Enterococcus faecalis bacteremia: please do the echo

faecalis (E. faecalis) is a disease of the elderly with an increasing incidence, often health-care associated and with in-hospital mortality rates around 10-20% [1]. E. faecalis IE is notoriously challenging to diagnose due to unspecific symptoms, often presenting with a complex clinical picture with low-grade fever and only moderately elevated infectious parameters [1]. In a newly published prospective multicenter study using echocardiography to screen E. faecalis bacteremia patients, we found an IE prevalence as high as 26% [2]. The 344 included patients with E. faecalis bacteremia had a mean age of 74 (±12) years confirming that it is indeed a disease of the elderly. The key feature of the study was that echocardiography was performed in all patients including transesophageal echocardiography (TEE) in 74% [2]. Transthoracic echocardiography (TTE) missed vegetations in half of the cases where TEE demonstrated vegetations, underlining the importance of TEE [2]. An earlier retrospective study performed in the same catchment area included 647 patients with E. faecalis bacteremia and found an IE prevalence of 12% [3]. The higher prevalence in our recent study [2] is in part explained by the general increasing prevalence of E. faecalis IE. However, we believe that the substantially lower IE prevalence in the retrospective study is also related to missed cases of IE due to much lower examination rates with TTE in 36% and TEE in 18% of the bacteremia cases [3]. To further substantiate this, we have analyzed unpublished data from the retrospective study to evaluate the likelihood of missed IE cases due to insufficient examinations [3]. From the 78 patients with IE, ten were not diagnosed until relapse of E. faecalis bacteremia following insufficient primary work up (initially only three out of ten had TTE and none had TEE). In the patients not diagnosed with IE, 37 patients had relapse of E. faecalis bacteremia and 28 (75%) of these patients were insufficiently examined with either no echocardiography at all (15), only initial echocardiography and not at relapse (seven) or only TTE at relapse (six) [3]. From analyzing the patient charts, the impression was that the primary reason why these patients were insufficiently examined, was that they were widely spread in different surgical and general internal medicine departments and not referred to an IE specialist nor for cardiac imaging. The combined evidence Editorial