Risk stratification score screening for infective endocarditis in patients with Gram-positive bacteraemia.

Background: A feared cause of bacteraemia with Gram-positives is infective endocarditis. Risk stratification scores can aid clinicians in determining the risk of endocarditis. Six proposed scores for the use in bacteraemia; Staphylococcus aureus (PREDICT, VIRSTA, POSITIVE), non-β-haemolytic streptococci (HANDOC) and Enterococcus faecalis (NOVA, DENOVA) were validated for predictive ability and the utilization of echocardiography was investigated.
Methods: Hospitalized adult patients with Gram-positive bacteraemia during 2017-2019 were evaluated retrospectively through medical records and the Swedish Death Registry. Baseline and score-specific data, definite endocarditis and echocardiographies performed were recorded. Sensitivity, specificity, negative and positive predictive values and echocardiography utilization were determined.
Results: 480 patients with bacteraemia were included and definite endocarditis was diagnosed in 20 (7.5%), 10 (6.6%), and 2 (3.2%) patients with S. aureus , non-β-haemolytic streptococci and E. faecalis, respectively. The sensitivities of the scores were 80-100% and specificities 8-77%. Negative predictive values of the six scores were 98-100%. VIRSTA, HANDOC, NOVA and DENOVA identified all, the PREDICT5 score missed 1/20 and the POSITIVE score missed 4/20 cases of endocarditis. Transoesophageal echocardiography was performed in 141 patients (29%). Thus, the risk stratification scores suggested an increase of 3-63 (7-77%) investigations with echocardiography.
Conclusions: All scores had negative-predictive values over 98%, therefore it can be concluded that PREDICT5, VIRSTA, POSITIVE, HANDOC and DENOVA are reasonable screening tools for endocarditis early on in Gram-positive bacteraemia. The use of risk stratification scores will lead to more echocardiographies.