Management and Outcomes of Infective Endocarditis in a Community Hospital Without Cardiac Surgery and its Referral Centre: A Retrospective Cohort Study (2018–2024)

Management and Outcomes of Infective Endocarditis in a Community Hospital Without Cardiac Surgery and its Referral Centre: A Retrospective Cohort Study (2018–2024) | 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 Article Management and Outcomes of Infective Endocarditis in a Community Hospital Without Cardiac Surgery and its Referral Centre: A Retrospective Cohort Study (2018–2024) Belen Jufresa-Michavila, Cristina Bayés-Ricart, Sara Grillo, Miguel Angel Consuegra-Perez, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8310248/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Apr, 2026 Read the published version in Scientific Reports → Version 1 posted 14 You are reading this latest preprint version Abstract Purpose Despite advances in diagnosis and management, infective endocarditis (IE) remains a life-threatening condition with a high mortality rate. Most data originate from cardiac surgery centers, limiting our understanding of outcomes in community settings. Our aim was to compare the management and clinical outcomes of IE in a community hospital (HSJD) and its surgical reference center (HSP) and to identify mortality predictors. Methods We conducted a retrospective cohort study (2018–2024) including all adult patients meeting the diagnostic criteria for IE. Mortality rates were compared across centers. Predictors of mortality were identified via Cox proportional hazards models. Results A total of 137 patients were included: 53 at HSJD and 84 at HSP. Thirty-day mortality did not differ significantly across centers (17.0% vs 11.9%), nor did longer follow-up. Independent predictors of 30-day mortality included a higher Charlson Comorbidity Index, Staphylococcus aureus infection, and sepsis-related complications. Surgery was performed in 30% of patients at HSJD and 43% at HSP. Among patients with a surgical indication, undergoing surgery was associated with a reduced risk of death across all follow-up periods. Patients who were not transferred to HSP were older, had higher comorbidity scores, and had twice the risk of death compared with transferred patients. Conclusion The outcomes for patients with IE diagnosed at a community hospital were comparable to those at a cardiac surgery referral centre. These findings suggest that effective IE management is feasible across different healthcare levels when supported by specialised clinicians and coordinated multidisciplinary management. Health sciences/Cardiology Health sciences/Diseases Health sciences/Medical research Health sciences/Risk factors Infective endocarditis community hospital referral hospital cardiac surgical procedures mortality Figures Figure 1 INTRODUCTION Infective endocarditis (IE) remains a life-threatening disease, with mortality rates ranging from 15–27% in Spanish population-based studies. 1,2 . Its management is increasingly complex due to aging populations, comorbidities, and the increasing use of prosthetic heart valves and cardiac devices 5 , 6 .. Outcomes may also be influenced by the healthcare pathway, with improved survival reported when diagnosis and treatment involve multidisciplinary endocarditis teams at high-volume referral centers 2 , 3 , 7 . Although most patients are initially treated in hospitals without cardiac surgery 1 , 2 , much of the evidence on prognostic factors derives from cohorts at surgical referral centers. These cohorts include both patients admitted directly and those transferred from community hospitals 8 – 10 , whereas patients treated exclusively in nonsurgical hospitals remain underrepresented. Excluding nonreferred cases may bias baseline characteristics and overestimate survival in studies conducted in tertiary centers 11 , 12 . Comparative data between community and referral hospitals are scarce. 11,13,14 . A French multicentre study reported poorer adherence to guidelines and higher mortality in patients managed solely in community hospitals, although these patients were also older and more comorbid 14 . These gaps limit our understanding of IE management and outcomes in community hospitals. This study aimed to compare the epidemiology, clinical presentation, microbiology, management, and outcomes of patients diagnosed with IE in a community hospital without cardiac surgery facilities and in its surgical referral center. The primary outcome was 30-day mortality; secondary aims included identifying predictors of death. METHODS Study design . We conducted an observational, retrospective cohort study of adult patients diagnosed with infective endocarditis (IE) at two hospitals in Catalonia: HSJD, a community hospital without cardiac surgery facilities, and HSP, its designated surgical referral center. The reporting followed the STROBE guidelines. Setting . HSJD is a 407-bed community hospital serving ~ 272,000 people in central Catalonia. Patients with IE are managed by internal medicine specialists with infectious disease expertise, and those with severe complications (e.g., septic shock, heart failure) are admitted to intensive care. Until April 2023, cardiac surgery was considered after ad hoc telephone consultation with the HSP’s endocarditis team; since then, cases have been systematically discussed at weekly online meetings or urgently when needed. HSP is a 600-bed university hospital in Barcelona that serves ~ 403,000 inhabitants. It offers advanced medical and surgical services, including cardiovascular surgery, which is available 24/7. Patients with suspected IE are admitted to Internal Medicine, the Infectious Diseases Unit, or Cardiology, depending on their presentation. All suspected or confirmed cases are reviewed weekly by a multidisciplinary endocarditis team comprising infectious disease specialists, cardiologists, cardiac surgeons, intensivists, pharmacologists, microbiologists, radiologists, nuclear medicine specialists, and neurologists. The HSP also receives referrals for surgical IE cases from the HSJD and other regional hospitals. Patients . We included all patients aged ≥ 18 years who were diagnosed with IE at HSJD or HSP between January 2018 and December 2024. To ensure comparability, patients referred to HSP from other hospitals were excluded. IE was diagnosed according to the European Society of Cardiology (ESC) criteria in force at the time (2015 or 2023) 3 , 15 . At HSJD, cases were identified through hospital discharge codes and confirmed by review of clinical records. At HSP, patients admitted before 2022 were identified retrospectively through discharge codes; from 2022 onwards, cases were prospectively recorded by an infectious disease specialist. Follow-up continued until April 30, 2025, when the database was administratively closed. Data extraction. Demographic, clinical, microbiological, therapeutic, and outcome data were extracted from electronic medical records at both hospitals and entered into a secure, password-protected REDCap database hosted at HSJD. Records were pseudonymized before entry, and access was limited to authorised study personnel. Data collection and database management were performed exclusively by investigators from HSJD and HSP. Statistical methods . Categorical variables are presented as frequencies and percentages, and continuous variables are presented as the means (SDs) or medians (IQRs), depending on their distributions. For group comparisons, the chi-square test or Fisher’s exact test was used for categorical variables, and the t test or Mann–Whitney U test was used for continuous variables. Incidence rates were expressed as cases per 100,000 person-years with 95% confidence intervals (CIs) estimated via the Poisson distribution; incidence rate ratios (IRRs) were used to compare centers. Mortality was assessed at 30 days, in-hospital, one year, and at the end of follow-up. Associations between clinical variables and mortality were analysed via Cox proportional hazards models. Univariable models identified potential predictors (p < 0.05). Given the limited number of events, a parsimonious multivariable model including the most clinically and statistically relevant variables was constructed. The results are reported as hazard ratios (HRs) with 95% CIs. Model assumptions were verified via Schoenfeld residuals for proportional hazards, Martingale residuals for linearity of continuous variables, and variance inflation factors (VIFs) for multicollinearity (VIF > 10 considered concerning). Analyses were conducted via IBM SPSS Statistics v29.0 and R v4.3.3. A two-sided p value < 0.05 was considered significant. Ethical considerations . The study was approved by the by the Institute for Research and Innovation in Life and Health Sciences in Central Catalonia (IRIS-CC) Research Ethics Committee (ref. 25/001) and conducted in accordance with the Declaration of Helsinki. The data were pseudonymized and handled in compliance with the EU GDPR. As a retrospective, observational study with no direct patient involvement, informed consent was waived. RESULTS A total of 137 patients were diagnosed with IE during the study period: 53 at the HSJD and 84 at the HSP. The incidence rate was 2.78 per 100,000 person-years at HSJD and 3.47 at HSP, yielding an incidence rate ratio (IRR) of 1.25 (95% CI, 0.88–1.76). The demographic and comorbidity data are shown in Table 1 . Age, sex, and Charlson comorbidity scores were similar across centers, although patients with HSP more often had ischemic heart disease, chronic heart failure, peptic ulcer disease, and solid malignancies. The episode characteristics are summarised in Table 2 . Definite IE was diagnosed more frequently at HSP (83.3% vs. 54.7%, p < 0.001), and multidisciplinary endocarditis team discussions were more common (82.1% vs. 54.9%, p < 0.001). Patients at HSP also undergo advanced imaging more often, including PET‒CT and transoesophageal echocardiography (TOE). Valve vegetation was identified significantly more often on TOE at HSP. Among IE-related complications, only acute kidney injury was significantly more common in patients at HSP. Microbiological findings were broadly comparable across centers, with Staphylococcus aureus being the leading pathogen, followed by viridans group streptococci and Enterococcus spp. Table 2 . Characterization of Infective Endocarditis episodes (see at the end of the manuscript) Management and clinical outcomes . The therapeutic interventions and outcomes are shown in Table 3 . The duration of intravenous antibiotic therapy was similar across hospitals. OPAT use was more common in patients at HSP, although the difference was not statistically significant. Surgical indications were identified in 56% of patients at HSJD and 50% at HSP, most often due to severe valve dysfunction, large vegetation, or paravalvular extension. Surgery was ultimately performed in 30% and 43% of patients, respectively (ns). The main reasons for withholding surgery were high operative risk, favourable medical response, and CNS complications. The median hospital stay was slightly longer at the time of HSP, but the difference was not significant. No differences were observed in relapse, 90-day readmission, or valve surgery during follow-up. The median follow-up was 727 days (IQR, 67–1398), with no center differences. Mortality did not differ between HSJD and HSP: 30-day (17% vs. 11.9%, p = 0.402), in-hospital (24.5% vs. 22.6%, p = 0.797), one-year (34% vs. 35.7%, p = 0.834), or end-of-follow-up (45.3% vs. 46.5%, p = 0.896). Predictors of mortality. Univariable and multivariable Cox analyses are shown in Table 4. In the adjusted model, a higher Charlson Comorbidity Index, S. aureus infection, and sepsis-related complications independently predicted 30-day mortality. At one year, the Charlson comorbidity index and incidence of sepsis at presentation remained significant. All model assumptions were satisfied. Adjusted survival curves confirmed similar mortality rates between hospitals (Fig. 1 ). Among patients with a surgical indication (Table 5 ), 30-day mortality was 0% (0/27) in those who underwent surgery versus 24.4% (11/45) in those who did not undergo surgery (p = 0.005). Surgically treated patients consistently had lower mortality rates at all follow-up points. Impact of transference and surgery among patients diagnosed at HSJD. Of the 53 patients diagnosed with HSJD, 21 (39.6%) had a surgical indication, and 19 (35.8%) were transferred (Table 6 ). Overall, mortality was greater among nontransferred patients, although the difference was not statistically significant: 20.6% vs. 10.5% at 30 days (RR, 1.96; 95% CI, 0.36–10.51) and 41.2% vs. 21.1% at one year (RR, 1.96; 95% CI, 0.75–5.10). The nontransferred patients were older (median 82 vs. 68 years; p = 0.002) and had higher Charlson scores (6 vs. 4; p = 0.032). Among nontransferred patients, 30-day mortality was 9.1% among those with a surgical indication versus 26.1% without (RR, 0.35; 95% CI, 0.05–2.67). Mortality was significantly greater in patients with surgical indications at all other follow-up points. At one year, the mortality rates were 54.5% and 34.8%, respectively (RR, 1.57; 95% CI, 0.25–3.41) (Table 6 ). DISCUSSION This population-based study compared patients with IE diagnosed at a community hospital without cardiac surgery facilities and those managed at its referral surgical center. Despite differences in complexity and resources, mortality rates did not differ significantly across hospitals. The 30-day mortality rate was 17% at the community hospital and 11.9% at the referral center, while the one-year mortality rate exceeded onethird of patients (34% vs. 35.7%). These findings are consistent with previous population-based studies 11 , 13 , 14 , 16 and reinforce that, despite advances in diagnostics, antimicrobial therapy, and surgery, IE remains associated with high mortality 8 . Independent predictors of 30-day mortality were a higher Charlson comorbidity index, Staphylococcus aureus infection, and sepsis-related complications, whereas the Charlson comorbidity index and sepsis at presentation predicted one-year mortality, which is in line with previous reports 1 , 11 , 17 . The incidence was slightly higher at the referral centre but not significantly different. Patient characteristics mirrored the evolving IE profile in high-income countries: older men with multiple comorbidities and frequent prosthetic valves or cardiac devices 1 , 6 , 18 , 19 . Although some baseline differences were observed (e.g., more chronic heart disease and acute kidney injury at HSP), the cohorts were otherwise comparable. Consistent with previous reports from high-income settings, S. aureus was responsible for one quarter of cases 1 , 6 , 8 , 10 , 11 , followed by viridans streptococci and enterococci. Notably, healthcare-related IE predominates, reflecting the growing risk among elderly patients with frequent healthcare exposure 5 , 6 , 19 , 20 . Diagnostic approaches differ across hospitals. Patients at the community hospital were less likely to undergo transoesophageal echocardiography (TOE) or PET-CT. TOE was performed in 60% of the HSJD patients, 74% of the HSP patients, and only 44% of the nontransferred patients. The limited use or availability of TOE in community settings may lead to underestimation of surgical indications and suboptimal management 21 Differences in imaging availability and expertise likely explain why more patients received a definitive IE diagnosis at the referral center. The systematic use of TOE, image sharing, and broader access to PET-CT in suspected prosthetic or device-related IE would help align community practice with guideline recommendations 3 , 4 . Surgery was performed in 30% of community-hospital patients and 45% of community-hospital patients at the referral center, which is consistent with recent reports 1 , 14 , 18 , 22 . The main reasons for withholding surgery were unacceptable risk, CNS complications, or favourable response to medical therapy, which are comparable between centers and are in line with previous reports 18 , 22 , 23 . In agreement with prior studies 9 , 10 , 17 , 22 , 23 , survival was markedly better among patients with surgical indications who underwent surgery, whereas nearly half of those managed medically died within one year 1 , 22 – 24 . This underscores not only the survival benefit of surgery but also the challenge of managing patients considered inoperable. Only 54.9% of the HSJD cases were discussed with the referral centre, mostly via ad hoc calls, whereas 82.1% of the cases were reviewed in structured multidisciplinary meetings at the referral centre. Although this difference may partly reflect incomplete clinical records, it nevertheless highlights an opportunity for improvement. Multidisciplinary endocarditis teams are increasingly recognised as essential for optimising IE management 3 , 4 , 7 . Since 2023, HSJD has participated in weekly online meetings, potentially improving coordination and outcomes. Referral practices varied considerably. In line with previous reports of patients diagnosed at community hospitals 1 , 13 , 14 , 36% of patients at the HSJD were transferred to the referral center. The nontransferred patients were older, had more comorbidities, and had nearly double the mortality rate at 30 days and one year, which is consistent with prior studies 1 , 11 , 14 . The limited number of diagnostic methods may have contributed to the underecognition of surgical indications at the community hospital. More than half of patients with an indication who did not undergo surgery died within one year, echoing the poor prognosis reported elsewhere 1 , 11 , 14 . Although surgery benefits survival across age groups, older patients rarely undergo surgery (6% >80 years vs. 46% ≤65 years in one Swedish study) 25 . Identifying high-risk but potentially salvageable elderly patients remains critical, with shared decision-making involving surgeons, endocarditis teams, and patients themselves. Finally, there were no significant between-centre differences in hospital stay, readmission, IE relapse, or follow-up surgery. OPAT use and duration were also similar, underscoring the integration of ambulatory care into IE management beyond tertiary settings. Limitations of this study include its modest sample size, limiting power to detect differences, and retrospective design, with possible documentation bias. We did not evaluate social determinants of health, which may influence outcomes. This study also has several important strengths. First, direct comparisons of the management and outcomes of patients with IE diagnosed at a community hospital versus a referral surgical centre are needed. By adopting a population-based approach, the study avoids the selection bias inherent in international registries and surgical-centre cohorts and provides a valuable opportunity to evaluate the logistics and coordination of interhospital transfers. Second, we conducted a detailed analysis of patients who were not referred. This is essential for fully assessing the impact of referral bias and identifying opportunities for improving IE management within community settings. Finally, a sensitivity analysis comparing mortality across multiple follow-up intervals offers a nuanced understanding of prognosis for patients diagnosed in both surgical and nonsurgical hospitals. In summary, mortality rates were comparable between patients diagnosed at a community hospital and those diagnosed at a referral surgical center. Given the limited evidence on IE management in community settings, our findings suggest that decentralised IE care is feasible when community hospitals have physicians experienced in IE and coordinated referral pathways. Our findings also underscore opportunities to improve IE management in community hospitals through wider use of TOE and PET-CT, routine surgical assessment for all eligible patients, and systematic multidisciplinary review. Declarations Competing interests The authors have no competing interests to declare that are relevant to the content of this article. Funding and competing interests This project was carried out with no funding . The authors have no competing interests to declare that are relevant to the content of this article. Acknowledgements The authors thank the members of the Endocarditis Team at Hospital de la Santa Creu i Sant Pau (Antonio Barros Membrilla, Manel Tauron, Mònica Velasco-Nuño, Luis Prats, Tobias Koller, Elena Rosselló, Ana Bonet-Basiero, Xavier Garcia-Moll, Antonino Ginel, Alessandro Sionis, Laura Rodriguez Sotelo, Montserrat Vila-Perales, Chi Hion Li, Patricia Amoros, Maria Alba Rivera-Martinez) for their invaluable contributions to patient care and collaboration in this study. We thank the Documentation and Clinical Information Unit of Hospital Sant Joan de Déu de Manresa for their assistance in identifying patients for this study. Data availability. The data are available upon reasonable request. References Calzado, S. et al. The hidden side of infective endocarditis: Diagnostic and management of 500 consecutive cases in noncardiac surgery centers (2009–2018). Surgery 174 , 602–610 (2023). Zulet, P. et al. 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Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 30 Apr, 2026 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 06 Feb, 2026 Reviews received at journal 18 Jan, 2026 Reviewers agreed at journal 09 Jan, 2026 Reviews received at journal 08 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviewers agreed at journal 31 Dec, 2025 Reviewers agreed at journal 31 Dec, 2025 Reviews received at journal 28 Dec, 2025 Reviewers agreed at journal 28 Dec, 2025 Reviewers invited by journal 26 Dec, 2025 Editor assigned by journal 25 Dec, 2025 Editor invited by journal 15 Dec, 2025 Submission checks completed at journal 11 Dec, 2025 First submitted to journal 11 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":191283,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of 30-day (Fig 1A) and one-year mortality (Fig 1B) between centres. Survival curves are derived from the adjusted Cox-regression models\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8310248/v1/5294abcec0d958f1d7759ef1.png"},{"id":108438026,"identity":"98e660e0-e062-4dd4-9faf-06d1e7795d09","added_by":"auto","created_at":"2026-05-04 16:05:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":396122,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8310248/v1/b76e537c-038d-46b8-8b92-a66d93c8bba8.pdf"},{"id":99291090,"identity":"e963175d-3aaa-400e-a314-d530617673cc","added_by":"auto","created_at":"2025-12-31 10:36:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":134903,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8310248/v1/2c3539b6031a35cfcfb10aa4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Management and Outcomes of Infective Endocarditis in a Community Hospital Without Cardiac Surgery and its Referral Centre: A Retrospective Cohort Study (2018–2024)","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eInfective endocarditis (IE) remains a life-threatening disease, with mortality rates ranging from 15\u0026ndash;27% in Spanish population-based studies. \u003csup\u003e1,2\u003c/sup\u003e. Its management is increasingly complex due to aging populations, comorbidities, and the increasing use of prosthetic heart valves and cardiac devices \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.. Outcomes may also be influenced by the healthcare pathway, with improved survival reported when diagnosis and treatment involve multidisciplinary endocarditis teams at high-volume referral centers \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough most patients are initially treated in hospitals without cardiac surgery \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, much of the evidence on prognostic factors derives from cohorts at surgical referral centers. These cohorts include both patients admitted directly and those transferred from community hospitals \u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, whereas patients treated exclusively in nonsurgical hospitals remain underrepresented. Excluding nonreferred cases may bias baseline characteristics and overestimate survival in studies conducted in tertiary centers \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eComparative data between community and referral hospitals are scarce. \u003csup\u003e11,13,14\u003c/sup\u003e. A French multicentre study reported poorer adherence to guidelines and higher mortality in patients managed solely in community hospitals, although these patients were also older and more comorbid \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThese gaps limit our understanding of IE management and outcomes in community hospitals. This study aimed to compare the epidemiology, clinical presentation, microbiology, management, and outcomes of patients diagnosed with IE in a community hospital without cardiac surgery facilities and in its surgical referral center. The primary outcome was 30-day mortality; secondary aims included identifying predictors of death.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e. We conducted an observational, retrospective cohort study of adult patients diagnosed with infective endocarditis (IE) at two hospitals in Catalonia: HSJD, a community hospital without cardiac surgery facilities, and HSP, its designated surgical referral center. The reporting followed the STROBE guidelines.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSetting\u003c/b\u003e. HSJD is a 407-bed community hospital serving\u0026thinsp;~\u0026thinsp;272,000 people in central Catalonia. Patients with IE are managed by internal medicine specialists with infectious disease expertise, and those with severe complications (e.g., septic shock, heart failure) are admitted to intensive care. Until April 2023, cardiac surgery was considered after ad hoc telephone consultation with the HSP\u0026rsquo;s endocarditis team; since then, cases have been systematically discussed at weekly online meetings or urgently when needed.\u003c/p\u003e \u003cp\u003eHSP is a 600-bed university hospital in Barcelona that serves\u0026thinsp;~\u0026thinsp;403,000 inhabitants. It offers advanced medical and surgical services, including cardiovascular surgery, which is available 24/7. Patients with suspected IE are admitted to Internal Medicine, the Infectious Diseases Unit, or Cardiology, depending on their presentation. All suspected or confirmed cases are reviewed weekly by a multidisciplinary endocarditis team comprising infectious disease specialists, cardiologists, cardiac surgeons, intensivists, pharmacologists, microbiologists, radiologists, nuclear medicine specialists, and neurologists. The HSP also receives referrals for surgical IE cases from the HSJD and other regional hospitals.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatients\u003c/b\u003e. We included all patients aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years who were diagnosed with IE at HSJD or HSP between January 2018 and December 2024. To ensure comparability, patients referred to HSP from other hospitals were excluded. IE was diagnosed according to the European Society of Cardiology (ESC) criteria in force at the time (2015 or 2023)\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAt HSJD, cases were identified through hospital discharge codes and confirmed by review of clinical records. At HSP, patients admitted before 2022 were identified retrospectively through discharge codes; from 2022 onwards, cases were prospectively recorded by an infectious disease specialist. Follow-up continued until April 30, 2025, when the database was administratively closed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData extraction.\u003c/b\u003e Demographic, clinical, microbiological, therapeutic, and outcome data were extracted from electronic medical records at both hospitals and entered into a secure, password-protected REDCap database hosted at HSJD. Records were pseudonymized before entry, and access was limited to authorised study personnel. Data collection and database management were performed exclusively by investigators from HSJD and HSP.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical methods\u003c/b\u003e. Categorical variables are presented as frequencies and percentages, and continuous variables are presented as the means (SDs) or medians (IQRs), depending on their distributions. For group comparisons, the chi-square test or Fisher\u0026rsquo;s exact test was used for categorical variables, and the t test or Mann\u0026ndash;Whitney U test was used for continuous variables.\u003c/p\u003e \u003cp\u003eIncidence rates were expressed as cases per 100,000 person-years with 95% confidence intervals (CIs) estimated via the Poisson distribution; incidence rate ratios (IRRs) were used to compare centers. Mortality was assessed at 30 days, in-hospital, one year, and at the end of follow-up. Associations between clinical variables and mortality were analysed via Cox proportional hazards models. Univariable models identified potential predictors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Given the limited number of events, a parsimonious multivariable model including the most clinically and statistically relevant variables was constructed. The results are reported as hazard ratios (HRs) with 95% CIs.\u003c/p\u003e \u003cp\u003eModel assumptions were verified via Schoenfeld residuals for proportional hazards, Martingale residuals for linearity of continuous variables, and variance inflation factors (VIFs) for multicollinearity (VIF\u0026thinsp;\u0026gt;\u0026thinsp;10 considered concerning). Analyses were conducted via IBM SPSS Statistics v29.0 and R v4.3.3. A two-sided p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthical considerations\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e The study was approved by the by the Institute for Research and Innovation in Life and Health Sciences in Central Catalonia (IRIS-CC) Research Ethics Committee (ref. 25/001) and conducted in accordance with the Declaration of Helsinki. The data were pseudonymized and handled in compliance with the EU GDPR. As a retrospective, observational study with no direct patient involvement, informed consent was waived.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 137 patients were diagnosed with IE during the study period: 53 at the HSJD and 84 at the HSP. The incidence rate was 2.78 per 100,000 person-years at HSJD and 3.47 at HSP, yielding an incidence rate ratio (IRR) of 1.25 (95% CI, 0.88\u0026ndash;1.76).\u003c/p\u003e\n\u003cp\u003eThe demographic and comorbidity data are shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Age, sex, and Charlson comorbidity scores were similar across centers, although patients with HSP more often had ischemic heart disease, chronic heart failure, peptic ulcer disease, and solid malignancies.\u003c/p\u003e\n\u003cp\u003eThe episode characteristics are summarised in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Definite IE was diagnosed more frequently at HSP (83.3% vs. 54.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and multidisciplinary endocarditis team discussions were more common (82.1% vs. 54.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients at HSP also undergo advanced imaging more often, including PET‒CT and transoesophageal echocardiography (TOE). Valve vegetation was identified significantly more often on TOE at HSP.\u003c/p\u003e\n\u003cp\u003eAmong IE-related complications, only acute kidney injury was significantly more common in patients at HSP. Microbiological findings were broadly comparable across centers, with \u003cem\u003eStaphylococcus aureus\u003c/em\u003e being the leading pathogen, followed by \u003cem\u003eviridans group streptococci\u003c/em\u003e and \u003cem\u003eEnterococcus\u003c/em\u003e spp.\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Characterization of Infective Endocarditis episodes (see at the end of the manuscript)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManagement and clinical outcomes\u003c/strong\u003e. The therapeutic interventions and outcomes are shown in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eThe duration of intravenous antibiotic therapy was similar across hospitals. OPAT use was more common in patients at HSP, although the difference was not statistically significant.\u003c/p\u003e\n\u003cp\u003eSurgical indications were identified in 56% of patients at HSJD and 50% at HSP, most often due to severe valve dysfunction, large vegetation, or paravalvular extension. Surgery was ultimately performed in 30% and 43% of patients, respectively (ns). The main reasons for withholding surgery were high operative risk, favourable medical response, and CNS complications.\u003c/p\u003e\n\u003cp\u003eThe median hospital stay was slightly longer at the time of HSP, but the difference was not significant. No differences were observed in relapse, 90-day readmission, or valve surgery during follow-up. The median follow-up was 727 days (IQR, 67\u0026ndash;1398), with no center differences.\u003c/p\u003e\n\u003cp\u003eMortality did not differ between HSJD and HSP: 30-day (17% vs. 11.9%, p\u0026thinsp;=\u0026thinsp;0.402), in-hospital (24.5% vs. 22.6%, p\u0026thinsp;=\u0026thinsp;0.797), one-year (34% vs. 35.7%, p\u0026thinsp;=\u0026thinsp;0.834), or end-of-follow-up (45.3% vs. 46.5%, p\u0026thinsp;=\u0026thinsp;0.896).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePredictors of mortality.\u003c/strong\u003e Univariable and multivariable Cox analyses are shown in Table 4. In the adjusted model, a higher Charlson Comorbidity Index, \u003cem\u003eS. aureus\u003c/em\u003e infection, and sepsis-related complications independently predicted 30-day mortality. At one year, the Charlson comorbidity index and incidence of sepsis at presentation remained significant. All model assumptions were satisfied.\u003c/p\u003e\n\u003cp\u003eAdjusted survival curves confirmed similar mortality rates between hospitals (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAmong patients with a surgical indication (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e), 30-day mortality was 0% (0/27) in those who underwent surgery versus 24.4% (11/45) in those who did not undergo surgery (p\u0026thinsp;=\u0026thinsp;0.005). Surgically treated patients consistently had lower mortality rates at all follow-up points.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImpact of transference and surgery among patients diagnosed at HSJD.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 53 patients diagnosed with HSJD, 21 (39.6%) had a surgical indication, and 19 (35.8%) were transferred (Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e). Overall, mortality was greater among nontransferred patients, although the difference was not statistically significant: 20.6% vs. 10.5% at 30 days (RR, 1.96; 95% CI, 0.36\u0026ndash;10.51) and 41.2% vs. 21.1% at one year (RR, 1.96; 95% CI, 0.75\u0026ndash;5.10). The nontransferred patients were older (median 82 vs. 68 years; p\u0026thinsp;=\u0026thinsp;0.002) and had higher Charlson scores (6 vs. 4; p\u0026thinsp;=\u0026thinsp;0.032).\u003c/p\u003e\n\u003cp\u003eAmong nontransferred patients, 30-day mortality was 9.1% among those with a surgical indication versus 26.1% without (RR, 0.35; 95% CI, 0.05\u0026ndash;2.67). Mortality was significantly greater in patients with surgical indications at all other follow-up points. At one year, the mortality rates were 54.5% and 34.8%, respectively (RR, 1.57; 95% CI, 0.25\u0026ndash;3.41) (Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis population-based study compared patients with IE diagnosed at a community hospital without cardiac surgery facilities and those managed at its referral surgical center. Despite differences in complexity and resources, mortality rates did not differ significantly across hospitals. The 30-day mortality rate was 17% at the community hospital and 11.9% at the referral center, while the one-year mortality rate exceeded onethird of patients (34% vs. 35.7%).\u003c/p\u003e \u003cp\u003eThese findings are consistent with previous population-based studies \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e and reinforce that, despite advances in diagnostics, antimicrobial therapy, and surgery, IE remains associated with high mortality \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Independent predictors of 30-day mortality were a higher Charlson comorbidity index, \u003cem\u003eStaphylococcus aureus\u003c/em\u003e infection, and sepsis-related complications, whereas the Charlson comorbidity index and sepsis at presentation predicted one-year mortality, which is in line with previous reports \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe incidence was slightly higher at the referral centre but not significantly different. Patient characteristics mirrored the evolving IE profile in high-income countries: older men with multiple comorbidities and frequent prosthetic valves or cardiac devices\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough some baseline differences were observed (e.g., more chronic heart disease and acute kidney injury at HSP), the cohorts were otherwise comparable. Consistent with previous reports from high-income settings, \u003cem\u003eS. aureus\u003c/em\u003e was responsible for one quarter of cases\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, followed by viridans streptococci and enterococci. Notably, healthcare-related IE predominates, reflecting the growing risk among elderly patients with frequent healthcare exposure\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDiagnostic approaches differ across hospitals. Patients at the community hospital were less likely to undergo transoesophageal echocardiography (TOE) or PET-CT. TOE was performed in 60% of the HSJD patients, 74% of the HSP patients, and only 44% of the nontransferred patients. The limited use or availability of TOE in community settings may lead to underestimation of surgical indications and suboptimal management\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Differences in imaging availability and expertise likely explain why more patients received a definitive IE diagnosis at the referral center. The systematic use of TOE, image sharing, and broader access to PET-CT in suspected prosthetic or device-related IE would help align community practice with guideline recommendations\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSurgery was performed in 30% of community-hospital patients and 45% of community-hospital patients at the referral center, which is consistent with recent reports \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. The main reasons for withholding surgery were unacceptable risk, CNS complications, or favourable response to medical therapy, which are comparable between centers and are in line with previous reports\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. In agreement with prior studies \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, survival was markedly better among patients with surgical indications who underwent surgery, whereas nearly half of those managed medically died within one year \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. This underscores not only the survival benefit of surgery but also the challenge of managing patients considered inoperable.\u003c/p\u003e \u003cp\u003eOnly 54.9% of the HSJD cases were discussed with the referral centre, mostly via ad hoc calls, whereas 82.1% of the cases were reviewed in structured multidisciplinary meetings at the referral centre. Although this difference may partly reflect incomplete clinical records, it nevertheless highlights an opportunity for improvement. Multidisciplinary endocarditis teams are increasingly recognised as essential for optimising IE management \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Since 2023, HSJD has participated in weekly online meetings, potentially improving coordination and outcomes.\u003c/p\u003e \u003cp\u003eReferral practices varied considerably. In line with previous reports of patients diagnosed at community hospitals \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, 36% of patients at the HSJD were transferred to the referral center. The nontransferred patients were older, had more comorbidities, and had nearly double the mortality rate at 30 days and one year, which is consistent with prior studies\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The limited number of diagnostic methods may have contributed to the underecognition of surgical indications at the community hospital. More than half of patients with an indication who did not undergo surgery died within one year, echoing the poor prognosis reported elsewhere \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Although surgery benefits survival across age groups, older patients rarely undergo surgery (6% \u0026gt;80 years vs. 46% \u0026le;65 years in one Swedish study) \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Identifying high-risk but potentially salvageable elderly patients remains critical, with shared decision-making involving surgeons, endocarditis teams, and patients themselves.\u003c/p\u003e \u003cp\u003eFinally, there were no significant between-centre differences in hospital stay, readmission, IE relapse, or follow-up surgery. OPAT use and duration were also similar, underscoring the integration of ambulatory care into IE management beyond tertiary settings.\u003c/p\u003e \u003cp\u003eLimitations of this study include its modest sample size, limiting power to detect differences, and retrospective design, with possible documentation bias. We did not evaluate social determinants of health, which may influence outcomes.\u003c/p\u003e \u003cp\u003eThis study also has several important strengths. First, direct comparisons of the management and outcomes of patients with IE diagnosed at a community hospital versus a referral surgical centre are needed. By adopting a population-based approach, the study avoids the selection bias inherent in international registries and surgical-centre cohorts and provides a valuable opportunity to evaluate the logistics and coordination of interhospital transfers. Second, we conducted a detailed analysis of patients who were not referred. This is essential for fully assessing the impact of referral bias and identifying opportunities for improving IE management within community settings. Finally, a sensitivity analysis comparing mortality across multiple follow-up intervals offers a nuanced understanding of prognosis for patients diagnosed in both surgical and nonsurgical hospitals.\u003c/p\u003e \u003cp\u003eIn summary, mortality rates were comparable between patients diagnosed at a community hospital and those diagnosed at a referral surgical center. Given the limited evidence on IE management in community settings, our findings suggest that decentralised IE care is feasible when community hospitals have physicians experienced in IE and coordinated referral pathways. Our findings also underscore opportunities to improve IE management in community hospitals through wider use of TOE and PET-CT, routine surgical assessment for all eligible patients, and systematic multidisciplinary review.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ecompeting\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was carried out with no funding\u003cins cite=\"mailto:Editor%202\" datetime=\"2025-10-07T17:54\"\u003e.\u003c/ins\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the members of the Endocarditis Team at Hospital de la Santa Creu i Sant Pau (Antonio Barros Membrilla, Manel Tauron, M\u0026ograve;nica Velasco-Nu\u0026ntilde;o, Luis Prats, Tobias Koller, Elena Rossell\u0026oacute;, Ana Bonet-Basiero, Xavier Garcia-Moll, Antonino Ginel, Alessandro Sionis, Laura Rodriguez Sotelo, Montserrat Vila-Perales, Chi Hion Li, Patricia Amoros, Maria Alba Rivera-Martinez) \u0026nbsp;for their invaluable contributions to patient care and collaboration in this study.\u003c/p\u003e\n\u003cp\u003eWe thank the Documentation and Clinical Information Unit of Hospital Sant Joan de D\u0026eacute;u de Manresa for their assistance in identifying patients for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are available upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCalzado, S. et al. 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Infect.\u003c/em\u003e \u003cb\u003e17\u003c/b\u003e, 769\u0026ndash;775 (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeric\u0026agrave;s, J. M. et al. Outcomes and Risk Factors of Septic Shock in Patients With Infective Endocarditis: A Prospective Cohort Study. \u003cem\u003eOpen. Forum Infect. Dis.\u003c/em\u003e \u003cb\u003e8\u003c/b\u003e, ofab119 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJensen, A. D. et al. Surgical treatment of patients with infective endocarditis: changes in temporal use, patient characteristics, and mortality\u0026mdash;a nationwide study. \u003cem\u003eBMC Cardiovasc. Disord\u003c/em\u003e. \u003cb\u003e22\u003c/b\u003e, 338 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, A., Gaca, J. G. \u0026amp; Chu, V. H. Management Considerations in Infective Endocarditis: A Review. \u003cem\u003eJAMA\u003c/em\u003e \u003cb\u003e320\u003c/b\u003e, 72 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJanszky, I., G\u0026eacute;mes, K., Ahnve, S., Asgeirsson, H. \u0026amp; M\u0026ouml;ller, J. Invasive Procedures Associated With the Development of Infective Endocarditis. \u003cem\u003eJ. Am. Coll. Cardiol.\u003c/em\u003e \u003cb\u003e71\u003c/b\u003e, 2744\u0026ndash;2752 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eN\u0026rsquo;cho-Mottoh, M-P-B. et al. The impact of transoesophageal echocardiography in elderly patients with infective endocarditis. \u003cem\u003eArch. Cardiovasc. Dis.\u003c/em\u003e \u003cb\u003e116\u003c/b\u003e, 258\u0026ndash;264 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Oslash;stergaard, L. et al. Long-term causes of death in patients with infective endocarditis who undergo medical therapy only or surgical treatment: a nationwide population-based study. \u003cem\u003eEur. J. Cardiothorac. Surg.\u003c/em\u003e \u003cb\u003e54\u003c/b\u003e, 860\u0026ndash;866 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIung, B. et al. Cardiac surgery during the acute phase of infective endocarditis: discrepancies between European Society of Cardiology guidelines and practices. \u003cem\u003eEur. Heart J.\u003c/em\u003e \u003cb\u003e37\u003c/b\u003e, 840\u0026ndash;848 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark, L. P. et al. Validated Risk Score for Predicting 6-Month Mortality in Infective Endocarditis. \u003cem\u003eJAHA\u003c/em\u003e \u003cb\u003e5\u003c/b\u003e, e003016 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRagnarsson, S., Salto-Alejandre, S., Str\u0026ouml;m, A., Olaison, L. \u0026amp; Rasmussen, M. Surgery Is Underused in Elderly Patients With Left‐Sided Infective Endocarditis: A Nationwide Registry Study. \u003cem\u003eJAHA\u003c/em\u003e ; 10: e020221. (2021).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section.\u003c/p\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":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Infective endocarditis, community hospital, referral hospital, cardiac surgical procedures, mortality","lastPublishedDoi":"10.21203/rs.3.rs-8310248/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8310248/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite advances in diagnosis and management, infective endocarditis (IE) remains a life-threatening condition with a high mortality rate. Most data originate from cardiac surgery centers, limiting our understanding of outcomes in community settings. Our aim was to compare the management and clinical outcomes of IE in a community hospital (HSJD) and its surgical reference center (HSP) and to identify mortality predictors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a retrospective cohort study (2018–2024) including all adult patients meeting the diagnostic criteria for IE. Mortality rates were compared across centers. Predictors of mortality were identified via Cox proportional hazards models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 137 patients were included: 53 at HSJD and 84 at HSP. Thirty-day mortality did not differ significantly across centers (17.0% vs 11.9%), nor did longer follow-up. Independent predictors of 30-day mortality included a higher Charlson Comorbidity Index, \u003cem\u003eStaphylococcus aureus\u003c/em\u003e infection, and sepsis-related complications. Surgery was performed in 30% of patients at HSJD and 43% at HSP. Among patients with a surgical indication, undergoing surgery was associated with a reduced risk of death across all follow-up periods. Patients who were not transferred to HSP were older, had higher comorbidity scores, and had twice the risk of death compared with transferred patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe outcomes for patients with IE diagnosed at a community hospital were comparable to those at a cardiac surgery referral centre. These findings suggest that effective IE management is feasible across different healthcare levels when supported by specialised clinicians and coordinated multidisciplinary management.\u003c/p\u003e","manuscriptTitle":"Management and Outcomes of Infective Endocarditis in a Community Hospital Without Cardiac Surgery and its Referral Centre: A Retrospective Cohort Study (2018–2024)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-31 10:36:16","doi":"10.21203/rs.3.rs-8310248/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-06T11:21:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-18T13:40:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309671416911500667835394611026979106625","date":"2026-01-09T08:28:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-08T07:22:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266613032299879618992426116649358412622","date":"2026-01-08T04:27:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122469935834982417518817971104805069116","date":"2025-12-31T16:22:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284394686828053306726482116032863010350","date":"2025-12-31T13:45:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-28T15:51:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263171290276547390361438194662705465106","date":"2025-12-28T14:28:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-26T08:47:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-25T10:28:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-15T07:17:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-11T10:44:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-12-11T10:13:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e1164520-0526-4c73-9be4-a41ff49a8a0f","owner":[],"postedDate":"December 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":60293847,"name":"Health sciences/Cardiology"},{"id":60293848,"name":"Health sciences/Diseases"},{"id":60293849,"name":"Health sciences/Medical research"},{"id":60293850,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-05-04T16:05:29+00:00","versionOfRecord":{"articleIdentity":"rs-8310248","link":"https://doi.org/10.1038/s41598-026-50918-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-04-30 15:58:18","publishedOnDateReadable":"April 30th, 2026"},"versionCreatedAt":"2025-12-31 10:36:16","video":"","vorDoi":"10.1038/s41598-026-50918-z","vorDoiUrl":"https://doi.org/10.1038/s41598-026-50918-z","workflowStages":[]},"version":"v1","identity":"rs-8310248","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8310248","identity":"rs-8310248","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}