Staphylococcal early-onset prosthetic valve endocarditis: a condition bound for surgery

Staphylococcal early-onset prosthetic valve endocarditis: a condition bound for surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Staphylococcal early-onset prosthetic valve endocarditis: a condition bound for surgery Antonio Santis, Eduardo Cukierkorn, Flavio Tarasoutchi, Roney Orismar Sampaio, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6745890/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Dec, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Early-onset prosthetic valve endocarditis (EO-PVE) is linked to poor in-hospital outcomes. Staphylococcus spp. poses a significant concern due to its higher mortality rates compared to other major infectious agents. Objectives: Provide a more detailed, comprehensive evaluation of the clinical characteristics and in-hospital mortality predictors related to staphylococcal EO-PVE. Methods: This observational, retrospective, single-center study was conducted at a tertiary hospital in Brazil over a 22-year period from 1997 to 2019. A total of 105 consecutive cases of left-heart staphylococcal EO-PVE were analyzed. Results: There was a predominance of coagulase-negative staphylococci prosthetic valve endocarditis (CoNS PVE) over Staphylococcus aureus prosthetic valve endocarditis (SAPVE) (76% and 24%, respectively). Prosthetic valve replacement for EO-PVE treatment was performed in 73% of cases. In-hospital mortality was 49%, with SAPVE associated with a higher in-hospital mortality than CoNS PVE (80% versus 43%, p < 0.001). In-hospital mortality predictors identified by univariate analysis included older age (p<0.001), aortic prosthetic endocarditis (p<0.001), peri-annular abscess (p=0.002), SAPVE (p<0.001), NYHA functional class III/IV (p=0.02), previous combined myocardial revascularization with valve replacement surgery (p=0.02), left ventricular dysfunction (p<0.001), leukocytosis (p=0.02), and higher C-reactive protein levels (p=0.006). In a multivariate analysis, SAPVE was found to be an independent risk factor for in-hospital mortality (odds ratio [OR] 10.2; p=0.006), while prosthetic valve replacement was associated with improved in-hospital survival (OR 0.2; p=0.04). Conclusion : Staphylococcal EO-PVE is associated with increased in-hospital mortality, particularly in SAPVE cases. In this study, all non-operated SAPVE patients died primarily due to fulminant septic shock. Prosthetic valve replacement was significantly linked to in-hospital survival, and only 5.7% of the study population survived without cardiac surgical intervention. Figures Figure 1 Figure 2 Figure 3 Introduction Prosthetic valve endocarditis (PVE) incidence ranges from 3 to 6% within 5 years of valve replacement surgery, with significant morbidity and in-hospital mortality. 1 , 2 Early-onset prosthetic valve endocarditis (EO-PVE) is defined as an infection diagnosed within one year after heart valve surgery. 3 The clinical use of this classification is justified by microbiological idiosyncrasies related to this specific period, characterized by a higher prevalence of virulent hospital-acquired agents. Among these, staphylococcal endocarditis stands out for its clinical aggressiveness, expressed in high mortality rates (up to 48.5% for Staphylococcus aureus [ S. aureus ]) and embolic complications. 4 Previous studies indicate that Staphylococcus aureus prosthetic infective endocarditis (SAPVE) is an independent factor associated with in-hospital mortality. 5 .Regarding the therapeutic approach, the main recommendations come from relatively small and retrospective studies, indicating higher mortality in non-operated patients 6 . This study aims to describe clinical characteristics, in-hospital mortality predictors, and the role of surgical treatment on staphylococcal EO-PVE. Methods Between 1997 and 2019, 201 consecutive patients from a single Brazilian medical center were diagnosed with EO-PVE according to the Duke modified criteria. 7 EO-PVE was defined when the endocarditis diagnosis was made within one year after valve replacement surgery. This is a sub-analysis of a previous study that described the microbiological profile of EO-PVE. 3 Among these patients, we found 105 cases with left-heart EO-PVE due to Staphylococcus spp. , with a predominance of Coagulase-Negative Staphylococci (CoNS) over Staphylococcus aureus (76% versus 24%, respectively). The primary outcome was in-hospital mortality. Demographic information, type of valve prostheses (mechanical or biological), laboratory findings, microbiological profile, echocardiographic characteristics, clinical features, and prosthetic valve replacement surgery requirement data were also collected. The primary indications for prosthetic valve replacement were severe heart failure related to prosthetic dysfunction, peri-annular abscess or aorto-cavitary fistulas, large mobile vegetations with systemic embolization (> 10 mm), and persistent sepsis despite properly guided antibiotic therapy for more than 5–7 days. 2 , 8 , 9 The local ethics committee approved the present study. Statistical Analysis All statistical analyses were performed with SPSS 21.0 statistical package (SPSS, Chicago, IL, USA). Quantitative variables were expressed as the means and standard deviations, while qualitative variables were reported as counts and frequencies. In univariate analysis, comparisons between groups were made using Student’s t-test, Kruskal-Wallis, chi-square, and ANOVA, as appropriate. For multivariate analysis, logistic regression analysis was used to predict the risk of in-hospital mortality. Values of p < 0.05 were considered statistically significant. Results The final population consisted of 105 patients (mean age 51.3 ± 16.4 years, with 63% male sex) with left-heart Staphylococcal endocarditis and perivalvular endocarditis (EO-PVE). The median time from the previous valve replacement surgery to the PVE diagnosis was 44 days (25–93). There was a predominance of CoNS PVE (n = 80, 76%) over SAPVE (n = 25, 24%; 60% methicillin-resistant Staphylococcus aureus [MRSA] , 40% methicillin-sensitive Staphylococcus aureus [MSSA] ), as represented in Fig. 1 . Regarding the Duke criteria, 98% of the study population had definitive criteria. Prosthetic valve replacement for PVE treatment was performed in 73% of the patients, and the overall in-hospital mortality was 49%. The main complications were peri-annular abscess (32%); severe heart failure - New York Heart Association (NYHA) functional classification III/IV- related to prosthetic dysfunction (21%); systemic embolization (18%), and aorto-cavitary fistulas (3%). (Table 1 ). In comparison with CoNS PVE, SAPVE was associated with a higher in-hospital mortality (80% versus 43%, p < 0.001) and a trend towards earlier clinical presentation and diagnosis (median time from valve replacement to the PVE diagnosis: 33 [18–94] versus 51.5 [25.7–91.5], p = 0.05). However, there was a higher rate of prosthetic valve replacement for endocarditis treatment in CoNS PVE than in SAPVE (83% versus 40%, p < 0.001, respectively) (Table 2 ). Only 5.7% (6/105) of patients were discharged from the hospital without surgical treatment. Table 1 Demographic data. All patients (n = 105) Mean age (years) 51.3 ± 16.4 Male sex 67 (63%) In-hospital mortality 52 (49%) Exclusive aortic endocarditis 61 (58%) Exclusive mitral endocarditis 39 (37.2%) Peri-annular abscess 34 (32%) Aorto-cavitary fistula 3 (2.8%) MSSA 10 (9.5%) MRSA 15 (14.2%) CoNS PVE 80 (76.1%) Severe Heart Failure related to prosthetic valve dysfunction (NYHA III/IV) 22 (21%) Systemic embolism 19 (18%) Median time from valve replacement surgery to diagnosis of PVE (in days) 44 (25–93) Vegetation 70 (66.6%) Biologic prosthetic valve 98 (93.3%) Combined mitral and aortic valve endocarditis 5 (4.8%) Prosthetic valve replacement 77 (73%) Definitive Duke criteria 103 (98%) Median time from PVE diagnosis to prosthetic valve replacement (in days) 6 (3–12) Data are expressed as mean ± standard deviation, median and interquartile range or number (%). MSSA: methicillin-sensitive Staphylococcus aureus ; MRSA: methicillin-resistant Staphylococcus aureus ; CoNS PVE: Coagulase-Negative Staphylococci prosthetic valve endocarditis; NYHA: New York Heart Association; PVE: Prosthetic valve endocarditis. Table 2 Comparison of demographic data between SAPVE and CoNS PVE All patients (n = 105) SAPVE (n = 25) CoNS PVE (n = 80) p-value Mean age (years) 51.3 ± 16.4 55.3 ± 16.5 50 ± 16.3 0.16 Male sex 67 (63%) 16 51 0.98 In-hospital mortality 52 (49%) 20 (80%) 32 (43%) 0.001 Exclusive aortic endocarditis 61 (58%) 14 47 0.73 Exclusive mitral endocarditis 39 (37%) 10 29 0.80 Peri-annular abscess 34 (32%) 10 24 0.35 Severe heart failure related to prosthetic valve dysfunction (NYHA III/IV) 22 (21%) 6 16 0.5 Systemic embolism 19 (18%) 3 16 0.36 Median time from valve replacement surgery to diagnosis of PVE (in days) 44 (25–93) 33 (18–94) 51.5 (25.7–91.5) 0.05 Vegetation 70 (66.6%) 17 53 0.87 Biologic prosthetic valve 98 (93.3%) 23 75 0.75 Prosthetic valve replacement 77 (73%) 10 (40%) 67 (83%) 0.001 Definitive Duke criteria 103 (98%) 25 (100%) 78 (97%) 0.42 Median time from PVE diagnosis to prosthetic valve replacement (in days) 6 (3–12) 9 (5.2–12,5) 6 (3–11) 0.35 Data are expressed as mean ± standard deviation, median and interquartile range or number (%). SAPVE: Staphylococcus aureus prosthetic valve endocarditis; CoNS PVE: Coagulase-Negative Staphylococci prosthetic valve endocarditis; NYHA: New York Heart Association; PVE: Prosthetic valve endocarditis. Regarding the SAPVE group, all patients who did not undergo prosthetic valve replacement died (n = 15). Despite having indications for valve surgery, 14 patients (93.3%) in this group evolved to fulminant septic shock (less than 24 hours from hospital admission), without proper time for planning the surgical intervention, as illustrated by Fig. 2 . Five patients with surgically treated SAPVE died of postoperative complications. On univariate analysis, significant risk factors for in-hospital mortality included older age (p < 0.001), aortic prosthetic endocarditis (p < 0.001), periannular abscess (p = 0.002), SAPVE (p < 0.001), NYHA functional class III/IV (p = 0.02), previous combined coronary artery bypass-grafting (CABG) with valve replacement surgery (p = 0.02), left ventricular dysfunction (p < 0.001), leukocytosis (p = 0.02) and higher C-reactive protein levels (p = 0.006), as presented in Table 3 . Also, prosthetic valve replacement was significantly associated with in-hospital survival (p < 0.001). The median time from PVE diagnosis to prosthetic valve replacement in the surgical group (n = 77) was 6 days (3–12), with no statistical difference between dead and alive groups. Table 3 Univariate analysis of in-hospital mortality in staphylococcal PVE Alive (n = 53) Dead (n = 52) p-value Age > 60 (years) 8 (15%) 25 (48%) < 0.001 Male sex 33 (62.2%) 34 (65.3%) 0.73 Exclusive aortic endocarditis 25(47.1%) 41 (78.8%) < 0.001 Previous combined valve replacement surgery with myocardial revascularization 3 (5.6%) 11 (21.1%) 0.02 Peri-annular abscess 10 (18.8%) 24 (46.1%) 0.002 Systemic embolism 1 (1.8%) 2 (3.8%) 0.54 SAPVE 5 (9.4%) 20 (38.4%) < 0.001 Severe heart failure related to prosthetic valve dysfunction (NYHA III/IV) 19 (35.8%) 26 (50%) 0.02 Systemic embolism 7 (13.2%) 12 (23%) 0.18 Median time from valve replacement surgery to diagnosis of PVE (in days) 35 (22–83) 48 (29.7–99.2) 0.27 Vegetation 34 (64.1%) 36 (69.2%) 0.58 Biologic prosthetic valve 49 (92.4%) 49 (94.2%) 0.71 Prosthetic valve replacement for endocarditis treatment 47 (88.6%) 30 (57.6%) < 0.001 Median time from PVE diagnosis to prosthetic valve replacement (in days) 7 (5-14.5) 5 (3–9) 0.06 LVEF (%) 61.9 ± 11.4 50.6 ± 18.4 < 0.001 Hemoglobin (mg/dL) 10.7 ± 1.96 10.3 ± 1.85 0.33 Leukocytes count (x10 3 cells/mm 3 ) 13 ± 6.17 16.2 ± 6.9 0.02 Platelet count (x10 3 cells/mm3) 189.4 ± 81.2 153.9 ± 92.8 0.06 C-reactive protein (mg/L) 96.2 ± 45.7 183.5 ± 89.4 0.006 Data are expressed as mean ± standard deviation, median and interquartile range or number (%). LVEF: Left ventricular ejection fraction; SAPVE: Staphylococcus aureus prosthetic valve endocarditis; NYHA: New York Heart Association; PVE: Prosthetic valve endocarditis. Multivariate analysis showed that SAPVE was an independent risk factor for in-hospital mortality (odds ratio [OR] 10.2; p = 0.006) and reinforced the potential protective effect of prosthetic valve replacement in staphylococcal EO-PVE (OR 0.2; p = 0.04). Discussion Although rare, EO-PVE has a high potential for clinical complications and a significant in-hospital mortality. From an etiopathogenic perspective, previous studies have demonstrated a predominance of staphylococcal infections in these scenarios, with a prevalence of nearly two-thirds of the cases. 2 , 10 The present work was designed due to the clinical relevance and scarcity of previous studies focusing on this etiological subgroup of PVE. 4 , 6 , 11 – 14 Staphylococcal EO-PVE demonstrates a high virulence with an in-hospital mortality of 49% and high rates of clinical complications (peri-annular abscess-32%, heart failure-NYHA class III/IV-21%, systemic embolization-18%). Moreover, staphylococcal EO-PVE often requires a combination treatment strategy with the association of proper antimicrobial therapy and valve replacement surgery (surgical rate of 73%). Staphylococcal EO-PVE was diagnosed correctly, with 98% of the study population presenting definitive endocarditis according to the Duke modified criteria. Vegetations were the most common echocardiographic feature (found in 66.6% of the cases). Figure 3 represents multiple prosthetic vegetations in a staphylococcal EO-PVE (panel A) and an aorto-right ventricular fistula (panel B). Regarding the staphylococcal species, coagulase-negative strains were predominant (76%) over S. aureus (24%), with some relevant clinical idiosyncrasies between them. SAPVE presented a higher fatality rate than CoNS PVE (80% versus 43%, p < 0.001) and a propensity to earlier clinical presentation (median time from previous valve replacement surgery to the PVE diagnosis of 33 days [18–94]). Conversely, SAPVE had a lower rate of prosthetic valve replacement than CoNS PVE (40% versus 83%, p < 0.001). Despite the inherent limitations of an observational study, the high mortality associated with SAPVE may be related to these observed lower rates of surgical treatment. The specific analysis of deaths in the SAPVE group demonstrated that from the 15 non-operated cases, 14 (93.3%) were due to fulminant septic shock leading to multiple organ dysfunction syndrome (MODS) in less than 24 hours. Thus, despite clinical indication, there was no proper time to perform the prosthetic valve replacement. In current guidelines, one of the most frequent indications for valve replacement in infective endocarditis is a clinical condition known as failure of etiologic treatment, defined by persistent sepsis despite proper antibiotic therapy for more than seven days. 2 , 8 , 9 .Our study, by reinforcing the aggressiveness of SAPVE with early-onset sepsis, suggests that the time window for proper surgical intervention in these situations could be narrower than in other etiologies. The definition of the standard 7-day period for treatment failure seems to be too compliant when considering such an inexorable evolution. Early prosthetic valve replacement, before clinical irreversibility, may be crucial in obtaining favorable outcomes. In this sepsis scenario, antibiotic and intensive care for achieving an optimal clinical condition for surgical intervention seem to be unfeasible. In contrast, Sohail et al. found a subgroup of patients with SAPVE in a previous retrospective and unicentric study, where exclusive clinical management could potentially avoid in-hospital mortality. This small group (4 patients) was characterized by age < 50 years with good clinical conditions and no cardiac complications or systemic embolization. 6 In our population, no cases with such a favorable outcome without surgical intervention existed. The univariate analysis showed 10 predictors of in-hospital mortality in this population. These predictors can be related to intrinsic features of the agent ( S. aureus infections), clinical complications (peri-annular abscess, severe heart failure - NYHA class III/IV - related to prosthetic valve dysfunction), laboratorial features (high leukocyte count and C-reactive protein levels), patient profile (older age, previous combined valve replacement surgery with myocardial revascularization, left ventricular dysfunction) and aortic prostheses involvement. The lack of valve replacement surgery was associated with in-hospital mortality. Multivariate analysis reinforces the potential protective role of surgical intervention in staphylococcal EO-PVE, with an 80% relative reduction in in-hospital mortality (OR 0.2, p < 0.04). Moreover, multivariate analysis also indicates SAPVE as an independent and strong predictor of in-hospital mortality, emphasizing the high clinical aggressiveness of S. aureus compared to other staphylococcal species. As indicated in Table 4 . Table 4 Multivariate analysis of in-hospital mortality in staphylococcal PVE OR 95% CI p-value SAPVE 10.2 1.89–55.2 0.006 Prosthetic valve replacement 0.2 0.04–0.93 0.04 CI: Confidence interval; OR: Odds ratio; PVE: Prosthetic valve replacement; SAPVE: Staphylococcus aureus prosthetic valve endocarditis. The present study has inherent limitations related to its unicentric and observational format. The intergroup comparative analysis is impaired due to the lack of matching and adjustment for confounders, treatment selection biases, and the lack of a randomization possibility. However, the findings are relevant considering the relative scarcity of staphylococcal EO-PVE in clinical practice. Conclusion In conclusion, staphylococcal EO-PVE mortality is high, especially in SAPVE, where the majority of deaths were concentrated in non-operated patients. In this group, despite surgical indication, the early onset of septic shock and MODS does not allow immediate surgical intervention. Prosthetic valve replacement was significantly associated with in-hospital survival, and only 5.7% of the study population survived without valve replacement surgery. Abbreviations - Early-onset prosthetic valve endocarditis = EO-PVE - Coagulase-negative staphylococci prosthetic valve endocarditis = CoNS PVE - Staphylococcus aureus prosthetic valve endocarditis = SAPVE - Multiple Organ Dysfunction Syndrome (MODS) Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and material Data sharing is not applicable to this article. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' contributions AS: Conception, Data Analysis, Review, and Writing EC: Writing and Review FT: Conception and Review ROS: Review MRP: Data Analysis and Review CMAB: Data Analysis and Review ETV: Data Analysis and Review FMAM: Analysis and Review TADA: Analysis, Writing, and Review GSS: Analysis, Writing, and Review TMVS: Review RFS: Conception, Analysis, Writing, and Review Acknowledgements Not applicable. Authors' information Not applicable. Clinical trial number: Not applicable Ethics approval and consent to participate The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and with the guidelines established by the Brazilian National Health Council, as set forth in Resolution CNS No. 466/2012. Ethical approval was granted by the Ethics Committee for the Analysis of Research Projects of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Comissão de Ética para Análise de Projetos de Pesquisa do HCFMUSP), under approval number 6151073 and Certificate of Presentation for Ethical Consideration (CAAE) 70354523.1.0000.0068. The approved study period was from July 1, 2023, to November 30, 2023. As this was a retrospective study using only data obtained from medical records, the requirement for individual informed consent was waived by the ethics committee. For further information, the ethics committee can be contacted at: • Phone: ‪+55 (11) 2661-7585 / 2661-1548 • Email: [email protected] • Address: Rua Dr. Ovídio Pires de Campos, 225 – 6th floor, São Paulo, Brazil • Office hours: 7:00 a.m. to 4:00 p.m. • Coordinator: Prof. Dr. Alfredo José Mansur • Vice-Coordinator: Prof. Dr. Joel Faintuch Acknowledgements The authors would like to thank all the patients who took part in this research and their respective families for all the support they provided. Funding The authors received no specific funding for this study. Conflicts of Interest No declarations. References Habib G, Thuny F, Avierinos JF. Prosthetic valve endocarditis: current approach and therapeutic options. Prog Cardiovasc Dis. 2008;50(4):274-281. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis: the task force for the management of infective endocarditis of the European Society of Cardiology (ESC) endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36(44):3075–128. Siciliano RF, Randi BA, Gualandro DM, et al. Early-onset prosthetic valve endocarditis definition revisited: Prospective study and literature review. Int J Infect Dis. 2018; 67:3-6. Abdallah L, Habib G, Remadi JP, Salaun E, Casalta JP, Tribouilloy C. Comparison of prognoses of Staphylococcus aureus left-sided prosthetic endocarditis and prosthetic endocarditis caused by other pathogens. Arch Cardiovasc Dis. 2016;109(10):542-549. Nataloni M, Pergolini M, Rescigno G, Mocchegiani R. Prosthetic valve endocarditis. J Cardiovasc Med (Hagerstown). 2010 Dec;11(12):869-83. Sohail MR, Martin KR, Wilson WR, Baddour LM, Harmsen WS, Steckelberg JM. Medical versus surgical management of Staphylococcus aureus prosthetic valve endocarditis. Am J Med. 2006;119(2):147-154. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30(4):633-638. Pettersson GB, Hussain ST. Current AATS guidelines on surgical treatment of infective endocarditis. Ann Cardiothorac Surg. 2019;8(6):630-644. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Muñoz D, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL; ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017 Sep 21;38(36):2739-2791. López J, Revilla A, Vilacosta I, et al. Definition, clinical profile, microbiological spectrum, and prognostic factors of early-onset prosthetic valve endocarditis. Eur Heart J. 2007;28(6):760-765. Galar A, Weil AA, Dudzinski DM, Muñoz P, Siedner MJ. Methicillin-Resistant Staphylococcus aureus Prosthetic Valve Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management. Clin Microbiol Rev. 2019 Feb 13;32(2):e00041-18. Hoerr V, Franz M, Pletz MW, Diab M, Niemann S, Faber C, Doenst T, Schulze PC, Deinhardt-Emmer S, Löffler B. S. aureus endocarditis: Clinical aspects and experimental approaches. Int J Med Microbiol. 2018 Aug;308(6):640-652. Murray RJ. Staphylococcus aureus infective endocarditis: diagnosis and management guidelines. Intern Med J. 2005 Dec;35 Suppl 2:S25-44. Tan HL, Chai LY, Yeo TC, Chia BL, Tambyah PA, Poh KK. Predictors of In-hospital Adverse Events in Patients with Prosthetic Valve Infective Endocarditis. Heart Lung Circ. 2015;24(7):705-709. 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Paixão","email":"","orcid":"","institution":"University of São Paulo Medical School","correspondingAuthor":false,"prefix":"","firstName":"Milena","middleName":"R.","lastName":"Paixão","suffix":""},{"id":497636377,"identity":"de88aa79-5e05-426d-ab7c-8a0387f16182","order_by":5,"name":"Carlos Manuel A. Brandao","email":"","orcid":"","institution":"University of São Paulo Medical School","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"Manuel A.","lastName":"Brandao","suffix":""},{"id":497636378,"identity":"70b6360a-ec90-4a66-971c-2a5708982f8d","order_by":6,"name":"Elinthon T. Veronese","email":"","orcid":"","institution":"University of Sao Paulo Medical School","correspondingAuthor":false,"prefix":"","firstName":"Elinthon","middleName":"T.","lastName":"Veronese","suffix":""},{"id":497636379,"identity":"a2d1df1c-c3c6-4bb1-9525-cf43046d8e84","order_by":7,"name":"Francisco Monteiro Almeida","email":"","orcid":"","institution":"University of São Paulo Medical School","correspondingAuthor":false,"prefix":"","firstName":"Francisco","middleName":"Monteiro","lastName":"Almeida","suffix":""},{"id":497636380,"identity":"8eb1fc16-9ba3-48bc-8b5c-17b2fb3f18ff","order_by":8,"name":"Tarso A. D. Accorsi","email":"","orcid":"","institution":"University of São Paulo Medical School","correspondingAuthor":false,"prefix":"","firstName":"Tarso","middleName":"A. D.","lastName":"Accorsi","suffix":""},{"id":497636381,"identity":"c44d5889-c633-4524-a56f-d374f0fa31df","order_by":9,"name":"Guilherme S. Spina","email":"","orcid":"","institution":"University of São Paulo Medical School","correspondingAuthor":false,"prefix":"","firstName":"Guilherme","middleName":"S.","lastName":"Spina","suffix":""},{"id":497636383,"identity":"96db1c5c-03d6-4acd-b10a-a4283e14a136","order_by":10,"name":"Tania Mara Varejão Strabelli","email":"","orcid":"","institution":"University of São Paulo Medical School","correspondingAuthor":false,"prefix":"","firstName":"Tania","middleName":"Mara Varejão","lastName":"Strabelli","suffix":""},{"id":497636385,"identity":"47b112fb-d84a-4a52-897c-c9cf9707c721","order_by":11,"name":"Rinaldo Focaccia Siciliano","email":"","orcid":"","institution":"University of Sao Paulo Medical School","correspondingAuthor":false,"prefix":"","firstName":"Rinaldo","middleName":"Focaccia","lastName":"Siciliano","suffix":""}],"badges":[],"createdAt":"2025-05-25 23:23:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6745890/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6745890/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-11999-9","type":"published","date":"2025-12-19T15:57:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88951855,"identity":"5b3e5f79-a048-4bf6-9a8f-21dc498d472e","added_by":"auto","created_at":"2025-08-13 05:55:36","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50991,"visible":true,"origin":"","legend":"\u003cp\u003eEtiologic distribution of staphylococcal early-onset prosthetic valve endocarditis.\u003c/p\u003e\n\u003cp\u003eCoNS PVE: Coagulase-Negative Staphylococci prosthetic valve endocarditis; MSSA: methicillin-sensitive \u003cem\u003eStaphylococcus aureus\u003c/em\u003e; MRSA: methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e; SAPVE: \u003cem\u003eStaphylococcus aureus\u003c/em\u003e prosthetic valve endocarditis.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6745890/v1/ba2fe7d2f8f73d78a383af9a.jpg"},{"id":88951860,"identity":"93e06d27-43ab-4977-b957-0bd2c208595d","added_by":"auto","created_at":"2025-08-13 05:55:36","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40964,"visible":true,"origin":"","legend":"\u003cp\u003eHistogram of death causes related to \u003cem\u003eStaphylococcus aureus\u003c/em\u003e prosthetic valve endocarditis (n=20). The major cause of death in the non-operated group (n=15) was fulminant septic shock and multiple organs dysfunction syndrome (MODS). Death causes in the operated group (n=5) were related to postoperative septic shock and bleeding.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6745890/v1/166ffc2cb952bfafa2cead7d.jpg"},{"id":88950400,"identity":"e6ff7e3c-afed-4613-a4ea-0683cc1b28d4","added_by":"auto","created_at":"2025-08-13 05:47:36","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":92519,"visible":true,"origin":"","legend":"\u003cp\u003eStaphylococcal early-onset prosthetic valve endocarditis examples. \u003cstrong\u003ePanel A:\u003c/strong\u003e multiple prosthetic vegetations with associated valvular dysfunction. \u003cstrong\u003ePanel B:\u003c/strong\u003e aorto-right ventricular fistula (yellow arrow).\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6745890/v1/d29f3aa17d1d5ca57d441900.jpg"},{"id":98813977,"identity":"ce48bd82-c5b9-4c00-bb94-df844e095148","added_by":"auto","created_at":"2025-12-22 16:08:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":945584,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6745890/v1/f89a206a-638f-431b-a9bf-3dd553e65251.pdf"},{"id":88950398,"identity":"d25c9089-88ba-4943-a847-4cbf9c2be012","added_by":"auto","created_at":"2025-08-13 05:47:36","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":60429,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryData.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6745890/v1/2d152294b9cd2206a40da05d.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Staphylococcal early-onset prosthetic valve endocarditis: a condition bound for surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProsthetic valve endocarditis (PVE) incidence ranges from 3 to 6% within 5 years of valve replacement surgery, with significant morbidity and in-hospital mortality.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Early-onset prosthetic valve endocarditis (EO-PVE) is defined as an infection diagnosed within one year after heart valve surgery.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e The clinical use of this classification is justified by microbiological idiosyncrasies related to this specific period, characterized by a higher prevalence of virulent hospital-acquired agents. Among these, staphylococcal endocarditis stands out for its clinical aggressiveness, expressed in high mortality rates (up to 48.5% for \u003cem\u003eStaphylococcus aureus\u003c/em\u003e [\u003cem\u003eS. aureus\u003c/em\u003e]) and embolic complications.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Previous studies indicate that \u003cem\u003eStaphylococcus aureus\u003c/em\u003e prosthetic infective endocarditis (SAPVE) is an independent factor associated with in-hospital mortality.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e .Regarding the therapeutic approach, the main recommendations come from relatively small and retrospective studies, indicating higher mortality in non-operated patients\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. This study aims to describe clinical characteristics, in-hospital mortality predictors, and the role of surgical treatment on staphylococcal EO-PVE.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eBetween 1997 and 2019, 201 consecutive patients from a single Brazilian medical center were diagnosed with EO-PVE according to the Duke modified criteria.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e EO-PVE was defined when the endocarditis diagnosis was made within one year after valve replacement surgery. This is a sub-analysis of a previous study that described the microbiological profile of EO-PVE.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Among these patients, we found 105 cases with left-heart EO-PVE due to \u003cem\u003eStaphylococcus spp.\u003c/em\u003e, with a predominance of Coagulase-Negative Staphylococci (CoNS) over \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (76% versus 24%, respectively). The primary outcome was in-hospital mortality. Demographic information, type of valve prostheses (mechanical or biological), laboratory findings, microbiological profile, echocardiographic characteristics, clinical features, and prosthetic valve replacement surgery requirement data were also collected. The primary indications for prosthetic valve replacement were severe heart failure related to prosthetic dysfunction, peri-annular abscess or aorto-cavitary fistulas, large mobile vegetations with systemic embolization (\u0026gt; 10 mm), and persistent sepsis despite properly guided antibiotic therapy for more than 5–7 days.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The local ethics committee approved the present study.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were performed with SPSS 21.0 statistical package (SPSS, Chicago, IL, USA). Quantitative variables were expressed as the means and standard deviations, while qualitative variables were reported as counts and frequencies. In univariate analysis, comparisons between groups were made using Student’s t-test, Kruskal-Wallis, chi-square, and ANOVA, as appropriate. For multivariate analysis, logistic regression analysis was used to predict the risk of in-hospital mortality. Values of p \u0026lt; 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe final population consisted of 105 patients (mean age 51.3\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4 years, with 63% male sex) with left-heart Staphylococcal endocarditis and perivalvular endocarditis (EO-PVE). The median time from the previous valve replacement surgery to the PVE diagnosis was 44 days (25\u0026ndash;93). There was a predominance of CoNS PVE (n\u0026thinsp;=\u0026thinsp;80, 76%) over SAPVE (n\u0026thinsp;=\u0026thinsp;25, 24%; 60% methicillin-resistant \u003cem\u003eStaphylococcus aureus [MRSA]\u003c/em\u003e, 40% methicillin-sensitive \u003cem\u003eStaphylococcus aureus [MSSA]\u003c/em\u003e), as represented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Regarding the Duke criteria, 98% of the study population had definitive criteria. Prosthetic valve replacement for PVE treatment was performed in 73% of the patients, and the overall in-hospital mortality was 49%. The main complications were peri-annular abscess (32%); severe heart failure - New York Heart Association (NYHA) functional classification III/IV- related to prosthetic dysfunction (21%); systemic embolization (18%), and aorto-cavitary fistulas (3%). (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In comparison with CoNS PVE, SAPVE was associated with a higher in-hospital mortality (80% \u003cem\u003eversus\u003c/em\u003e 43%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a trend towards earlier clinical presentation and diagnosis (median time from valve replacement to the PVE diagnosis: 33 [18\u0026ndash;94] \u003cem\u003eversus\u003c/em\u003e 51.5 [25.7\u0026ndash;91.5], p\u0026thinsp;=\u0026thinsp;0.05). However, there was a higher rate of prosthetic valve replacement for endocarditis treatment in CoNS PVE than in SAPVE (83% \u003cem\u003eversus\u003c/em\u003e 40%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Only 5.7% (6/105) of patients were discharged from the hospital without surgical treatment.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic data.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAll patients\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean age (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51.3\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67 (63%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn-hospital mortality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52 (49%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExclusive aortic endocarditis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61 (58%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExclusive mitral endocarditis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (37.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeri-annular abscess\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (32%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAorto-cavitary fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (2.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMSSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (9.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMRSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (14.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoNS PVE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80 (76.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere Heart Failure related to prosthetic valve dysfunction (NYHA III/IV)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (21%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystemic embolism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (18%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian time from valve replacement surgery to diagnosis of PVE (in days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44 (25\u0026ndash;93)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVegetation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70 (66.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiologic prosthetic valve\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98 (93.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCombined mitral and aortic valve endocarditis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (4.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProsthetic valve replacement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77 (73%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDefinitive Duke criteria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e103 (98%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian time from PVE diagnosis to prosthetic valve replacement (in days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (3\u0026ndash;12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median and interquartile range or number (%).\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eMSSA: methicillin-sensitive \u003cem\u003eStaphylococcus aureus\u003c/em\u003e; MRSA: methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e; CoNS PVE: Coagulase-Negative Staphylococci prosthetic valve endocarditis; NYHA: New York Heart Association; PVE: Prosthetic valve endocarditis.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of demographic data between SAPVE and CoNS PVE\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAll patients\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSAPVE\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCoNS PVE (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean age (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51.3\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55.3\u0026thinsp;\u0026plusmn;\u0026thinsp;16.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67 (63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn-hospital mortality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52 (49%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (80%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32 (43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExclusive aortic endocarditis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61 (58%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExclusive mitral\u003c/p\u003e\u003cp\u003eendocarditis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (37%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeri-annular abscess\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (32%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere heart failure related to prosthetic valve dysfunction (NYHA III/IV)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystemic embolism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian time from valve replacement surgery to diagnosis of PVE (in days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44 (25\u0026ndash;93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (18\u0026ndash;94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51.5 (25.7\u0026ndash;91.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVegetation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70 (66.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiologic prosthetic valve\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98 (93.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProsthetic valve replacement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77 (73%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67 (83%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDefinitive Duke criteria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e103 (98%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78 (97%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian time from PVE diagnosis to prosthetic valve replacement (in days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (3\u0026ndash;12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (5.2\u0026ndash;12,5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (3\u0026ndash;11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eData are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median and interquartile range or number (%).\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eSAPVE: \u003cem\u003eStaphylococcus aureus\u003c/em\u003e prosthetic valve endocarditis; CoNS PVE: Coagulase-Negative Staphylococci prosthetic valve endocarditis; NYHA: New York Heart Association; PVE: Prosthetic valve endocarditis.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRegarding the SAPVE group, all patients who did not undergo prosthetic valve replacement died (n\u0026thinsp;=\u0026thinsp;15). Despite having indications for valve surgery, 14 patients (93.3%) in this group evolved to fulminant septic shock (less than 24 hours from hospital admission), without proper time for planning the surgical intervention, as illustrated by Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Five patients with surgically treated SAPVE died of postoperative complications.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eOn univariate analysis, significant risk factors for in-hospital mortality included older age (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), aortic prosthetic endocarditis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), periannular abscess (p\u0026thinsp;=\u0026thinsp;0.002), SAPVE (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), NYHA functional class III/IV (p\u0026thinsp;=\u0026thinsp;0.02), previous combined coronary artery bypass-grafting (CABG) with valve replacement surgery (p\u0026thinsp;=\u0026thinsp;0.02), left ventricular dysfunction (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), leukocytosis (p\u0026thinsp;=\u0026thinsp;0.02) and higher C-reactive protein levels (p\u0026thinsp;=\u0026thinsp;0.006), as presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Also, prosthetic valve replacement was significantly associated with in-hospital survival (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The median time from PVE diagnosis to prosthetic valve replacement in the surgical group (n\u0026thinsp;=\u0026thinsp;77) was 6 days (3\u0026ndash;12), with no statistical difference between dead and alive groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUnivariate analysis of in-hospital mortality in staphylococcal PVE\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDead\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;60 (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (15%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (48%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (62.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (65.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExclusive aortic endocarditis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25(47.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (78.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious combined valve replacement surgery with myocardial revascularization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (5.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (21.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeri-annular abscess\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (18.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (46.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystemic embolism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSAPVE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (9.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (38.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere heart failure related to prosthetic valve dysfunction (NYHA III/IV)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (35.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystemic embolism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (13.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian time from valve replacement surgery to diagnosis of PVE (in days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35 (22\u0026ndash;83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (29.7\u0026ndash;99.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVegetation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (64.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (69.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiologic prosthetic valve\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49 (92.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (94.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProsthetic valve replacement for endocarditis treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (88.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (57.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian time from PVE diagnosis to prosthetic valve replacement (in days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (5-14.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (3\u0026ndash;9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLVEF (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeukocytes count (x10\u003csup\u003e3\u003c/sup\u003e cells/mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u0026thinsp;\u0026plusmn;\u0026thinsp;6.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlatelet count (x10\u003csup\u003e3\u003c/sup\u003e cells/mm3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e189.4\u0026thinsp;\u0026plusmn;\u0026thinsp;81.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e153.9\u0026thinsp;\u0026plusmn;\u0026thinsp;92.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-reactive protein (mg/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96.2\u0026thinsp;\u0026plusmn;\u0026thinsp;45.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e183.5\u0026thinsp;\u0026plusmn;\u0026thinsp;89.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median and interquartile range or number (%).\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eLVEF: Left ventricular ejection fraction; SAPVE: \u003cem\u003eStaphylococcus aureus\u003c/em\u003e prosthetic valve endocarditis; NYHA: New York Heart Association; PVE: Prosthetic valve endocarditis.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMultivariate analysis showed that SAPVE was an independent risk factor for in-hospital mortality (odds ratio [OR] 10.2; p\u0026thinsp;=\u0026thinsp;0.006) and reinforced the potential protective effect of prosthetic valve replacement in staphylococcal EO-PVE (OR 0.2; p\u0026thinsp;=\u0026thinsp;0.04).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough rare, EO-PVE has a high potential for clinical complications and a significant in-hospital mortality. From an etiopathogenic perspective, previous studies have demonstrated a predominance of staphylococcal infections in these scenarios, with a prevalence of nearly two-thirds of the cases.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e The present work was designed due to the clinical relevance and scarcity of previous studies focusing on this etiological subgroup of PVE.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eStaphylococcal EO-PVE demonstrates a high virulence with an in-hospital mortality of 49% and high rates of clinical complications (peri-annular abscess-32%, heart failure-NYHA class III/IV-21%, systemic embolization-18%). Moreover, staphylococcal EO-PVE often requires a combination treatment strategy with the association of proper antimicrobial therapy and valve replacement surgery (surgical rate of 73%).\u003c/p\u003e\u003cp\u003eStaphylococcal EO-PVE was diagnosed correctly, with 98% of the study population presenting definitive endocarditis according to the Duke modified criteria. Vegetations were the most common echocardiographic feature (found in 66.6% of the cases). Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e represents multiple prosthetic vegetations in a staphylococcal EO-PVE (panel A) and an aorto-right ventricular fistula (panel B).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eRegarding the staphylococcal species, coagulase-negative strains were predominant (76%) over S. aureus (24%), with some relevant clinical idiosyncrasies between them. SAPVE presented a higher fatality rate than CoNS PVE (80% \u003cem\u003eversus\u003c/em\u003e 43%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a propensity to earlier clinical presentation (median time from previous valve replacement surgery to the PVE diagnosis of 33 days [18\u0026ndash;94]). Conversely, SAPVE had a lower rate of prosthetic valve replacement than CoNS PVE (40% \u003cem\u003eversus\u003c/em\u003e 83%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Despite the inherent limitations of an observational study, the high mortality associated with SAPVE may be related to these observed lower rates of surgical treatment. The specific analysis of deaths in the SAPVE group demonstrated that from the 15 non-operated cases, 14 (93.3%) were due to fulminant septic shock leading to multiple organ dysfunction syndrome (MODS) in less than 24 hours. Thus, despite clinical indication, there was no proper time to perform the prosthetic valve replacement. In current guidelines, one of the most frequent indications for valve replacement in infective endocarditis is a clinical condition known as failure of etiologic treatment, defined by persistent sepsis despite proper antibiotic therapy for more than seven days.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e .Our study, by reinforcing the aggressiveness of SAPVE with early-onset sepsis, suggests that the time window for proper surgical intervention in these situations could be narrower than in other etiologies. The definition of the standard 7-day period for treatment failure seems to be too compliant when considering such an inexorable evolution. Early prosthetic valve replacement, before clinical irreversibility, may be crucial in obtaining favorable outcomes. In this sepsis scenario, antibiotic and intensive care for achieving an optimal clinical condition for surgical intervention seem to be unfeasible. In contrast, Sohail et al. found a subgroup of patients with SAPVE in a previous retrospective and unicentric study, where exclusive clinical management could potentially avoid in-hospital mortality. This small group (4 patients) was characterized by age\u0026thinsp;\u0026lt;\u0026thinsp;50 years with good clinical conditions and no cardiac complications or systemic embolization.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e In our population, no cases with such a favorable outcome without surgical intervention existed.\u003c/p\u003e\u003cp\u003eThe univariate analysis showed 10 predictors of in-hospital mortality in this population. These predictors can be related to intrinsic features of the agent (\u003cem\u003eS. aureus\u003c/em\u003e infections), clinical complications (peri-annular abscess, severe heart failure - NYHA class III/IV - related to prosthetic valve dysfunction), laboratorial features (high leukocyte count and C-reactive protein levels), patient profile (older age, previous combined valve replacement surgery with myocardial revascularization, left ventricular dysfunction) and aortic prostheses involvement. The lack of valve replacement surgery was associated with in-hospital mortality. Multivariate analysis reinforces the potential protective role of surgical intervention in staphylococcal EO-PVE, with an 80% relative reduction in in-hospital mortality (OR 0.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.04). Moreover, multivariate analysis also indicates SAPVE as an independent and strong predictor of in-hospital mortality, emphasizing the high clinical aggressiveness of \u003cem\u003eS. aureus\u003c/em\u003e compared to other staphylococcal species. As indicated in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariate analysis of in-hospital mortality in staphylococcal PVE\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSAPVE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.89\u0026ndash;55.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProsthetic valve replacement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.04\u0026ndash;0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eCI: Confidence interval; OR: Odds ratio; PVE: Prosthetic valve replacement; SAPVE: \u003cem\u003eStaphylococcus aureus\u003c/em\u003e prosthetic valve endocarditis.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe present study has inherent limitations related to its unicentric and observational format. The intergroup comparative analysis is impaired due to the lack of matching and adjustment for confounders, treatment selection biases, and the lack of a randomization possibility. However, the findings are relevant considering the relative scarcity of staphylococcal EO-PVE in clinical practice.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, staphylococcal EO-PVE mortality is high, especially in SAPVE, where the majority of deaths were concentrated in non-operated patients. In this group, despite surgical indication, the early onset of septic shock and MODS does not allow immediate surgical intervention. Prosthetic valve replacement was significantly associated with in-hospital survival, and only 5.7% of the study population survived without valve replacement surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e- Early-onset prosthetic valve endocarditis = EO-PVE\u003c/p\u003e\n\u003cp\u003e- Coagulase-negative staphylococci prosthetic valve endocarditis = CoNS PVE\u003c/p\u003e\n\u003cp\u003e- Staphylococcus aureus prosthetic valve endocarditis = SAPVE\u003c/p\u003e\n\u003cp\u003e- Multiple Organ Dysfunction Syndrome (MODS)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Data sharing is not applicable to this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;AS: Conception, Data Analysis, Review, and Writing\u003cbr\u003e\u0026nbsp;EC: Writing and Review\u003cbr\u003e\u0026nbsp;FT: Conception and Review\u003cbr\u003e\u0026nbsp;ROS: Review\u003cbr\u003e\u0026nbsp;MRP: Data Analysis and Review\u003cbr\u003e\u0026nbsp;CMAB: Data Analysis and Review\u003cbr\u003e\u0026nbsp;ETV: Data Analysis and Review\u003cbr\u003e\u0026nbsp;FMAM: Analysis and Review\u003cbr\u003e\u0026nbsp;TADA: Analysis, Writing, and Review\u003cbr\u003e\u0026nbsp;GSS: Analysis, Writing, and Review\u003cbr\u003e\u0026nbsp;TMVS: Review\u003cbr\u003e\u0026nbsp;RFS: Conception, Analysis, Writing, and Review\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eClinical trial number:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eNot applicable\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and with the guidelines established by the Brazilian National Health Council, as set forth in Resolution CNS No. 466/2012. Ethical approval was granted by the Ethics Committee for the Analysis of Research Projects of the Hospital das Cl\u0026iacute;nicas da Faculdade de Medicina da Universidade de S\u0026atilde;o Paulo (Comiss\u0026atilde;o de \u0026Eacute;tica para An\u0026aacute;lise de Projetos de Pesquisa do HCFMUSP), under approval number 6151073 and Certificate of Presentation for Ethical Consideration (CAAE) 70354523.1.0000.0068. The approved study period was from July 1, 2023, to November 30, 2023.\u003c/p\u003e\n\u003cp\u003eAs this was a retrospective study using only data obtained from medical records, the requirement for individual informed consent was waived by the ethics committee.\u003c/p\u003e\n\u003cp\u003eFor further information, the ethics committee can be contacted at:\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Phone: ‪+55 (11) 2661-7585 / 2661-1548\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Email: [email protected]\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Address: Rua Dr. Ov\u0026iacute;dio Pires de Campos, 225 \u0026ndash; 6th floor, S\u0026atilde;o Paulo, Brazil\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Office hours: 7:00 a.m. to 4:00 p.m.\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Coordinator: Prof. Dr. Alfredo Jos\u0026eacute; Mansur\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Vice-Coordinator: Prof. Dr.\u0026nbsp;Joel\u0026nbsp;Faintuch\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the patients who took part in this research and their respective families for all the support they provided.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;No declarations.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHabib G, Thuny F, Avierinos JF. Prosthetic valve endocarditis: current approach and therapeutic options. Prog Cardiovasc Dis. 2008;50(4):274-281.\u003c/li\u003e\n\u003cli\u003eHabib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis: the task force for the management of infective endocarditis of the European Society of Cardiology (ESC) endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36(44):3075\u0026ndash;128.\u003c/li\u003e\n\u003cli\u003eSiciliano RF, Randi BA, Gualandro DM, et al. Early-onset prosthetic valve endocarditis definition revisited: Prospective study and literature review. Int J Infect Dis. 2018; 67:3-6.\u003c/li\u003e\n\u003cli\u003eAbdallah L, Habib G, Remadi JP, Salaun E, Casalta JP, Tribouilloy C. Comparison of prognoses of Staphylococcus aureus left-sided prosthetic endocarditis and prosthetic endocarditis caused by other pathogens. Arch Cardiovasc Dis. 2016;109(10):542-549.\u003c/li\u003e\n\u003cli\u003eNataloni M, Pergolini M, Rescigno G, Mocchegiani R. Prosthetic valve endocarditis. J Cardiovasc Med (Hagerstown). 2010 Dec;11(12):869-83.\u003c/li\u003e\n\u003cli\u003eSohail MR, Martin KR, Wilson WR, Baddour LM, Harmsen WS, Steckelberg JM. Medical versus surgical management of Staphylococcus aureus prosthetic valve endocarditis. Am J Med. 2006;119(2):147-154.\u003c/li\u003e\n\u003cli\u003eLi JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30(4):633-638. \u003c/li\u003e\n\u003cli\u003ePettersson GB, Hussain ST. Current AATS guidelines on surgical treatment of infective endocarditis. Ann Cardiothorac Surg. 2019;8(6):630-644.\u003c/li\u003e\n\u003cli\u003eBaumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Mu\u0026ntilde;oz D, Rosenhek R, Sj\u0026ouml;gren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL; ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017 Sep 21;38(36):2739-2791.\u003c/li\u003e\n\u003cli\u003eL\u0026oacute;pez J, Revilla A, Vilacosta I, et al. Definition, clinical profile, microbiological spectrum, and prognostic factors of early-onset prosthetic valve endocarditis. Eur Heart J. 2007;28(6):760-765.\u003c/li\u003e\n\u003cli\u003eGalar A, Weil AA, Dudzinski DM, Mu\u0026ntilde;oz P, Siedner MJ. Methicillin-Resistant Staphylococcus aureus Prosthetic Valve Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management. Clin Microbiol Rev. 2019 Feb 13;32(2):e00041-18.\u003c/li\u003e\n\u003cli\u003eHoerr V, Franz M, Pletz MW, Diab M, Niemann S, Faber C, Doenst T, Schulze PC, Deinhardt-Emmer S, L\u0026ouml;ffler B. S. aureus endocarditis: Clinical aspects and experimental approaches. Int J Med Microbiol. 2018 Aug;308(6):640-652.\u003c/li\u003e\n\u003cli\u003eMurray RJ. Staphylococcus aureus infective endocarditis: diagnosis and management guidelines. Intern Med J. 2005 Dec;35 Suppl 2:S25-44.\u003c/li\u003e\n\u003cli\u003eTan HL, Chai LY, Yeo TC, Chia BL, Tambyah PA, Poh KK. Predictors of In-hospital Adverse Events in Patients with Prosthetic Valve Infective Endocarditis. Heart Lung Circ. 2015;24(7):705-709.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6745890/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6745890/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eEarly-onset prosthetic valve endocarditis (EO-PVE) is linked to poor in-hospital outcomes. Staphylococcus spp. poses a significant concern due to its higher mortality rates compared to other major infectious agents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eProvide a more detailed, comprehensive evaluation of the clinical characteristics and in-hospital mortality predictors related to staphylococcal EO-PVE.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis observational, retrospective, single-center study was conducted at a tertiary hospital in Brazil over a 22-year period from 1997 to 2019. A total of 105 consecutive cases of left-heart staphylococcal EO-PVE were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThere was a predominance of coagulase-negative staphylococci prosthetic valve endocarditis (CoNS PVE) over Staphylococcus aureus prosthetic valve endocarditis (SAPVE) (76% and 24%, respectively). Prosthetic valve replacement for EO-PVE treatment was performed in 73% of cases. In-hospital mortality was 49%, with SAPVE associated with a higher in-hospital mortality than CoNS PVE (80% versus 43%, p \u0026lt; 0.001). In-hospital mortality predictors identified by univariate analysis included older age (p\u0026lt;0.001), aortic prosthetic endocarditis (p\u0026lt;0.001), peri-annular abscess (p=0.002), SAPVE (p\u0026lt;0.001), NYHA functional class III/IV (p=0.02), previous combined myocardial revascularization with valve replacement surgery (p=0.02), left ventricular dysfunction (p\u0026lt;0.001), leukocytosis (p=0.02), and higher C-reactive protein levels (p=0.006). In a multivariate analysis, SAPVE was found to be an independent risk factor for in-hospital mortality (odds ratio [OR] 10.2; p=0.006), while prosthetic valve replacement was associated with improved in-hospital survival (OR 0.2; p=0.04).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Staphylococcal EO-PVE is associated with increased in-hospital mortality, particularly in SAPVE cases. In this study, all non-operated SAPVE patients died primarily due to fulminant septic shock. Prosthetic valve replacement was significantly linked to in-hospital survival, and only 5.7% of the study population survived without cardiac surgical intervention.\u003c/p\u003e","manuscriptTitle":"Staphylococcal early-onset prosthetic valve endocarditis: a condition bound for surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 05:47:31","doi":"10.21203/rs.3.rs-6745890/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-09T16:48:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T20:02:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-17T22:00:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296673144148358645832416672096336927144","date":"2025-08-12T10:48:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61673877484820059116498367457434108302","date":"2025-08-12T10:21:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-07T09:52:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-22T18:12:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-04T09:35:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-03T01:13:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-07-03T01:11:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3c8095a-f596-44a3-996d-61fff7041f25","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T16:01:56+00:00","versionOfRecord":{"articleIdentity":"rs-6745890","link":"https://doi.org/10.1186/s12879-025-11999-9","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-12-19 15:57:48","publishedOnDateReadable":"December 19th, 2025"},"versionCreatedAt":"2025-08-13 05:47:31","video":"","vorDoi":"10.1186/s12879-025-11999-9","vorDoiUrl":"https://doi.org/10.1186/s12879-025-11999-9","workflowStages":[]},"version":"v1","identity":"rs-6745890","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6745890","identity":"rs-6745890","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}