What Impacts the Decision to Obtain Transesophageal Echocardiogram for Staphylococcus aureus Bacteremia?
Background: IDSA guidelines recommend transesophageal echocardiogram (TEE) to rule out infective endocarditis (IE) in all patients with Staphylococcus aureus bacteremia (SAB). Despite this recommendation, TEE is uncommonly used for SAB. The low utilization of TEE is hypothesized to be due to poor access to TEE and the potential complications of anesthesia and endoscopy. The purpose of this study is to evaluate which factors are associated with obtaining TEE for SAB.
Methods: This is a prospective observational cohort of hospitalized patients with SAB at an urban public safety net hospital in Denver CO between 7/1/2013 and 4/29/2014. Patient level information was obtained from the medical record. The attending ID physician was contacted via a standardized email to determine why TEE was/was not performed. Statistics were calculated using the chi-square, Kruskal-Wallis, and student's t-test of means.
Results: SAB was present in 93 patients, and 24% underwent TEE. Patient age, comorbid medical conditions, and source of SAB were not associated with TEE. 59 patients completed therapy during the study period. Patients who underwent TEE tended to have a longer duration of bacteremia (median 4.5 vs 3.0, P=0.19). 11% of patients who received <28 days of treatment had a TEE while 24% of those who received ³28 days of treatment had a TEE (P=0.24). The most common reasons that ID physicians cited for not performing TEE were (1) low clinical suspicion of IE (55%); or (2) another indication for an extended duration of treatment (44%). More than 1 reason was cited in 41% of cases (Figure 1).
Conclusion: TEE is uncommonly used for the
evaluation of SAB at this facility, particularly in patients who receive a
short course of antibiotics. ID physicians reported not performing TEE because
they clinically considered IE to be unlikely or had already identified an
indication for an extended treatment duration. Further
work must be done to determine if TEE results drove physicians to prescribe
longer treatment duration or if TEE is a marker for patients with more
complicated disease. Clinical outcomes should also be evaluated to ensure that
not performing TEE is not associated with recurrent disease.
Figure 1. Reasons infectious diseases physicians do not obtain TEE in the setting of SAB.
C. S. Price, None
T. Jenkins, None
B. Knepper, None
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