{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T14:17:06Z","timestamp":1778681826485,"version":"3.51.4"},"reference-count":44,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,4,26]],"date-time":"2026-04-26T00:00:00Z","timestamp":1777161600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Background\/Objectives: Infective endocarditis (IE) carries substantial mortality, particularly in middle-income settings where patient profiles and microbial ecology differ from those of cohorts used to derive international prognostic scores. Syndrome-specific, locally grounded decision aids for empirical therapy are also scarce. We aimed to identify predictors of in-hospital mortality, externally evaluate the RiskE and ICE scores, and construct a Bayesian weighted-incidence syndromic combination antibiogram (WISCA) for IE. Methods: We conducted a retrospective cohort study of consecutive adults with definite or possible IE admitted between January 2019 and January 2026. Candidate predictors were screened in two phases, and a clinically specified model was estimated with maximum-likelihood and Firth penalization, with 1000-replicate bootstrap optimism correction. Calibration was assessed with bootstrap calibration plots and the Hosmer\u2013Lemeshow test. Discrimination was compared against RiskE and ICE using DeLong\u2019s test and reclassification metrics. For empirical coverage, we built a WISCA using identified pathogens, reporting both non-Bayesian bootstrap estimates and Bayesian hierarchical partial-pooling estimates with species- and antibiotic-level random intercepts; analyses were also stratified by IE type. Results: In-hospital mortality was 22.9% in a young cohort (median 37 years) characterized by high hemodialysis prevalence (47.4%), substantial right-sided IE (46.4%), and Staphylococcus aureus predominance (32%) with no methicillin-resistant isolates. Vasopressor-requiring shock (Firth OR 9.23, 95% CI 2.40\u201340.61) and acute heart failure (OR 10.01, 95% CI 2.78\u201341.07) were the strongest predictors; the final model achieved an AUC of 0.922 (optimism-corrected 0.908), significantly outperforming RiskE (0.598) and ICE (0.632). The Bayesian WISCA identified multiple carbapenem-sparing and anti-MRSA\u2013sparing regimens with adequate coverage (\u226580%), particularly for community-acquired IE, supporting stewardship-oriented empirical selection. Coverage was consistently lower in healthcare-associated IE. Conclusions: A parsimonious three-variable model provided strong, locally valid mortality prediction in this hemodialysis-predominant, MRSA-free cohort, substantially outperforming European-derived scores. External validation in independent cohorts is required before clinical adoption. The Bayesian WISCA demonstrated that adequate empirical coverage is achievable without routine broad-spectrum agents, offering institution-specific guidance for stewardship-compatible regimen selection; multicenter validation is warranted.<\/jats:p>","DOI":"10.3390\/medsci14020214","type":"journal-article","created":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T08:12:31Z","timestamp":1777363951000},"page":"214","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["In-Hospital Mortality Predictors and a Bayesian Weighted-Incidence Antibiogram in Infective Endocarditis: A Seven-Year Cohort Study from a Mexican Tertiary University Hospital"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-8297-7936","authenticated-orcid":false,"given":"Itzel Elizabeth","family":"Garibay-Padilla","sequence":"first","affiliation":[{"name":"Departamento de Cardiolog\u00eda, Antiguo Hospital Civil de Guadalajara \u201cFray Antonio Alcalde\u201d, Guadalajara 44280, Mexico"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-4438-5875","authenticated-orcid":false,"given":"Jorge Eduardo","family":"Hernandez-Del R\u00edo","sequence":"additional","affiliation":[{"name":"Departamento de Cardiolog\u00eda, Antiguo Hospital Civil de Guadalajara \u201cFray Antonio Alcalde\u201d, Guadalajara 44280, Mexico"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-9099-9512","authenticated-orcid":false,"given":"Dayana Estefania","family":"Orozco-Sepulveda","sequence":"additional","affiliation":[{"name":"Departamento de Cardiolog\u00eda, Antiguo Hospital Civil de Guadalajara \u201cFray Antonio Alcalde\u201d, Guadalajara 44280, Mexico"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7086-2966","authenticated-orcid":false,"given":"Christian","family":"Gonzalez-Padilla","sequence":"additional","affiliation":[{"name":"Departamento de Cardiolog\u00eda, Antiguo Hospital Civil de Guadalajara \u201cFray Antonio Alcalde\u201d, Guadalajara 44280, Mexico"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4967-8969","authenticated-orcid":false,"given":"Tomas","family":"Miranda-Aquino","sequence":"additional","affiliation":[{"name":"Departamento de Cardiolog\u00eda, Antiguo Hospital Civil de Guadalajara \u201cFray Antonio Alcalde\u201d, Guadalajara 44280, Mexico"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-6380-9573","authenticated-orcid":false,"given":"Vanessa","family":"Salas-Bonales","sequence":"additional","affiliation":[{"name":"Departamento de Cardiolog\u00eda, Antiguo Hospital Civil de Guadalajara \u201cFray Antonio Alcalde\u201d, Guadalajara 44280, Mexico"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0251-6425","authenticated-orcid":false,"given":"Judith Carolina","family":"De Arcos-Jim\u00e9nez","sequence":"additional","affiliation":[{"name":"Centro Universitario de Tlajomulco, Universidad de Guadalajara, Tlajomulco de Zu\u00f1iga 45641, Mexico"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-1901-392X","authenticated-orcid":false,"given":"Jaime","family":"Brise\u00f1o-Ram\u00edrez","sequence":"additional","affiliation":[{"name":"Internal Medicine Department, Hospital Civil de Oriente, T\u00f3nala 45425, Mexico"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,26]]},"reference":[{"key":"ref_1","unstructured":"Global Burden of Cardiovascular Diseases and Risks 2023 Collaborators (2025). Global, regional, and national burden of cardiovascular diseases and risk factors in 204 countries and territories, 1990\u20132023. J. Am. Coll. Cardiol., 86, 2167\u20132243."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1016\/j.amjcard.2025.02.023","article-title":"Epidemiological profile and mortality of infective endocarditis over the past decade: A systematic review and meta-analysis of 133 studies","volume":"244","author":"Tzoumas","year":"2025","journal-title":"Am. J. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Feng, J., Liu, P., Li, H., Chen, H., Shen, Q., Liu, H., and Hu, J. (2025). Global, regional, and national burden of endocarditis, 1990\u20132021: A systematic analysis of the GBD 2021 study. BMC Cardiovasc. Disord., 25.","DOI":"10.1186\/s12872-025-05034-7"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1016\/S0140-6736(24)01098-5","article-title":"Infective endocarditis","volume":"404","author":"Li","year":"2024","journal-title":"Lancet"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Mutagaywa, R.K., Vroon, J.C., Fundikira, L., Wind, A.M., Kunambi, P., Manyahi, J., Kamuhabwa, A., Kwesigabo, G., Chamuleau, S.A., and Cramer, M.J. (2022). Infective endocarditis in developing countries: An update. Front. Cardiovasc. Med., 9.","DOI":"10.3389\/fcvm.2022.1007118"},{"key":"ref_6","first-page":"5","article-title":"Infective endocarditis: 10-year experience in a non-cardiovascular center","volume":"92","year":"2022","journal-title":"Arch. Cardiol. M\u00e9x."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1435","DOI":"10.1136\/heartjnl-2016-311093","article-title":"Risk score for cardiac surgery in active left-sided infective endocarditis","volume":"103","author":"Olmos","year":"2017","journal-title":"Heart"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e003016","DOI":"10.1161\/JAHA.115.003016","article-title":"Validated risk score for predicting 6-month mortality in infective endocarditis","volume":"5","author":"Park","year":"2016","journal-title":"J. Am. Heart Assoc."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Rizzo, V., Salmasi, M.Y., Sabetai, M., Primus, C., Sandoe, J., Lewis, M., Woldman, S., and Athanasiou, T. (2023). Infective endocarditis: Do we have an effective risk score model? A systematic review. Front. Cardiovasc. Med., 10.","DOI":"10.3389\/fcvm.2023.1093363"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1177\/00033197241310571","article-title":"Comparisons of risk scores for infective endocarditis surgery: A meta-analysis","volume":"77","author":"Agrawal","year":"2026","journal-title":"Angiology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1087","DOI":"10.2147\/CLEP.S566997","article-title":"Enhanced risk stratification in infective endocarditis surgery: A comprehensive external validation of all available mortality prediction scores","volume":"17","author":"Mikus","year":"2025","journal-title":"Clin. Epidemiol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"312","DOI":"10.1016\/j.ijid.2022.02.022","article-title":"Clinical, microbiological, and imaging characteristics of infective endocarditis in Latin America: A systematic review","volume":"117","year":"2022","journal-title":"Int. J. Infect. Dis."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"3948","DOI":"10.1093\/eurheartj\/ehad193","article-title":"2023 ESC Guidelines for the management of endocarditis","volume":"44","author":"Delgado","year":"2023","journal-title":"Eur. Heart J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"35","DOI":"10.37201\/req\/092.2021","article-title":"Infective endocarditis treated in a secondary hospital: Epidemiological, clinical, microbiological characteristics and prognosis","volume":"35","year":"2022","journal-title":"Rev. Esp. Quimioter."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"381","DOI":"10.1086\/664768","article-title":"Demonstration of the weighted-incidence syndromic combination antibiogram: An empiric prescribing decision aid","volume":"33","author":"Hebert","year":"2012","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Briseno-Ram\u00edrez, J., G\u00f3mez-Quiroz, A., Avila-Cardenas, B.B., De Arcos-Jim\u00e9nez, J.C., Perales-Guerrero, L., Andrade-Villanueva, J.F., and Mart\u00ednez-Ayala, P. (2025). Development of a weighted-incidence syndromic combination antibiogram (WISCA) to guide empiric antibiotic treatment for ventilator-associated pneumonia in a Mexican tertiary care university hospital. BMC Infect. Dis., 25.","DOI":"10.1186\/s12879-025-10677-0"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"G\u00f3mez-Quiroz, A., Avila-Cardenas, B.B., De Arcos-Jim\u00e9nez, J.C., Perales-Guerrero, L., Mart\u00ednez-Ayala, P., and Briseno-Ramirez, J. (2025). The clinical implications of inappropriate therapy in community-onset urinary tract infections and the development of a Bayesian hierarchical weighted-incidence syndromic combination antibiogram. Antibiotics, 14.","DOI":"10.20944\/preprints202501.0905.v1"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"72","DOI":"10.24293\/ijcpml.v31i1.2223","article-title":"Antibiotic susceptibility among infective endocarditis population: Syndromic antibiogram evaluation at Indonesian National Cardiovascular Center","volume":"31","author":"Indrawati","year":"2024","journal-title":"Indones. J. Clin. Pathol. Med. Lab."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1186\/s13756-021-00939-2","article-title":"Development of a weighted-incidence syndromic combination antibiogram to guide the choice of the empiric antibiotic treatment for urinary tract infection in paediatric patients: A Bayesian approach","volume":"10","author":"Barbieri","year":"2021","journal-title":"Antimicrob. Resist. Infect. Control"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1186\/s12941-024-00673-8","article-title":"Application of the weighted-incidence syndromic combination antibiogram (WISCA) to guide the empiric antibiotic treatment of febrile neutropenia in oncological paediatric patients","volume":"23","author":"Liberati","year":"2024","journal-title":"Ann. Clin. Microbiol. Antimicrob."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Salm, J., Ikker, F., Noory, E., Beschorner, U., Kramer, T.S., Westermann, D., and Zeller, T. (2024). Weighted-incidence syndromic combination antibiogram (WISCA) to support empirical antibiotic therapy decisions in infected ischemic leg ulcers\u2014A feasibility study. J. Clin. Med., 13.","DOI":"10.3390\/jcm13206219"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1086\/313753","article-title":"Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis","volume":"30","author":"Li","year":"2000","journal-title":"Clin. Infect. Dis."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2090","DOI":"10.1001\/jama.2025.20516","article-title":"Development and validation of the Sequential Organ Failure Assessment (SOFA)-2 score","volume":"334","author":"Ranzani","year":"2025","journal-title":"JAMA"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Steyerberg, E.W. (2019). Clinical Prediction Models, Springer. [2nd ed.].","DOI":"10.1007\/978-3-030-16399-0"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Harrell, F.E. (2015). Regression Modeling Strategies, Springer. [2nd ed.].","DOI":"10.1007\/978-3-319-19425-7"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"55","DOI":"10.7326\/M14-0697","article-title":"Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD)","volume":"162","author":"Collins","year":"2015","journal-title":"Ann. Intern. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1093\/biomet\/80.1.27","article-title":"Bias reduction of maximum likelihood estimates","volume":"80","author":"Firth","year":"1993","journal-title":"Biometrika"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"837","DOI":"10.2307\/2531595","article-title":"Comparing the areas under two or more correlated receiver operating characteristic curves","volume":"44","author":"DeLong","year":"1988","journal-title":"Biometrics"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1002\/sim.4085","article-title":"Extensions of net reclassification improvement calculations to measure usefulness of new biomarkers","volume":"30","author":"Pencina","year":"2011","journal-title":"Stat. Med."},{"key":"ref_30","unstructured":"CLSI (2024). M39: Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data, Clinical and Laboratory Standards Institute. [5th ed.]."},{"key":"ref_31","first-page":"1","article-title":"brms: An R package for Bayesian multilevel models using Stan","volume":"80","year":"2017","journal-title":"J. Stat. Softw."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1128\/AAC.00277-10","article-title":"Pharmacokinetics-pharmacodynamics of tigecycline in patients with community-acquired pneumonia","volume":"56","author":"Rubino","year":"2012","journal-title":"Antimicrob. Agents Chemother."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1699","DOI":"10.1093\/cid\/cis270","article-title":"Excess deaths associated with tigecycline after approval based on noninferiority trials","volume":"54","author":"Prasad","year":"2012","journal-title":"Clin. Infect. Dis."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2466","DOI":"10.1056\/NEJMoa1112843","article-title":"Early surgery versus conventional treatment for infective endocarditis","volume":"366","author":"Kang","year":"2012","journal-title":"N. Engl. J. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"100048","DOI":"10.1016\/j.clinsp.2022.100048","article-title":"Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study","volume":"77","author":"Mejia","year":"2022","journal-title":"Clinics"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1171","DOI":"10.1016\/j.amjcard.2013.05.060","article-title":"Impact of a multidisciplinary management strategy on the outcome of patients with native valve infective endocarditis","volume":"112","author":"Chirillo","year":"2013","journal-title":"Am. J. Cardiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1097\/CRD.0000000000000095","article-title":"Right-sided infective endocarditis and pulmonary infiltrates: An update","volume":"24","author":"Chahoud","year":"2016","journal-title":"Cardiol. Rev."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"712","DOI":"10.1016\/j.jiph.2024.02.017","article-title":"Changing trends in clinical characteristics and in-hospital mortality of patients with infective endocarditis over four decades","volume":"17","author":"Santos","year":"2024","journal-title":"J. Infect. Public Health"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Elderia, A., Hinzmann, J., Soehne, P., Bennour, W., Wahlers, T., and Weber, C. (2025). Surgery in Staphylococcus aureus infective endocarditis. J. Clin. Med., 14.","DOI":"10.3390\/jcm14197114"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"ofac647","DOI":"10.1093\/ofid\/ofac647","article-title":"Prevalence and mortality of infective endocarditis in community-acquired and healthcare-associated Staphylococcus aureus bacteremia","volume":"9","author":"Voldstedlund","year":"2022","journal-title":"Open Forum Infect. Dis."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1080\/01621459.1972.10482387","article-title":"On Simpson\u2019s paradox and the sure-thing principle","volume":"67","author":"Blyth","year":"1972","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"530","DOI":"10.1183\/09031936.00094112","article-title":"Survivor bias and risk assessment","volume":"40","author":"Miller","year":"2012","journal-title":"Eur. Respir. J."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1001\/archinternmed.2008.603","article-title":"Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: The ICE-PCS","volume":"169","author":"Murdoch","year":"2009","journal-title":"Arch. Intern. Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"710","DOI":"10.1093\/aje\/kwk052","article-title":"Relaxing the rule of ten events per variable in logistic and Cox regression","volume":"165","author":"Vittinghoff","year":"2007","journal-title":"Am. J. Epidemiol."}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/2\/214\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T13:37:02Z","timestamp":1778679422000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/2\/214"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,26]]},"references-count":44,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["medsci14020214"],"URL":"https:\/\/doi.org\/10.3390\/medsci14020214","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,26]]}}}