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Peer-reviewedCC BYEClinicalMedicine

Enterococcus faecalis bacteraemia and infective endocarditis: a systematic review and meta-analysis.

  • Giovanni Mori1
  • Alessandro Castelli1
  • Andrea Cordin2
  • Giovanni Lorenzin3
  • Roberto Bonmassari4
  • Francesco Onorati2,5
  • Alberto Maino2,6
  • Massimiliano Lanzafame1,2
  • Vito Racanelli2,6
  • Nicola Susca6
6 affiliations
  1. 1Infectious Diseases Unit, Santa Chiara Hospital, Azienda Sanitaria Universitaria Integrata del Trentino (ASUIT), Trento, Italy.
  2. 2Center for Medical Sciences (CISMed), University of Trento, Trento, Italy.
  3. 3Microbiology Unit, Santa Chiara Hospital, Azienda Sanitaria Universitaria Integrata del Trentino (ASUIT), Trento, Italy.
  4. 4Department of Cardiology, Santa Chiara Hospital, Azienda Sanitaria Universitaria Integrata del Trentino (ASUIT), Trento, Italy.
  5. 5Department of Cardiac Surgery, Santa Chiara Hospital, Azienda Sanitaria Universitaria Integrata del Trentino (ASUIT), Trento, Italy.
  6. 6Internal Medicine Division, Santa Chiara Hospital, Azienda Sanitaria Universitaria Integrata del Trentino (ASUIT), Trento, Italy.
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Abstract

Background

Rates of infective endocarditis (IE) in Enterococcus faecalis bloodstream infection (EF-BSI) vary more than 20-fold across published cohorts. We aimed to estimate the true IE prevalence, quantify the role of echocardiographic ascertainment in driving this variation, and assess the diagnostic performance of IE prediction scores.Methods

We conducted a systematic review and meta-analysis (PubMed, Embase, Scopus, and Web of Science searched from inception to 16 August 2026; PROSPERO registration CRD420251240242) of observational studies reporting IE prevalence in confirmed EF-BSI episodes. Risk of bias was assessed with the Quality in Prognostic Studies (QUIPS) tool. Pooled prevalence was estimated with a generalised linear mixed model (logit scale). Meta-regression with echocardiographic coverage as the moderator was used to derive an ascertainment-adjusted prevalence. Diagnostic performance of the NOVA, DENOVA, and MEFIER scores was summarised by random-effects pooling.Findings

Fifteen studies (11,157 EF-BSI episodes) were included. Crude pooled IE prevalence was 11.8% (95% confidence interval [CI] 8.1-16.8; I² = 97.3%). In studies with systematic echocardiography (k = 2), pooled prevalence was 24.2% (21.5-27.2; I² = 0.0%). Meta-regression explained up to 91.5% of between-study variance; estimated plateau IE prevalence was approximately 30%. Pooled DENOVA sensitivity was 88.7% (78.9-94.3%) and specificity 84.0% (77.8-88.7%); prospective validation yielded sensitivity 79.2% (negative predictive value [NPV] 93.0%). NOVA had high sensitivity (95.6%) but low specificity (30.7%). Certainty of evidence was low (Grading of Recommendations Assessment, Development and Evaluation [GRADE]).Interpretation

Once ascertainment is accounted for, approximately one quarter of EF-BSI episodes are complicated by IE. These findings support a shift from selective to routine echocardiography, with transoesophageal echocardiography (TEE) as the definitive modality. Existing scores can prioritise and sequence imaging but do not identify a subgroup in whom it may be safely omitted.Funding

Cassa di Risparmio di Trento e Rovereto (GRAM+ TN project).

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Cite

BibTeXRIS
BibTeX
@article{mori2026enterococcus,
  title = {{Enterococcus faecalis bacteraemia and infective endocarditis: a systematic review and meta-analysis.}},
  author = {Giovanni Mori and Alessandro Castelli and Andrea Cordin and Giovanni Lorenzin and Roberto Bonmassari and Francesco Onorati and Alberto Maino and Massimiliano Lanzafame and Vito Racanelli and Nicola Susca},
  journal = {EClinicalMedicine},
  year = {2026},
  month = sep,
  doi = {10.1016/j.eclinm.2026.104241},
  url = {https://europepmc.org/article/MED/42923940},
  note = {CC BY},
}
RIS
TY  - JOUR
TI  - Enterococcus faecalis bacteraemia and infective endocarditis: a systematic review and meta-analysis.
AU  - Giovanni Mori
AU  - Alessandro Castelli
AU  - Andrea Cordin
AU  - Giovanni Lorenzin
AU  - Roberto Bonmassari
AU  - Francesco Onorati
AU  - Alberto Maino
AU  - Massimiliano Lanzafame
AU  - Vito Racanelli
AU  - Nicola Susca
PY  - 2026
DA  - 2026/09/22
JO  - EClinicalMedicine
DO  - 10.1016/j.eclinm.2026.104241
UR  - https://europepmc.org/article/MED/42923940
AB  - Background  Rates of infective endocarditis (IE) in Enterococcus faecalis bloodstream infection (EF-BSI) vary more than 20-fold across published cohorts. We aimed to estimate the true IE prevalence, quantify the role of echocardiographic ascertainment in driving this variation, and assess the diagnostic performance of IE prediction scores.Methods  We conducted a systematic review and meta-analysis (PubMed, Embase, Scopus, and Web of Science searched from inception to 16 August 2026; PROSPERO registration CRD420251240242) of observational studies reporting IE prevalence in confirmed EF-BSI episodes. Risk of bias was assessed with the Quality in Prognostic Studies (QUIPS) tool. Pooled prevalence was estimated with a generalised linear mixed model (logit scale). Meta-regression with echocardiographic coverage as the moderator was used to derive an ascertainment-adjusted prevalence. Diagnostic performance of the NOVA, DENOVA, and MEFIER scores was summarised by random-effects pooling.Findings  Fifteen studies (11,157 EF-BSI episodes) were included. Crude pooled IE prevalence was 11.8% (95% confidence interval [CI] 8.1-16.8; I² = 97.3%). In studies with systematic echocardiography (k = 2), pooled prevalence was 24.2% (21.5-27.2; I² = 0.0%). Meta-regression explained up to 91.5% of between-study variance; estimated plateau IE prevalence was approximately 30%. Pooled DENOVA sensitivity was 88.7% (78.9-94.3%) and specificity 84.0% (77.8-88.7%); prospective validation yielded sensitivity 79.2% (negative predictive value [NPV] 93.0%). NOVA had high sensitivity (95.6%) but low specificity (30.7%). Certainty of evidence was low (Grading of Recommendations Assessment, Development and Evaluation [GRADE]).Interpretation  Once ascertainment is accounted for, approximately one quarter of EF-BSI episodes are complicated by IE. These findings support a shift from selective to routine echocardiography, with transoesophageal echocardiography (TEE) as the definitive modality. Existing scores can prioritise and sequence imaging but do not identify a subgroup in whom it may be safely omitted.Funding  Cassa di Risparmio di Trento e Rovereto (GRAM+ TN project).
SN  - 2589-5370
ER  -