Appropriateness of Preoperative Antimicrobial Therapy Does not Impact Outcomes Following Surgery for Infective Endocarditis
Squiers, John Jay
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BACKGROUND: A long-standing paradigm of the surgical management of infective endocarditis was to delay surgery until the infection was adequately treated out of concern for increased technical difficulties due to acutely inflamed valvular tissue present during active infection. Up to half of patients with infective endocarditis may initially receive bacteriologically inadequate antimicrobial therapy, delaying time to surgery in these patients. However, several benefits of earlier surgery in certain patients with infective endocarditis and guideline-directed indication(s) for surgery have emerged over the last decade. Thus, surgeons are increasingly faced with a decision whether to operate on patients with infective endocarditis whose infection may not be adequately treated prior to surgery. OBJECTIVE: We sought to examine the characteristics of patients with infective endocarditis requiring surgical treatment and to determine whether the appropriateness of preoperative antimicrobial therapy impacted their short-term and long-term outcomes. METHODS: Records of 335 consecutive patients undergoing valve surgery to treat infective endocarditis between 1990-2013 at a single center were retrospectively reviewed. All patients with definite or possible infective endocarditis, defined by modified Duke criteria, and with positive blood cultures prior to surgery were included in the study. Two infectious disease clinicians, blinded to patient outcomes, graded appropriateness of preoperative antimicrobial regimens. RESULTS: A total of 270 patients (190 men; mean age 46.2 years) met inclusion criteria. Appropriate preoperative antimicrobial therapy was administered to 217 (80%) patients. Enterococci and fungal infections were more common in the inappropriately treated group, as was recurrent infective endocarditis. A history of viral hepatitis was less common in the inappropriately treated group. Otherwise, there were no significant differences in the rates of baseline comorbidities, valve involvement, or etiologic microorganisms among the groups. Operative mortality was 12.9% overall, with no significant difference between the appropriately (14%) and inappropriately (8%) treated groups (p=0.28). There was no difference in unadjusted, all-cause, five-year survival between the appropriately (48%) and inappropriately (52%) treated groups (log-rank p=0.30). CONCLUSION: There were no significant differences in short- and long-term mortality between patients receiving appropriate versus inappropriate preoperative antimicrobial therapy prior to valve surgery for infective endocarditis. Surgeons should not hesitate to operate on patients with infective endocarditis and a guideline-directed indication for valve surgery, even if their preoperative antimicrobial regimen has been inadequate.