Management of Infective Endocarditis in a Secondary Care Trust: A Service Evaluation of Treatment Outcomes and Multidisciplinary Involvement
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1.Abstract 1.1 Background Infective endocarditis (IE) is a complex and life-threatening condition, requiring multidisciplinary team (MDT) input for optimal management. 1.2 Objectives This study aimed to review the demographics, infection management, and clinical outcomes of patients treated for IE at Chelsea and Westminster Hospital NHS Foundation Trust (CWFT), a secondary care provider in London. This study evaluated local IE service provision against national and international guidelines to identify areas for service improvement. 1.3 Methods A retrospective cohort study was conducted, identifying adult patients (≥18 years) treated for IE at CWFT between September 2023 and August 2024. Patients who received >10 days of intravenous amoxicillin, flucloxacillin, cefazolin, or vancomycin were screened. Patients who received a full course of IE treatment were included. Clinical records were reviewed for demographic, microbiological, imaging, MDT involvement, and clinical outcome data. 1.4 Results 31 patients met the inclusion criteria. The median age was 77 years (IQR 53–85) and 74% were male. Staphylococcus aureus (35%) and Enterococcus faecalis (29%) were the most common pathogens. Only 12 patients (39%) were discussed at a cardiothoracic MDT, and 2 patients lacked cardiology input. Microbiology consultations occurred in all cases, but only 55% had documented antimicrobial plans. Outpatient therapy was used in 36% of cases. Adverse outcomes of IE treatment included in-hospital mortality in 12.9% (n=4) and decline functional baseline in 29% (n=9). 1.5 Conclusions While key treatment standards were largely met, gaps in MDT involvement and documentation were identified. Implementation of a dedicated IE MDT may increase adherence to guidelines and improve secondary care service provision.
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Dear Authors, thank you for addressing the reviewer comments and submitting your revised manuscript. I have reviewed the amendments and am satisfied that they address the reviewers’ suggestions and I am delighted to accept your manuscript for publication. This is a study that would be of interest to the field and is reproducible with the amendments made.
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Dear Authors, thank you for submitting your manuscript to Access Microbiology. It has now been reviewed by two experts in the field, whose comments are attached at the bottom of this email. It was noted that your manuscript was well written and structured. However, both reviewers commented on the approach taken and request further clarification on some of the methods. I welcome the authors to review the manuscript in-line with the reviewer’s comments.
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Comments to Author
The selection criteria chosen introduce both a survivor bias (> 10-day treatment) and a Gram-positive bias (antibiotic selection). I acknowledge the authors mention this in their discussion on 'Limitations'. Could they explain why they used these selection criteria rather than diagnostic codes at discharge, a common criterion in retrospective cohort studies? It greatly limits the generalisability of the study and makes their outcome data unreliable. For example, in the NIDUS study (Denmark) half of the mortality had already occurred by day 10. I presume the chart review was entered into a form looking at various clinical and non-clinical parameters. If the authors are happy to provide their chart review form as a supplement to the article, that might assist others who wish to replicate their project. In table 1 …
Comments to Author
The selection criteria chosen introduce both a survivor bias (> 10-day treatment) and a Gram-positive bias (antibiotic selection). I acknowledge the authors mention this in their discussion on 'Limitations'. Could they explain why they used these selection criteria rather than diagnostic codes at discharge, a common criterion in retrospective cohort studies? It greatly limits the generalisability of the study and makes their outcome data unreliable. For example, in the NIDUS study (Denmark) half of the mortality had already occurred by day 10. I presume the chart review was entered into a form looking at various clinical and non-clinical parameters. If the authors are happy to provide their chart review form as a supplement to the article, that might assist others who wish to replicate their project. In table 1 it would be helpful to include the total number of blood cultures performed before commencement of IE targeted antibiotic therapy, especially in instances where there was no growth or only a single positive culture. If the data were at hand, it would be helpful differentiate bioprosthetic from mechanical from TAVI as the imaging challenges for each are quite different. I cannot find any mention of how many patients underwent valve replacement or other surgery, other than a sentence in paragraph 6.3 about unplanned emergency surgery. Were most/all these surgical patients excluded from the study because of early transfer before the 10-day antibiotic course had been reached? If so, this should be explicitly stated in the text, as it is evidence of selection bias.
Please confirm that no generative AI tools or large language models have been used to generate this peer review report or to assist with any part of the peer review process.
I confirm no generative AI tools were used in preparation of this review.
Please rate the manuscript for methodological rigour
Poor
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
The manuscript : Management of infective endocarditis in a secondary care trust : A service evaluation of treatment outcomes and multidisciplinary involvement , is well structured and clinically relevant addressing an important and challenging area .Of course some areas could be strengthened to improve clarity along with methodology 1. Inclusion criteria : The method of identifying cases ( > 10 days of Iv Abx ) introduces bias. You have acknowledged, better to explain why these antibiotics are chosen as screening markers and whether any cases of IE treated with alternate regimen. Can use the guidelines for the same. 2. Definition of full course of IE treatment : This is not defined 3. MDT involvement : More detail needed, like How MDT referral were made, what were the struggles like structural , awareness …
Comments to Author
The manuscript : Management of infective endocarditis in a secondary care trust : A service evaluation of treatment outcomes and multidisciplinary involvement , is well structured and clinically relevant addressing an important and challenging area .Of course some areas could be strengthened to improve clarity along with methodology 1. Inclusion criteria : The method of identifying cases ( > 10 days of Iv Abx ) introduces bias. You have acknowledged, better to explain why these antibiotics are chosen as screening markers and whether any cases of IE treated with alternate regimen. Can use the guidelines for the same. 2. Definition of full course of IE treatment : This is not defined 3. MDT involvement : More detail needed, like How MDT referral were made, what were the struggles like structural , awareness -related or documentation related. 4. Outcome measures : what is meant by decline in functional baseline .
Please confirm that no generative AI tools or large language models have been used to generate this peer review report or to assist with any part of the peer review process.
I confirm no generative AI tools were used in preparation of this review.
Please rate the manuscript for methodological rigour
Very good
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
No: None needed
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