Clinical characteristics, management and outcomes of enterococcal infective endocarditis: an ancillary study from the ESC-EORP EURO-ENDO registry

Aims Enterococcal infective endocarditis (EIE) represents a growing proportion of infective endocarditis (IE) cases, particularly among elderly and comorbid patients. EIE poses diagnostic and therapeutic challenges, notably regarding optimal antimicrobial therapy and surgical decision-making. We aimed to compare the clinical characteristics, management, and outcomes of EIE vs. non-enterococcal IE (NEIE) in the ESC-EORP EURO-ENDO registry.Methods and results This ancillary analysis of the prospective EURO-ENDO registry included adult patients with definite or possible IE enrolled between January 2016 and March 2018. Patients with monomicrobial EIE were compared with those with NEIE. Clinical, microbiological, imaging, and therapeutic data were analysed. Multivariable logistic regression including EuroSCORE II and valve status identified independent predictors of in-hospital mortality. Among 3083 patients, 365 (12%) had monomicrobial EIE. Compared with NEIE, EIE patients were older (mean 68 vs. 58 years), had more comorbidities, and more frequent prosthetic valve involvement (41% vs. 26%). Aortic valve localization and colonic uptake on PET/CT were also more common. In-hospital mortality was similar (16% vs. 17%). After adjustment for EuroSCORE II and valve status, EIE was not independently associated with higher in-hospital mortality (adjusted OR 0.67 [95% confidence interval 0.42-1.04]; P = 0.083). Among 195 EIE patients with 1-year follow-up, recurrence occurred in 6%. Healthcare-associated acquisition, prosthetic valve infection, and recurrence were associated with worse outcomes and lower surgical rates.Conclusion EIE affects older, high-risk patients. After adjustment for operative risk, mortality was comparable to other aetiologies, highlighting the need for tailored diagnostic and therapeutic strategies.Infective endocarditis (IE) is a serious infection of the heart valves. One specific form, called enterococcal endocarditis, is becoming more common, especially in older patients with other health problems and in those who have had recent contact with hospitals or medical procedures.We analysed data from over 3000 patients in the large European EURO-ENDO registry to better understand how enterococcal endocarditis differs from other forms of IE. We found that patients with enterococcal IE were older, sicker, and more likely to have artificial heart valves, such as those implanted during open-heart surgery or through transcatheter techniques (TAVI).Although their symptoms were sometimes less severe at the beginning, these patients had fewer surgeries and more frequent recurrences of the infection. We also found that early surgery and better imaging techniques, such as PET scans, were linked to better outcomes.This study highlights the need for personalized treatment strategies in this vulnerable population, including better diagnostic tools, more consistent use of surgery when needed, and thorough investigation for hidden sources of infection, such as colon cancer. Improving the care of patients with enterococcal endocarditis could help prevent relapses and save lives.