Spondylodiscitis complicating infective endocarditis

Vertebral osteomyelitis in patients with infective endocarditis: prevalence, risk factors and mortality

PURPOSE

Infective endocarditis (IE) can be complicated by vertebral osteomyelitis (VO). This study investigates risk factors associated with VO in patients with infective endocarditis, and 6-month mortality and relapse rates in patients with IE and concomitant VO.

METHODS

We performed a observational study in two hospitals between September 2016 and October 2022. Patients with possible or definite IE according European Society of Cardiology (2015) modified criteria were retrieved from the local endocarditis team registries. The VO diagnosis was based on radiological signs, irrespective of clinical symptoms. Multivariable logistic regression analysis was performed to identify risk factors for vertebral osteomyelitis.

RESULTS

We included 633 consecutive patients with IE. A total of 229 (36.2%) patients had prosthetic valves and 127 (20.1%) had cardiac implantable electronic devices. The most frequent causative micro-organism was Streptococcus species (217, 34.3%), followed by Staphylococcus aureus (167, 26.4%). VO was diagnosed in 73 patients (11.5%, 95% CI 9.0%-14.0%). Enterococcus spp.(OR 2.48, 95% CI 1.31-4.52) and age (OR 1.04 per year, 95% CI 1.02-1.06) were independently associated with concomitant VO. The 6-month mortality risk did not differ between patients with (16/73, 21.9%) or without (110/560, 19.6%) VO (HR 1.13, 95% CI 0.67-1.91). Relapse rate was higher in patients with VO but the difference was not statistically significant (16.1 vs. 7.5%, OR 3.62, 95% CI 0.94-13.34).

CONCLUSIONS

Twelve percent of patients with IE also had VO. Among older patients and patients with IE caused by enterococci, there should be a higher index of suspicion for vertebral infection.

The Evolving Landscape of Infective Endocarditis: Difficult-to-Treat Resistance Bacteria and Novel Diagnostics at the Foreground

Infective endocarditis (IE) is a relatively rare but potentially life-threatening disease characterized by substantial mortality and long-term sequelae among the survivors. In recent decades, a dramatic change in the profile of patients diagnosed with IE has been observed primarily in developed countries, most likely due to an aging population and a recent increase in invasive medical procedures. Nowadays, the typical IE patient is usually older, with complex comorbidities, and a history significant for cardiac disease, including degenerative heart valve disease, prosthetic valves, or cardiovascular implantable electronic devices (CIEDs). Moreover, as patient risk factors change, predisposing them to more healthcare-associated IE, the microbiology of IE is also shifting; there are growing concerns regarding the rise in the incidence of IE caused by difficult-to-treat resistance (DTR) bacteria in at-risk patients with frequent healthcare contact. The present review aims to explore the evolving landscape of IE and summarize the current knowledge on novel diagnostics to ensure timely diagnosis and outline optimal therapy for DTR bacterial IE.

2-[18F]F-p-Aminobenzoic Acid Specifically Detects Infective Endocarditis in Positron Emission Tomography

BACKGROUND

Infective endocarditis (IE) is a life-threatening disease with high mortality, particularly when caused by Staphylococcus aureus (S aureus). Traditional diagnosis relies on clinical assessment, blood cultures, and imaging (eg, echocardiography) but lacks methods for direct bacterial detection on the endothelium. Positron emission tomography (PET)/computed tomography is emerging as valuable in unclear IE cases. This study evaluates 2-[18F]F-p-aminobenzoic acid (2-[18F]F-PABA), a bacteria-specific PET tracer, for detecting IE.

METHODS

In vitro assays measured 2-[18F]F-PABA uptake by S aureus, distinguishing living bacteria from dead cells. A mouse model of IE provided proof-of-concept PET/magnetic resonance imaging (MRI) data for diagnosing IE. Additionally, a subcutaneous abscess model with larger bacterial vegetations was used to enhance imaging of bacterial uptake.

RESULTS

2-[18F]F-PABA uptake by S aureus was confirmed in vitro, with accumulation limited to living bacteria and varying across strains. In vivo, 2-[18F]F-PABA PET/MRI successfully visualized IE in mice. In the subcutaneous abscess model, the tracer effectively localized S aureus vegetations, emphasizing its potential in detecting bacterial foci.

CONCLUSIONS

This study highlights the potential of 2-[18F]F-PABA PET imaging for direct visualization of IE. Future research may further investigate its diagnostic performance in larger models, aiming toward clinical application as a precise, pathogen-specific imaging tool for managing IE.

Spondylodiscitis of the thoraco-lumbar spine: diagnostic performance of dual-energy CT vs MRI

OBJECTIVE

Dual-energy computed tomography (DECT) could combine the high-resolution bone window images made available by multi-detector CT technology with its capability to identify bone marrow edema (BME) in the spine, for diagnosing spondylodiscitis. Our objective was to compare the diagnostic performance of contrast-enhanced MRI and non-contrast DECT to identify spondylodiscitis of the thoraco-lumbar spine.

MATERIALS AND METHODS

This prospective study included 77 consecutive participants (39 males; mean age of 61) who underwent DECT and MRI (within 7 days) between January 2020 and October 2023. DECT data were post-processed on a dedicated offline workstation (SyngoVia® VB20) by using a three-material decomposition algorithm. Four radiologists, blinded to clinical data, evaluated non-contrast DECT and contrast-enhanced MRI images. The diagnosis of spondylodiscitis was based on vertebral edema, disc edema, endplate erosions, and paraspinal involvement. Diagnostic accuracy values were calculated by using biopsy as a standard of reference. A multi-reader multi-case analysis was performed.

RESULTS

Biopsy revealed a diagnosis of spondylodiscitis in 46 patients (60%). Thoracic and lumbar spondylodiscitis were diagnosed in 37/46 (80%) and 9/46 (20%) patients, respectively. DECT and MRI overall sensitivity, specificity, and AUC were 0.91, 0.89, and 0.90, and 0.94, 0.93, and 0.93, respectively. At lumbar and thoracic levels, the difference between AUC values between DECT and MRI was not significant (p = 0.15). For DECT and MRI, a very good inter-reader agreement was achieved (k = 0.90 and k = 0.97, respectively).

CONCLUSIONS

Contrast-enhanced MRI represents the most accurate imaging tool for the diagnosis of spondylodiscitis. However, only a non-significant drop in diagnostic performance was achieved by evaluating non-contrast DECT images.

KEY POINTS

Question To compare the diagnostic performance of contrast-enhanced MRI and non-contrast DECT for identifying spondylodiscitis of the thoraco-lumbar spine. Findings MRI was not significantly superior compared to DECT in diagnosing spondylodiscitis, whereas the inter-reader agreement was near perfect for both MRI and DECT. Clinical relevance DECT represents a fast and accurate imaging tool for the demonstration of BME, erosions, and peri-vertebral inflammation in thoraco-lumbar spondylodiscitis.

Splenic abscess and infective endocarditis

OBJECTIVE

To determine the background, bacteriological, clinical and radiological findings, associated lesions, treatment and outcome of splenic abscesses (SAs) in infective endocarditis (IE).

METHODS

Retrospective study (2005-2021) of 474 patients with definite IE. The diagnosis of SA was made in 36 (7.6%) patients (31, 86.1%, males, mean age = 51.3) on abdominal CT.

RESULTS

The main implicated organisms were Streptococcus spp (36.1%), Enterococcus faecalis (27.7%), Staphyloccus spp (19.4%). Rare agents were present in 10 patients (27.8%). Pre-existing conditions included a prosthetic valve (19.4%), previous IE (13.9%), intravenous drug use (8.4%), diabetes (25%) alcohol abuse (13.9%), liver disease (5.5%). Vegetations ≥ 15 mm were present in 36.1%. Common presentations were abdominal pain (19.4%) and left-sided pleural effusion (16.5%). SA were more often small (50%; 7 multiple) than large (36.1%; 1 multiple) or microabscesses (13.9%, 3 multiple). Associated complications were extrasplenic abscesses (brain, 11.1%; lung, 5.5%; liver, 2.8%), infectious aneurysms (16.7%: 3 intracranial, 1 splenic, 1 hepatic, 1 popliteal), emboli (brain, 52.8%; spleen, 44.4%, 5 evolving to SA; kidney, 22.2%; aorta, 2.8%), osteoarticular infections (25%). Twenty-eight (77.8%) patients only received antimicrobials, 7 (19.4%) underwent splenectomy, after cardiac surgery in 5. One had percutaneous drainage. The outcome was uneventful (follow-up 3 months-14 years; mean: 17.2 months).

CONCLUSION

In SA-IE patients, the prevalence of vegetation size, Enterococcus faecalis, rare germs, diabetes, osteo-arthritic involvement and cancer was higher than in non-SA patients. Some SAs developed from splenic infarcts. IE-patients with evidence of splenic emboli should be evaluated for a possible abcedation. Cardiac surgery before splenectomy was safe.

The effects of spondylodiscitis on the inflammation burden in infective endocarditis

BACKGROUND

This study investigates the effects of spondylodiscitis on the inflammation burden in infective endocarditis patients.

METHODS

A prospective, observational study was conducted between September 2018 and October 2022 in a non-surgical teaching hospital. Patients with a definite or possible and treated as infective endocarditis were recruited from the Alkmaar Endocarditis Team meetings. Spondylodiscitis was diagnosed based on symptoms and radiological findings. The inflammation burden was defined as the area under the C‑reactive protein (CRP) curve.

RESULTS

174 consecutive patients with infective endocarditis were included (mean age 73 years, 34.5% female). Concomitant spondylodiscitis was present in 32 patients (18%), frequently associated with Streptococcus species (38%). At admission, the mean level of CRP was significantly higher in patients with concomitant spondylodiscitis (p = 0.004). The median CRP area under the curve was significantly higher in spondylodiscitis patients (4.2 × 106 min.mg/l [1.2 × 105 - 1.6 × 107 min.mg/l] vs 2.0 × 106 min.mg/l [8.7 × 104 - 1.6 × 107 min.mg/l], p < 0.001). This difference remained during the whole treatment period. At 6 months of follow-up, rates of mortality and relapse of infective endocarditis were not significantly different.

CONCLUSION

The prevalence of spondylodiscitis in non-referred patients with infective endocarditis was 18%. Endocarditis patients with spondylodiscitis had an increased inflammation burden at and during admission. This difference in normalisation of CRP levels was particularly apparent in the final phase of antibiotic treatment but not related to infectious complications. Despite an augmented inflammation burden, spondylodiscitis was not associated with mortality, cardiac surgery or infectious relapse.

Unexpected Infective Endocarditis: Towards a New Alert for Clinicians

Despite the clear indications and worldwide application of specific guidelines, the recognition of Infective Endocarditis (IE) may be challenging in day-to-day clinical practice. Significant changes in the epidemiological and clinical profile of IE have been observed, including variations in the populations at risk and an increased incidence in subjects without at-risk cardiac disease. Emergent at-risk populations for IE particularly include immunocompromised patients with a comorbidity burden (e.g., cancer, diabetes, dialysis), requiring long-term central venous catheters or recurrent healthcare interventions. In addition, healthy subjects, such as skin-contact athletes or those with piercing implants, may be exposed to the transmission of highly virulent bacteria (through the skin or mucous), determining endothelial lesions and subsequent IE, despite the absence of pre-existing at-risk cardiac disease. Emergent at-risk populations and clinical presentation changes may subvert the conventional paradigm of IE toward an unexpected clinical scenario. Owing to its unusual clinical context, IE might be overlooked, resulting in a challenging diagnosis and delayed treatment. This review, supported by a series of clinical cases, analyzed the subtle and deceptive phenotypes subtending the complex syndrome of unexpected IE. The awareness of an unexpected clinical course should alert clinicians to also consider IE diagnosis in patients with atypical features, enhancing vigilance for preventive measures in an emergent at-risk population untargeted by conventional workflows.

Infective endocarditis and spondylodiscitis-impact of sequence of surgical therapy on survival and recurrence rate

OBJECTIVES

To date, there are no standardized treatment algorithms or recommendations for patients with infective endocarditis (IE) and concomitant spondylodiscitis (SD). Therefore, our aim was to analyse whether the sequence of surgical treatment of IE and SD has an impact on postoperative outcome and to identify risk factors for survival and postoperative recurrence.

METHODS

Patients with IE underwent surgery in 4 German university hospitals between 1994 and 2022. Univariable and multivariable analyses were performed to identify possible predictors of 30-day/1-year mortality and recurrence of IE and/or SD.

RESULTS

From the total IE cohort (n = 3991), 150 patients (4.4%) had concomitant SD. Primary surgery for IE was performed in 76.6%, and primary surgery for SD in 23.3%. The median age was 70.0 (64.0-75.6) years and patients were mostly male (79.5%). The most common pathogens detected were enterococci and Staphylococcus aureus followed by streptococci, and coagulase-negative Staphylococci. If SD was operated on first, 30-day mortality was significantly higher than if IE was operated on 1st (25.7% vs 11.4%; P = 0.037) and we observed a tendency for a higher 1-year mortality. If IE was treated 1st, we observed a higher recurrence rate within 1 year (12.2% vs 0%; P = 0.023). Multivariable analysis showed that primary surgery for SD was an independent predictor of 30-day mortality.

CONCLUSIONS

Primary surgical treatment for SD was an independent risk factor for 30-day mortality. When IE was treated surgically 1st, the recurrence rate of IE and/or SD was higher.

Prevalence of Infective Endocarditis among Patients with Staphylococcus aureus Bacteraemia and Bone and Joint Infections

We aimed to evaluate the occurrence of infective endocarditis (IE) among patients with bone and joint infections (BJIs) and Staphylococcus aureus bacteraemia. This observational study was conducted at Lausanne University Hospital, Switzerland, from 2014 to 2023, and included episodes involving BJI, S. aureus bacteraemia, and cardiac imaging studies. The endocarditis team defined IE. Among the 384 included episodes, 289 (75%) involved native BJI (NBJI; 118 septic arthritis, 105 acute vertebral or non-vertebral osteomyelitis, 101 chronic osteitis), and 112 (29%) involved orthopedic implant-associated infection (OIAI; 78 prosthetic joint infection and 35 osteosynthesis/spondylodesis infection). Fifty-one episodes involved two or more types of BJI, with 17 episodes exhibiting both NBJI and OIAI. IE was diagnosed in 102 (27%) episodes. IE prevalence was 31% among patients with NBJI and 13% among patients with OIAI (p < 0.001). The study revealed a high prevalence of IE among S. aureus bacteraemic patients with NBJI, with notably lower prevalence among those with OIAI.

The impact of concomitant infective endocarditis in patients with spondylodiscitis and isolated spinal epidural empyema and the diagnostic accuracy of the modified duke criteria

Background

The co-occurrence of infective endocarditis (IE) and primary spinal infections (PSI) like spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been reported in up to 30% of cases and represents a life-threatening infection that requires multidisciplinary management to be successful. Therefore, we aimed to characterize the clinical phenotypes of PSI patients with concomitant IE and furthermore to assess the accuracy of the modified Duke criteria in this specific population.

Methods

We conducted a retrospective cohort study in consecutive SD and ISEE patients treated surgically at our University Spine Center between 2002 and 2022 who have undergone detailed phenotyping comprising demographic, clinical, imaging, laboratory, and microbiologic assessment. Comparisons were performed between PSI patients with IE (PSICIE) and without IE (PSIWIE) to identify essential differences.

Results

Methicillin-susceptible Staphylococcus aureus (MSSA) was the most common causative pathogen in PSICIE group (13 patients, 54.2%) and aortic valve IE was the most common type of IE (12 patients, 50%), followed by mitral valve IE (5 patients, 20.8%). Hepatic cirrhosis (p < 0.011; OR: 4.383; 95% CI: 1.405-13.671), septic embolism (p < 0.005; OR: 4.387; 95% CI: 1.555-12.380), and infection with Streptococcus spp. and Enterococcus spp. (p < 0.003; OR: 13.830; 95% CI: 2.454-77.929) were identified as significant independent risk factors for the co-occurrence of IE and PSI in our cohort. The modified Duke criteria demonstrated a sensitivity of 100% and a specificity of 66.7% for the detection of IE in PSI patients. Pathogens were detected more frequently via blood cultures in the PSICIE group than in the PSIWIE group (PSICIE: 23, 95.8% vs. PSIWIE: 88, 62.4%, p < 0.001). Hepatic cirrhosis (PSICIE: 10, 41.7% vs. PSIWIE: 33, 21.6%, p = 0.042), pleural abscess (PSICIE: 9, 37.5% vs. PSIWIE: 25, 16.3%, p = 0.024), sepsis (PSICIE: 20, 83.3% vs. PSIWIE: 67, 43.8%, p < 0.001), septic embolism (PSICIE: 16/23, 69.6% vs. PSIWIE: 37/134, 27. 6%, p < 0.001) and meningism (PSICIE: 8/23, 34.8% vs. PSIWIE: 21/152, 13.8%, p = 0.030) occurred more frequently in PSICIE than in PSIWIE patients. PSICIE patients received longer intravenous antibiotic therapy (PSICIE: 6 [4-7] w vs. PSIWIE: 4 [2.5-6] w, p < 0.001) and prolonged total antibiotic therapy overall (PSICIE: 11 [7.75-12] w vs. PSIWIE: 8 [6-12] w, p = 0.014). PSICIE patients spent more time in the hospital than PSIWIE (PSICIE: 43.5 [33.5-53.5] days vs. PSIWIE: 31 [22-44] days, p = 0.003).

Conclusions

We report distinct clinical, radiological, and microbiological phenotypes in PSICIE and PSIWIE patients and further demonstrate the diagnostic accuracy of the modified Duke criteria in patients with PSI and concomitant IE. In the high-risk population of PSI patients, the modified Duke criteria might benefit from amending pleural abscess, meningism, and sepsis as minor criteria and hepatic cirrhosis as major criterion.

Impact of Aortic Root Abscess on Surgical Outcomes of Infective Endocarditis

Locally destructive infective endocarditis (IE) of the aortic valve complicated by abscess formation in the aortic root may seriously affect patients' outcomes. Surgical repair of such conditions is often challenging. This is a single-center observational analysis of consecutive patients treated surgically for IE between 2009 and 2019. We divided the cohort into two groups considering the presence of an aortic root abscess and compared the characteristics and postoperative outcomes of patients accordingly. Moreover, we examined three different procedures performed in abscess patients regarding operative data and postoperative results: an isolated surgical aortic valve replacement (AVR), AVR with patch reconstruction of the aortic root (AVR + RR) or the Bentall procedure. The whole cohort comprised 665 patients, including 140 (21.0%) patients with an aortic root abscess and 525 (78.9%) as the control group. The abscess group of patients received either AVR (66.4%), AVR + RR (17.8%), or the Bentall procedure (15.7%). The mean age in the whole cohort was 62.1 ± 14.8. The mean EuroSCORE II was 8.0 ± 3.5 in the abscess group and 8.4 ± 3.7 in the control group (p = 0.259). The 30-day and 1-year mortality rates were 19.6% vs. 11.3% (p = 0.009) and 40.1% vs. 29.6% (p = 0.016) in the abscess compared to the control group. The multivariable regression analysis did not reveal aortic root abscess as an independent predictor of mortality. Rather, age > 60 correlated with 30-day mortality and infection with Streptococcus spp. correlated with 1-year mortality. In the analysis according to the performed procedures, KM estimates exhibited comparable long-term survival (log-rank p = 0.325). IE recurrence was noticed in 12.3% of patients after AVR, 26.7% after AVR + RR and none after Bentall (p = 0.069). We concluded that patients with an aortic root abscess suffer worse short and long-term outcomes compared to other IE patients. The post-procedural survival among ARA patients did not significantly vary based on the procedures performed.

Diagnostics, Management, and Outcomes in Patients with Pyogenic Spinal Intra- or Epidural Abscess

BACKGROUND

Owing to the lack of evidence on the diagnostics, clinical course, treatment, and outcomes of patients with extremely rare spinal intradural abscess (SIA) and spinal epidural abscess (SEA), we retrospectively analyzed and compared a cohort of patients to determine the phenotyping of both entities.

METHODS

Over a period of 20 years, we retrospectively analyzed the electronic medical records of 78 patients with SIA and SEA.

RESULTS

The patients with SIA showed worse motor scores (MS scores) on admission (SIA: 20 ± 26 vs. SEA: 75 ± 34, p < 0.001), more often with an ataxic gait (SIA: 100% vs. SEA: 31.8%, p < 0.001), and more frequent bladder or bowel dysfunction (SIA: 91.7% vs. SEA: 27.3%, p < 0.001) compared to the SEA patients. Intraoperative specimens showed a higher diagnostic sensitivity in the SEA patients than the SIA patients (SIA: 66.7% vs. SEA: 95.2%, p = 0.024), but various pathogens such as Staphylococcus aureus (SIA 33.3% vs. SEA: 69.4%) and Streptococci and Enterococci (SIA 33.3% vs. SEA: 8.1%, p = 0.038) were detected in both entities. The patients with SIA developed sepsis more often (SIA: 75.0% vs. SEA: 18.2%, p < 0.001), septic embolism (SIA: 33.3% vs. SEA: 8.3%, p = 0.043), signs of meningism (SIA: 100% vs. 18.5%, p < 0.001), ventriculitis or cerebral abscesses (SIA: 41.7% vs. SEA: 3.0%, p < 0.001), and pneumonia (SIA: 58.3% vs. SEA: 13.6%, p = 0.002). The mean MS score improved in both patient groups after surgery (SIA: 20 to 35 vs. SEA: 75 to 90); however, the SIA patients showed a poorer MS score at discharge (SIA: 35 ± 44 vs. SEA: 90 ± 20, p < 0.001). C-reactive protein (CrP) (SIA: 159 to 49 vs. SEA: 189 to 27) and leukocyte count (SIA: 15 to 9 vs. SEA: 14 to 7) were reduced at discharge. The SIA patients had higher rates of disease-related mortality (SIA: 33.3% vs. SEA: 1.5%, p = 0.002), had more pleural empyema (SIA: 58.3% vs. SEA: 13.6%, p = 0.002), required more than one surgery (SIA: 33.3% vs. SEA 13.6%, p = 0.009), were treated longer with intravenous antibiotics (7 ± 4 w vs. 3 ± 2 w, p < 0.001) and antibiotics overall (12 ± 10 w vs. 7 ± 3 w, p = 0.022), and spent more time in the hospital (SIA: 58 ± 36 vs. SEA: 26 ± 20, p < 0.001) and in the intensive care unit (SIA: 14 ± 18 vs. SEA: 4 ± 8, p = 0.002).

CONCLUSIONS

Our study highlighted distinct clinical phenotypes and outcomes between both entities, with SIA patients displaying a markedly less favorable disease course in terms of complications and outcomes.

Spine immobilization and neurological outcome in Vertebral Osteomyelitis. SPONDIMMO, a prospective multicentric cohort

OBJECTIVE

The aim of our study was to describe spine immobilization in a multicentric cohort of vertebral osteomyelitis (VO), and evaluate its association with neurological complications during follow-up.

METHODS

We prospectively included patients from 2016 to 2019 in 11 centers. Immobilization, imaging, and neurological findings were specifically analyzed during a 6-month follow-up period.

RESULTS

250 patients were included, mostly men (67.2%, n=168). Mean age was 66.7 ± 15 years. Diagnosis delay was 25 days. The lumbo-sacral spine was most frequently involved (56.4%). At diagnosis, 25.6% patients (n=64) had minor neurological signs and 9.2% (n=23) had major ones. Rigid bracing was prescribed for 63.5% (n=162) of patients, for a median of 6 weeks, with variability between centers (p<0.001). The presence of epidural inflammation and abscess on imaging was associated with higher rates of rigid bracing prescription (OR 2.33, p=0.01). Frailness and endocarditis were negatively associated with rigid bracing prescription (OR 0.65, p<0.01, and OR 0.42, p<0.05, respectively). During follow up, new minor or major neurological complications occurred in respectively 9.2% (n=23) and 6.8% (n=17) of patients, with similar distribution between immobilized and non-immobilized patients.

CONCLUSION

Spine immobilization prescription during VO remains heterogeneous and seems associated inflammatory lesions on imaging but negatively associated with frailness and presence of endocarditis. Neurological complications can occur despite rigid bracing. Our data suggest that in absence of any factor associated with neurological complication spine bracing might not be systematically indicated. We suggest that spine immobilization should be discussed for each patient after carefully evaluating their clinical signs and imaging findings.

Spontaneous spondylodiscitis and endocarditis: interdisciplinary experience from a tertiary institutional case series and proposal of a treatment algorithm

Previously, the simultaneous presence of endocarditis (IE) has been reported in 3–30% of spondylodiscitis cases. The specific implications on therapy and outcome of a simultaneous presence of both diseases are not yet fully evaluated. Therefore, the aim of this study was to investigate the influence of a simultaneously present endocarditis on the course of therapy and outcome of spondylodiscitis. A prospective database analysis of 328 patients diagnosed with spontaneous spondylodiscitis (S) using statistical analysis with propensity score matching was conducted. Thirty-six patients (11.0%) were diagnosed with concurrent endocarditis (SIE) by means of transoesophageal echocardiography. In our cohort, the average age was 65.82 ± 4.12 years and 64.9% of patients were male. The incidence of prior cardiac or renal disease was significantly higher in the SIE group (coronary heart disease SIE n = 13/36 vs. S n = 57/292, p < 0.05 and chronic heart failure n = 11/36 vs. S n = 41/292, p < 0.05, chronic renal failure SIE n = 14/36 vs. S n = 55/292, p < 0.05). Complex interdisciplinary coordination and diagnostics lead to a significant delay in surgical intervention (S = 4.5 ± 4.5 days vs. SIE = 8.9 ± 9.5 days, p < 0.05). Mortality did not show statistically significant differences: S (13.4%) and SIE (19.1%). Time to diagnosis and treatment is a key to efficient treatment and patient safety. In order to counteract delayed therapy, we developed a novel therapy algorithm based on the analysis of treatment processes of the SIE group. We propose a clear therapy pathway to avoid frequently observed pitfalls and delays in diagnosis to improve patient care and outcome.