Clinical Reasoning of Infectious Diseases Physicians Behind the Use or Nonuse of Transesophageal Echocardiography in Staphylococcus aureus Bacteremia.
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ABSTRACT:
SUBMITTER: Young H
PROVIDER: S-EPMC5102142 | biostudies-literature | 2016 Oct
REPOSITORIES: biostudies-literature
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Clinical Reasoning of Infectious Diseases Physicians Behind the Use or Nonuse of Transesophageal Echocardiography in <i>Staphylococcus aureus</i> Bacteremia.
Young Heather H Knepper Bryan C BC Price Connie S CS Heard Susan S Jenkins Timothy C TC
Open forum infectious diseases 20160928 4
In this prospective cohort with <i>Staphylococcus aureus</i> bacteremia, transesophageal echocardiography (TEE) was performed in 24% of cases. Consulting Infectious Diseases physicians most frequently cited low suspicion for endocarditis due to rapid clearance of blood cultures and the presence of a secondary focus requiring an extended treatment duration as reasons for foregoing TEE. ...[more]
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Project description:BackgroundInfective endocarditis (IE) is the most feared complication of Staphylococcus aureus bacteremia (SAB). Transesophageal echocardiogram (TEE) is generally recommended for all patients with SAB; however, supporting data for this are limited. We previously developed a scoring system, "PREDICT," that quantifies the risk of IE and identifies patients who would most benefit most from undergoing TEE. The current prospective investigation aims to validate this score.MethodsWe prospectively screened all consecutive adults (≥18 years) hospitalized with SAB at 3 Mayo Clinic sites between January 2015 and March 2017.ResultsOf 220 patients screened, 199 with SAB met study criteria and were included in the investigation. Of them, 23 (11.6%) patients were diagnosed with definite IE within 12 weeks of initial presentation based on modified Duke's criteria. Using the previously derived PREDICT model, the day 1 score of ≥4 had a sensitivity of 30.4% and a specificity of 93.8%, whereas a day 5 score of ≤2 had a sensitivity and negative-predictive value of 100%. Additional factors including surgery or invasive procedure in the past 30 days, prosthetic heart valve, and higher number of positive blood culture bottles in the first set of cultures were associated with increased risk of IE independent of the day 5 risk score.ConclusionsWe validated the previously developed PREDICT scoring tools for stratifying risk of IE, and the need for undergoing a TEE, among cases of SAB. We also identified other factors with predictive potential, although larger prospective studies are needed to further evaluate possible enhancements to the current scoring system.
| S-EPMC8492221 | biostudies-literature
Project description:BackgroundEchocardiography is fundamental for diagnosing infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB), but whether all such patients require transesophageal echocardiography (TEE) is controversial.MethodsWe identified SAB cases between February 2008 and April 2012. We compared sensitivity and specificity of transthoracic echocardiography (TTE) and TEE for evidence of IE, and we determined impacts of IE risk factors and TTE image quality on comparative sensitivities of TTE and TEE and their impact on clinical decision making.ResultsOf 215 evaluable SAB cases, 193 (90%) had TTE and 130 (60%) had TEE. In 119 cases with both tests, IE was diagnosed in 29 (24%), for whom endocardial involvement was evident in 25 (86%) by TEE, vs only 6 (21%) by TTE (P < .001). Transesophageal echocardiography was more sensitive than TTE regardless of risk factors. Even among the 66 cases with adequate or better quality TTE images, sensitivity was only 4 of 17 (24%) for TTE, vs 16 of 17 (94%) for TEE (P < .001). Among 130 patients with TEE, the TEE results, alone or with TTE results, influenced treatment duration in 56 (43%) cases and led to valve surgery in at least 4 (6%). It is notable that, despite vigorous efforts to obtain both tests routinely, TEE was not done in 86 cases (40%) for various reasons, including pathophysiological contraindications (14%), patient refusal or other patient-related factors (16%), and provider declination or system issues (10%).ConclusionsPatients with SAB should undergo TEE when possible to detect evidence for IE, especially if the results might affect management.
| S-EPMC5407216 | biostudies-literature
Project description:Background:The risk of endocarditis among patients with Staphylococcus aureus bacteremia is not uniform, and a number of different scores have been developed to identify patients whose risk is less than 5%. The optimal echocardiography strategy for these patients is uncertain. Methods:We used decision analysis and Monte Carlo simulation using input parameters taken from the existing literature. The model examined patients with S aureus bacteremia whose risk of endocarditis is less than 5%, generally those with nosocomial or healthcare-acquired bacteremia, no intracardiac prosthetic devices, and a brief duration of bacteremia. We examined 6 echocardiography strategies, including the use of transesophageal echocardiography, transthoracic echocardiography, both modalities, and neither. The outcome of the model was 90-day survival. Results:The optimal echocardiography strategy varied with the risk of endocarditis and the procedural mortality associated with transesophageal echocardiography. No echocardiography strategy offered an absolute benefit in 90-day survival of more than 0.5% compared with the strategy of not performing echocardiography and treating with short-course therapy. Strategies using transesophageal echocardiography were never preferred if the mortality of this procedure was greater than 0.5%. Conclusions:In patients identified to be at low risk of endocarditis, the choice of echocardiography strategy appears to exert a very small influence on 90-day survival. This finding may render test-treatment trials unfeasible and should prompt clinicians to focus on other, more important, management considerations in these patients.
| S-EPMC6288770 | biostudies-other
Project description:BackgroundIt is unclear whether the use of clinical prediction rules is sufficient to rule out infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB) without an echocardiogram evaluation, either transthoracic (TTE) and/or transesophageal (TEE). Our primary purpose was to test the usefulness of PREDICT, POSITIVE, and VIRSTA scores to rule out IE without echocardiography. Our secondary purpose was to evaluate whether not performing an echocardiogram evaluation is associated with higher mortality.MethodsWe conducted a unicentric retrospective cohort including all patients with a first SAB episode from January 2015 to December 2020. IE was defined according to modified Duke criteria. We predefined threshold cutoff points to consider that IE was ruled out by means of the mentioned scores. To assess 30-day mortality, we used a multivariable regression model considering performing an echocardiogram as covariate.ResultsOut of 404 patients, IE was diagnosed in 50 (12.4%). Prevalence of IE within patients with negative PREDICT, POSITIVE, and VIRSTA scores was: 3.6% (95% CI 0.1-6.9%), 4.9% (95% CI 2.2-7.7%), and 2.2% (95% CI 0.2-4.3%), respectively. Patients with negative VIRSTA and negative TTE had an IE prevalence of 0.9% (95% CI 0-2.8%). Performing an echocardiogram was independently associated with lower 30-day mortality (OR 0.24 95% CI 0.10-0.54, p = 0.001).ConclusionPREDICT and POSITIVE scores were not sufficient to rule out IE without TEE. In patients with negative VIRSTA score, it was doubtful if IE could be discarded with a negative TTE. Not performing an echocardiogram was associated with worse outcomes, which might be related to presence of occult IE. Further studies are needed to assess the usefulness of clinical prediction rules in avoiding echocardiographic evaluation in SAB patients.
| S-EPMC8955153 | biostudies-literature
Project description:Methicillin-resistant Staphylococcus aureus (MRSA) is a significant cause of health care-associated infections. Vancomycin remains an acceptable treatment option. There has been a welcome increase in the number of agents available for the treatment of MRSA infection. These drugs have certain differentiating attributes and may offer some advantages over vancomycin, but they also have significant limitations. These agents provide some alternative when no other options are available.
| S-EPMC5204005 | biostudies-other
Project description:The Infectious Diseases Society of America infection-specific guidelines provide limited guidance on the management of focal infections complicated by secondary bacteremias. We address the following 3 commonly encountered questions and management considerations regarding uncomplicated bacteremia not due to Staphylococcus aureus: the role and choice of oral antibiotics focusing on oral beta-lactams, the shortest effective duration of therapy, and the role of repeat blood cultures.
| S-EPMC5952922 | biostudies-other
Project description:Several management strategies may improve outcomes in patients with Staphylococcus aureus bacteremia.To review evidence of management strategies for S. aureus bacteremia to determine whether transesophageal echocardiography is necessary in all adult cases and what is the optimal antibiotic therapy for methicillin-resistant S. aureus (MRSA) bacteremia.A PubMed search from inception through May 2014 was performed to identify studies addressing the role of transesophageal echocardiography in S. aureus bacteremia. A second search of PubMed, EMBASE, and the Cochrane Library from January 1990 through May 2014 was performed to find studies addressing antibiotic treatment for MRSA bacteremia. Studies reporting outcomes from antibiotic therapy for MRSA bacteremia were included. All searches, which were limited to English and focused on adults, were augmented by review of bibliographic references from included studies. The quality of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation system with consensus of independent evaluations by at least 2 of the authors.In 9 studies with a total of 4050 patients, use of transesophageal echocardiography was associated with higher rates of a diagnosis of endocarditis (14%-28%) compared with transthoracic echocardiography (2%-15%). In 4 studies, clinical or transthoracic echocardiography findings did not predict subsequent transesophageal echocardiography findings of endocarditis. Five studies identified clinical or transthoracic echocardiography characteristics associated with low risk of endocarditis (negative predictive values from 93% to 100%). Characteristics associated with a low risk of endocarditis include absence of a permanent intracardiac device, sterile follow-up blood cultures within 4 days after the initial set, no hemodialysis dependence, nosocomial acquisition of S. aureus bacteremia, absence of secondary foci of infection, and no clinical signs of infective endocarditis. Of 81 studies of antibiotic therapy for MRSA bacteremia, only 1 high-quality trial was identified. In that study of 246 patients with S. aureus bacteremia, daptomycin was not inferior to vancomycin or an antistaphylococcal penicillin, each in combination with low-dose, short-course gentamicin (clinical success rate, 44.2% [53/120] vs 41.7% [48/115]; absolute difference, 2.4% [95% CI, -10.2% to 15.1%]).All adult patients with S. aureus bacteremia should undergo echocardiography. Characteristics of low-risk patients with S. aureus bacteremia for whom transesophageal echocardiography can be safely avoided have been identified. Vancomycin and daptomycin are the first-line antibiotic choices for MRSA bacteremia. Well-designed studies to address the management of S. aureus bacteremia are needed.
| S-EPMC4263314 | biostudies-other
Project description:BackgroundTo understand the clinical, bacterial, and host characteristics associated with recurrent Staphylococcus aureus bacteremia (R-SAB), patients with R-SAB were compared to contemporaneous patients with a single episode of SAB (S-SAB).MethodsAll SAB isolates underwent spa genotyping. All isolates from R-SAB patients underwent pulsed-field gel electrophoresis (PFGE). PFGE-indistinguishable pairs from 40 patients underwent whole genome sequencing (WGS). Acute phase plasma from R-SAB and S-SAB patients was matched 1:1 for age, race, sex, and bacterial genotype, and underwent cytokine quantification using 25-analyte multiplex bead array.ResultsR-SAB occurred in 69 (9.1%) of the 756 study patients. Of the 69 patients, 30 experienced relapse (43.5%) and 39 reinfection (56.5%). Age, race, hemodialysis dependence, presence of foreign body, methicillin-resistant Staphyloccus aureus, and persistent bacteremia were individually associated with likelihood of recurrence. Multivariate risk modeling revealed that black hemodialysis patients were nearly 2 times more likely (odds ratio [OR] = 9.652 [95% confidence interval [CI], 5.402-17.418]) than white hemodialysis patients (OR = 4.53 [95% CI, 1.696-10.879]) to experience R-SAB. WGS confirmed PFGE interpretations in all cases. Median RANTES (regulated on activation, normal T cell expressed and secreted) levels in acute phase plasma from the initial episode of SAB were higher in R-SAB than in matched S-SAB controls (P = .0053, false discovery rate < 0.10).ConclusionThis study identified several risk factors for R-SAB. The largest risk for R-SAB is among black hemodialysis patients. Higher RANTES levels in R-SAB compared to matched controls warrants further study.
| S-EPMC8315037 | biostudies-literature
Project description:Importance:Echocardiography to detect infective endocarditis is regarded as a key quality indicator in the care of patients with Staphylococcus aureus bacteremia, but its application varies markedly between reported series. Understanding the reasons for this variation in practice is important to improve the use of this investigation. Objective:To identify expert clinicians' preferred echocardiography strategy for a variety of S aureus bacteremia scenarios in a hypothetical setting free from extrinsic constraints. Design, Setting, and Participants:Anonymous web-based survey study comprising 50 text-based scenarios describing patients with S aureus bacteremia and various combinations of risk factors for endocarditis. Other variables included patient age and the presence of an extracardiac focus of infection warranting prolonged treatment. The survey was emailed to participants between September 2018 and March 2019. Each respondent was asked to recommend 1 of 6 echocardiography strategies for up to 8 randomly selected scenarios. Respondents were primarily infectious diseases physicians, and more than half reported an annual caseload of more than 20 cases of S aureus bacteremia. Main Outcomes and Measures:The proportion of respondents selecting each of the 6 echocardiography strategies was calculated alongside Wilson score confidence intervals. Modified Fleiss κ statistics were used to described interrespondent variability. Generalized estimating equations were used to assess the associations between respondent- and scenario-level variables and the recommendation of an echocardiography strategy with a low negative likelihood ratio for infective endocarditis (ie, a highly exclusionary strategy). Results:A total of 656 respondents from 24 countries provided 4837 echocardiography recommendations across the 50 scenarios. Echocardiography recommendations were associated with scenarios' burden of endocarditis risk (multivariate odds ratio per point of the VIRSTA score, 1.4; 95% CI, 1.4-1.5; P < .001). Poor interrespondent agreement was seen across all scenarios (modified Fleiss κ, 0.06; 95% CI, 0.05-0.07) but was most notable for scenarios with a lower risk of endocarditis (modified Fleiss κ, 0.04; 95% CI, 0.03-0.05). The presence of an extracardiac focus of infection was also associated with the choice of echocardiography strategy (odds ratio for highly exclusionary strategy, 0.51; 95% CI, 0.45-0.58). Respondent location in continental Europe was associated with recommendations in favor of a highly exclusionary strategy (odds ratio, 1.8; 95% CI, 1.3-2.5) compared with location in Australia or New Zealand. Conclusions and Relevance:In this study, expert clinicians demonstrated active stratification by risk of endocarditis when making echocardiography recommendations for hypothetical patients with S aureus bacteremia. Substantial disagreement existed as to whether patients at lower risk of endocarditis should undergo transesophageal echocardiography-based echocardiography strategies.
| S-EPMC7146099 | biostudies-literature
Project description:BackgroundIn patients with Staphylococcus aureus bacteremia (SAB), endocarditis evaluation includes transthoracic echocardiography (TTE) and, in patients at increased risk of endocarditis, subsequent transesophageal echocardiography (TEE). Whether performing TTE before TEE influences clinicians' decision making has not been well studied in patients deemed to warrant TEE.MethodsIn this retrospective case series, we studied clinician behavior at a large Veterans Affairs medical center regarding the care of adult patients diagnosed with SAB who completed both TTE and TEE (n = 206 episodes of SAB). The timing of key patient management decisions was compared to the timing of the patient's TTE and TEE. It was inferred whether each management decision could have been informed by TTE alone versus TTE plus subsequent TEE. Management decisions included the following: documentation of antibiotic treatment duration, initiation of synergistic antibiotics, consultation of relevant specialists, ordering of relevant imaging studies, and performance of valve surgery or cardiac device explanation.ResultsThe primary outcome (any of the above 5 management decisions taking place) occurred after completion of TTE but before TEE in 13 SAB episodes (6.3%). The primary outcome occurred after completion of both TTE and TEE in 178 SAB episodes (86.4%). Documentation of antibiotic treatment duration accounted for the large majority of observed management decisions.ConclusionsAmong patients with SAB who are deemed to warrant TEE for endocarditis evaluation, TTE results alone rarely prompt clinical management decisions.
| S-EPMC9297306 | biostudies-literature