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Benefit of Echocardiography in Patients With Staphylococcus aureus Bacteremia at Low Risk of Endocarditis.

ABSTRACT: 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.

SUBMITTER: Heriot GS

PROVIDER: S-EPMC6288770 | biostudies-other | 2018 Dec

REPOSITORIES: biostudies-other

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Benefit of Echocardiography in Patients With <i>Staphylococcus aureus</i> Bacteremia at Low Risk of Endocarditis.

Heriot George S GS Tong Steven Y C SYC Cheng Allen C AC Liew Danny D

Open forum infectious diseases 20181211 12

<h4>Background</h4>The risk of endocarditis among patients with <i>Staphylococcus aureus</i> 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.<h4>Methods</h4>We used decision analysis and Monte Carlo simulation using input parameters taken from the existing literature. The model examined patients with <i>S aureus</i> bacteremia whose risk of endoca ...[more]

PMID: 30555848

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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.

Dataset Information

Benefit of Echocardiography in Patients With Staphylococcus aureus Bacteremia at Low Risk of Endocarditis.

Publications

Benefit of Echocardiography in Patients With <i>Staphylococcus aureus</i> Bacteremia at Low Risk of Endocarditis.

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