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Delahaye et al. (1) recently emphasized the importance of screening for potential portals of entry to minimize the risk of recurrent episodes of infective endocarditis (IE). Yet, I have some concerns about their suggestion that a colonoscopy should be performed for patients ≥50 years of age who are treated for IE, whatever the causative microorganism.
The evolving epidemiology of IE shows: 1) staphylococci are now mostly implicated; and 2) elderly patients are mostly affected because of health care–associated infections. Thus, the conclusions by Delahaye et al. (1) should be weighed against the risk/benefit ratio of a systematic colonoscopy in case of a staphylococcal infective endocarditis (SIE), especially in elderly patients. In fact, adverse events during colonoscopy include gastrointestinal bleeding, perforation, and cardiovascular and pulmonary complications, and recent reviews have stressed the higher risk of such complications in the elderly (2). IE remains a life-threatening clinical condition with an estimated recurrence risk of 1% to 3% per patient-year. Yet, the published data regarding the epidemiology of recurrent IE has seldom been reported. Martinez-Selles et al. (3) found that 6 of 143 patients experienced 8 recurrences that occurred within 3 to 18 months after the initial episode, mostly related to a suboptimal treatment of the first IE (3). Indeed, comparing the microbiology of initial and recurrent IE episodes, none of the 6 patients experienced a switch for the identified strains between staphylococci and streptococci. Delahaye et al. (1) found a colonic lesion in only 1 of 75 patients with an SIE. Hence, this study provides little evidence that a diagnostic colonoscopy must be automatic in case of SIE. Although colonoscopy can be done safely most of the time even in elderly patients, we must not under-rate the potential portals of entry for IE or the potential adverse events of this procedure. Consequently, we probably need further and prospective studies to better evaluate this suggestion in case of SIE. Meanwhile, the use of immunochemical fecal blood tests could remain an attractive option, especially in elderly patients.
Please note: Dr. Baty has reported that he has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation