Abstract Background Despite advances in treatment, Staphylococcus aureus infective endocarditis (SA-IE) still carries significant risk, with in-hospital mortality rates ranging between 20-30%. Guidelines recommend consideration of surgery in all cases with SA-IE. Currently, data comparing outcomes of patients with SA-IE, who undergo surgery to patients who solely receive medical therapy are scarce. Purpose To compare characteristics of patients with SA-IE who undergo surgery to SA-IE patients who receive medical therapy alone. Methods Using the National Danish Endocarditis Studies (NIDUS) registry to identify all patients with first-time left-sided SA-IE between 2016 and 2021. Patients were classified into two groups: 1) patients who underwent surgery + medical therapy, and 2) patients who solely received medical therapy . Baseline characteristics from the two groups were assessed. Results We identified 888 patients with first-time left-sided SA-IE: 153 (17.2%) patients underwent surgery + medical therapy (median age 63.7 years; 71.2% male), and 735 (82.8%) received medical therapy alone (median age 75.2 years; 57.3% male). Patients receiving medical therapy alone had higher degrees of comorbidities such as diabetes (17.0% vs 27.4%), congestive heart failure (5.2% vs 18.9%), and the presence of cardiac implantable electronic devices (2.6% vs 13.9%). Patients who underwent surgery had larger vegetations compared with medical therapy alone, as 87 (56.9%) patients who underwent surgery had vegetations 10 mm compared to 149 (20.3%) in the medical therapy alone group. Surgical patients presented with higher degrees of complications from IE at admission, such as sepsis (50.3% vs. 32.8%) and emboli (26.8% vs. 9.9%). In surgical patients, class I surgical indication was present in 74 (48.3%), whereas in patients receiving medical therapy alone, class I indications were present in 66 (9.0%) patients. For patients who underwent surgery, 25 (16.3%) died during admission, compared to 206 (28.0%) patients who received medical therapy alone. After adjusting for confounders, in-hospital mortality remained lower in surgical patients (HR = 0.53 95% CI 0.35-0.81. Conclusion Patients who received medical therapy alone for SA-IE were older and had more comorbidities, which underlines patient selection and balance between risk and benefit of surgery. Patients who undergo surgery exhibit more severe disease progression at admission, characterized by larger vegetations and higher incidence of complications. These findings highlight the complexity of clinical decision-making in SA-IE and the need for further investigations into optimal management strategies in the future. Our results suggest that risk-assessment is critical when selecting patients with SA-IE for surgery.
Tajik et al. (2025) studied this question.