Keywords
- infective endocarditis, systemic embolization, left-sided endocarditis, antibiotic therapy, embolic events, vegetation size, prosthetic valve endocarditis, mitral valve infection, streptococcal endocarditis, risk factors, transesophageal echocardiography
- MeSH terms
- Adult, Aged, Anti-Bacterial Agents, Aortic Valve, Embolism, Endocarditis, Bacterial, Female, Heart Valve Prosthesis, Humans, Male, Middle Aged, Mitral Valve, Prospective Studies, Risk Factors, Staphylococcal Infections, Streptococcal Infections, Incidence, Prosthesis-Related Infections, Echocardiography, Transesophageal
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