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JACC Cardiovasc Imaging. 2015 Aug;8(8):924-31. doi: 10.1016/j.jcmg.2015.02.027. Epub 2015 Jul 15.

Use of Transthoracic Echocardiography in the Management of Low-Risk Staphylococcus aureus Bacteremia: Results From a Retrospective Multicenter Cohort Study.

Author information

1
Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada.
2
Mount Sinai Hospital, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
3
Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
4
Mount Sinai Hospital, Toronto, Ontario, Canada.
5
Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada; Lakeridge Health, Oshawa, Ontario, Canada.
6
Trillium Health Partners, Mississauga, Ontario, Canada.
7
North York General Hospital, Toronto, Ontario, Canada.
8
Hospital for Sick Children, Toronto, Ontario, Canada.
9
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
10
Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Mount Sinai Hospital, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
11
Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada; Mount Sinai Hospital, Toronto, Ontario, Canada. Electronic address: amorris@mtsinai.on.ca.

Abstract

OBJECTIVES:

The aim of this study was to develop a prediction model to identify patients with low-risk Staphylococcus aureus bacteremia (SAB), in whom infective endocarditis (IE) can be ruled out based on transthoracic echocardiogram (TTE).

BACKGROUND:

S. aureus is a major cause of bacteremia and often leads to IE. Current guidelines recommend performing transesophageal echocardiography on all patients or treating all patients empirically with prolonged intravenous antibiotics; however, this approach is resource intensive, many physicians do not adhere to guidelines, and recent studies suggest that low-risk patients may not require transesophageal echocardiography.

METHODS:

We conducted a retrospective cohort study of 833 consecutive hospitalized patients with SAB from 7 academic and community hospitals in Toronto, Canada, over a 3-year period (2007 to 2010). Patients who received a TTE within 28 days of bacteremia (n = 536) were randomly divided into derivation and validation cohorts. Multivariable logistic regression analysis was used to determine high-risk criteria for IE in the derivation cohort, and criteria were then applied to the validation cohort to determine diagnostic properties.

RESULTS:

Four high-risk criteria predicted IE: indeterminate or positive TTE (p < 0.001), community-acquired bacteremia (p = 0.034), intravenous drug use (p < 0.001), and high-risk cardiac condition (p < 0.004). In the validation cohort, the presence of any 1 of the high-risk criteria had 97% sensitivity (95% confidence interval [CI]: 87% to 100%) and 99% negative predictive value (95% CI: 96% to 100%) for IE. The negative likelihood ratio was 0.05 (95% CI: 0.007 to 0.35).

CONCLUSIONS:

A normal TTE ruled out IE in patients without community-acquired SAB, high-risk cardiac conditions, and intravenous drug use. This study provides evidence that clinical risk stratification combined with a normal TTE may be adequate to rule out IE in most patients with SAB.

KEYWORDS:

Staphylococcus aureus; bacteremia; echocardiogram; endocarditis

PMID:
26189120
DOI:
10.1016/j.jcmg.2015.02.027
[Indexed for MEDLINE]
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