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Lindberg H, Löfström E, Rasmussen M. Risk stratification score screening for infective endocarditis in patients with Gram-positive bacteraemia. Infect Dis (Lond) 2022; 54:488-496. [DOI: 10.1080/23744235.2022.2049360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Helena Lindberg
- Department of Infectious Diseases, Hospital of Halland, Halmstad, Sweden
| | - Emma Löfström
- Department of Clinical Microbiology, Hospital of Halland, Halmstad, Sweden
| | - Magnus Rasmussen
- Division of Infection, Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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2
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Calderón-Parra J, Diego-Yagüe I, Santamarina-Alcantud B, Mingo-Santos S, Mora-Vargas A, Vázquez-Comendador JM, Fernández-Cruz A, Muñez-Rubio E, Gutiérrez-Villanueva A, Sánchez-Romero I, Ramos-Martínez A. Unreliability of Clinical Prediction Rules to Exclude without Echocardiography Infective Endocarditis in Staphylococcus aureus Bacteremia. J Clin Med 2022; 11:jcm11061502. [PMID: 35329827 PMCID: PMC8955153 DOI: 10.3390/jcm11061502] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It 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. METHODS We 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. RESULTS Out 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). CONCLUSION PREDICT 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.
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Affiliation(s)
- Jorge Calderón-Parra
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (I.D.-Y.); (A.M.-V.); (J.M.V.-C.); (A.F.-C.); (E.M.-R.); (A.G.-V.); (A.R.-M.)
- Investigational Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), 28222 Majadahonda, Spain
- Correspondence:
| | - Itziar Diego-Yagüe
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (I.D.-Y.); (A.M.-V.); (J.M.V.-C.); (A.F.-C.); (E.M.-R.); (A.G.-V.); (A.R.-M.)
| | | | - Susana Mingo-Santos
- Cardiology Department, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain;
| | - Alberto Mora-Vargas
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (I.D.-Y.); (A.M.-V.); (J.M.V.-C.); (A.F.-C.); (E.M.-R.); (A.G.-V.); (A.R.-M.)
| | - José Manuel Vázquez-Comendador
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (I.D.-Y.); (A.M.-V.); (J.M.V.-C.); (A.F.-C.); (E.M.-R.); (A.G.-V.); (A.R.-M.)
| | - Ana Fernández-Cruz
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (I.D.-Y.); (A.M.-V.); (J.M.V.-C.); (A.F.-C.); (E.M.-R.); (A.G.-V.); (A.R.-M.)
- Investigational Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), 28222 Majadahonda, Spain
| | - Elena Muñez-Rubio
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (I.D.-Y.); (A.M.-V.); (J.M.V.-C.); (A.F.-C.); (E.M.-R.); (A.G.-V.); (A.R.-M.)
- Investigational Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), 28222 Majadahonda, Spain
| | - Andrea Gutiérrez-Villanueva
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (I.D.-Y.); (A.M.-V.); (J.M.V.-C.); (A.F.-C.); (E.M.-R.); (A.G.-V.); (A.R.-M.)
| | - Isabel Sánchez-Romero
- Microbiology Service, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (B.S.-A.); (I.S.-R.)
| | - Antonio Ramos-Martínez
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Spain; (I.D.-Y.); (A.M.-V.); (J.M.V.-C.); (A.F.-C.); (E.M.-R.); (A.G.-V.); (A.R.-M.)
- Investigational Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), 28222 Majadahonda, Spain
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3
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Mun SJ, Kim SH, Huh K, Cho SY, Kang CI, Chung DR, Peck KR. Role of echocardiography in uncomplicated Staphylococcus aureus catheter-related bloodstream infections. Medicine (Baltimore) 2021; 100:e25679. [PMID: 33950948 PMCID: PMC8104220 DOI: 10.1097/md.0000000000025679] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/06/2021] [Indexed: 01/04/2023] Open
Abstract
Uncomplicated bacteremia and catheter-related bloodstream infection (CRBSI) are frequently suggested as factors associated with low risk of infective endocarditis in Staphylococcus aureus bacteremia (SAB). Nevertheless, guidelines recommend that echocardiography in all patients with SAB. We evaluated the effects of echocardiography on patient outcomes. Patients with uncomplicated S. aureus CRBSI were retrospectively identified between January 2013 and June 2018 at a 1950-bed, tertiary-care university hospital. Treatment failure was defined as any case of relapse or all-cause death within 90 days. Of 890 SAB patients, 95 with uncomplicated S. aureus CRBSI were included. Thirty-two patients underwent echocardiography within 30 days of their first positive blood culture. Two patients who underwent echocardiography revealed right-sided infective endocarditis. One patient who did not undergo echocardiography experienced recurrent SAB (peripheral CRBSI) 85 days after his first positive blood culture. There were no SAB-related deaths. The Kaplan-Meier curves of treatment failure showed no significant differences between patients who did and did not undergo echocardiography (P = .77). In multivariable analysis, risk factors for treatment failure were liver cirrhosis (hazard ratio: 9.60; 95% confidence interval: 2.13-43.33; P = .003) and other prostheses (hazard ratio: 63.79; 95% confidence interval: 5.05-805.40; P = .001). This study did not verify the putative association between treatment failure and implementation of echocardiography in patients with uncomplicated S. aureus CRBSI. Given the low observed rates of adverse outcomes, routine echocardiography might not be obligatory and could be performed on an individual basis.
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Affiliation(s)
- Seok Jun Mun
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Inje University Busan Paik Hospital, Busan
| | - Si-Ho Kim
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon
| | - Kyungmin Huh
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sun Young Cho
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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4
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Shah S, Gupta T, White CJ, Jain S, Ramee E, Qamruddin S, Kemmerly SA. Optimizing cardiovascular imaging in Staphylococcus aureus endocarditis. Echocardiography 2021; 38:574-581. [PMID: 33704836 DOI: 10.1111/echo.15022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/13/2021] [Accepted: 02/08/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The shift toward value-based health care drives physicians to examine opportunities to optimize use of healthcare resources. There is discordance between providers' use of cardiovascular imaging (CVI) in assessing patients for infective endocarditis (IE) with Staphylococcus aureus bacteremia (SAB). An evidence-based algorithm was created to minimize variation of CVI use. The primary objective was to ensure sensitivity of the algorithm to recommend CVI in patients suspected of IE. METHODS A retrospective review evaluated patients at Ochsner Medical Center who developed SAB between 1/1/13 and 12/31/14. Predefined patient demographics, use of CVI, outcomes, and 12-week follow-up for readmission after first positive blood culture were collected from chart review. The created algorithm was applied retrospectively to determine its sensitivity and specificity in recommending the right CVI test. RESULTS 181 patients admitted were admitted with SAB, of which 114 (63%) were male. There were 115 TTEs and 55 TEEs performed. Out of 15 patients diagnosed with IE, 3 were found on TTE and 12 were found on TEE. The algorithm would have recommended a TEE in all 15 patients who had high-risk features for IE and a true diagnosis of IE, suggesting a sensitivity of 100% and specificity of 74.7% for the algorithm to have recommended a highly sensitive CVI modality. CONCLUSION This algorithm optimizes CVI for diagnosing IE in patients with SAB. As healthcare adapts to a value-based system, use of best-practice algorithms will promote consistency in practice among providers and help optimize patient outcomes and use of resources.
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Affiliation(s)
- Sangeeta Shah
- Department of Cardiology, Pauley Heart Center, Virginia Commonwealth University Health Sciences, Richmond, VA, USA
| | - Tripti Gupta
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA.,University of Queensland Ochsner School of Medicine, Brisbane, Australia
| | - Christopher J White
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA.,University of Queensland Ochsner School of Medicine, Brisbane, Australia
| | - Surma Jain
- University of Queensland Ochsner School of Medicine, Brisbane, Australia.,Department of Pulmonary and Critical Care, Ochsner Clinical Foundation, New Orleans, LA, USA
| | - Emily Ramee
- University of Queensland Ochsner School of Medicine, Brisbane, Australia.,Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Salima Qamruddin
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, USA.,University of Queensland Ochsner School of Medicine, Brisbane, Australia
| | - Sandra A Kemmerly
- Department of Infectious Disease, Ochsner Clinic Foundation, New Orleans, LA, USA
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5
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Lam JC, Gregson DB, Somayaji R, Robinson S, Conly JM, Welikovitch L, Parkins MD. Forgoing transesophageal echocardiogram in selected patients with complicated Staphylococcus aureus bacteremia. Eur J Clin Microbiol Infect Dis 2021; 40:623-631. [PMID: 33392784 DOI: 10.1007/s10096-020-04097-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 08/21/2020] [Indexed: 10/22/2022]
Abstract
Infective endocarditis (IE) has been increasingly recognized as an important complication of Staphylococcus aureus bacteremia (SAB), leading to a low threshold for echocardiography and extended treatment with anti-staphylococcal agents. However, outside of IE, many indications for prolonged anti-staphylococcal therapy courses are present. We sought to determine the frequency in which findings from a transesophageal echocardiogram (TEE) changed clinical SAB management in a large Canadian health region. Residents (> 18 years) with SAB from 2012 to 2014 who underwent transthoracic echocardiogram (TTE) and TEE were assessed. Patients potentially benefiting from an extended course of anti-staphylococcal agents were defined a priori. Patient demographics, treatment (including surgical), and clinical outcomes were extracted and evaluated. Of the 705 episodes of SAB that underwent a screening echocardiogram, 203 episodes underwent both a TTE and TEE, of which 92.1% (187/203) contained an a priori indication for extended anti-staphylococcal therapy. Regardless of TEE results, actual duration of therapy did not differ in SAB episodes that had ≥ 1 extended anti-staphylococcal therapy criteria (36.7 days, IQR 23.4-48.6 vs. 43.8 days, IQR 33.3-49.5, p = 0.17). Additionally, there were no cases in which TEE was utilized as the sole reason to shorten duration of therapy or proceed to surgery for those with SAB. Routine performance of TEE may be unnecessary in all SAB as many patients have pre-existing indications for extended anti-staphylococcal therapy independent of TEE findings. An algorithm to selectively identify cases of SAB that would benefit from TEE can reduce resource and equipment expenditure and patient risks associated with TEE.
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Affiliation(s)
- John C Lam
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Daniel B Gregson
- Departments of Medicine and Pathology & Laboratory Medicine, Calgary Laboratory Services, and the Snyder Institute for Chronic Disease, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Ranjani Somayaji
- Departments of Medicine and Microbiology, Immunology & Infectious Diseases, Snyder Institute for Chronic Disease, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Stephen Robinson
- Department of Medicine, Dalhousie University, 5849 University Ave, Halifax, NS, B3H 4R2, Canada
| | - John M Conly
- Departments of Medicine and Microbiology, Immunology & Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Lisa Welikovitch
- Department of Cardiac Sciences, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Michael D Parkins
- Departments of Medicine and Microbiology, Immunology & Infectious Diseases, Snyder Institute for Chronic Disease, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
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6
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Green J, Howard J, Shankar A, Clinghan R, Luff T, Birch M, Pithie A, Werno A, Metcalf S, Chambers S. Assessing the impact of a 'bundle of care' approach to Staphylococcus aureus bacteraemia in a tertiary hospital. Infect Prev Pract 2020; 2:100096. [PMID: 34368726 PMCID: PMC8336039 DOI: 10.1016/j.infpip.2020.100096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/18/2020] [Indexed: 11/17/2022] Open
Abstract
Background Staphylococcus aureus bacteraemia is associated with significant morbidity and mortality. There is evidence that standardised care bundle implementation may improve the rates of appropriate investigations and improve overall management. A S. aureus bacteraemia care bundle was introduced at Christchurch Hospital, New Zealand in early 2014. We assessed the impact of the intervention on the management and outcome of S. aureus bacteraemia. Methods A cohort study of cases of S. aureus bacteraemia was conducted following standardised care bundle introduction. Prospective enrolment of post-intervention patients occurred from 1st January 2014 to 30th June 2015, with retrospective review of pre-intervention cases from 1st January 2009 to 31st December 2013. Results In the pre-intervention period 447 patients had at least one episode of S. aureus bacteraemia compared to 151 patients in the post-intervention period. The two groups were similar by gender, ethnicity, and age. Significant increases in Infectious Diseases consultation rate (86.6% vs 94.8%; p=0.009), echocardiography (76.3% vs 96.3%; p<0.001), urine culture (74.0% vs 91.9%; p<0.001), follow up blood cultures (44.2% vs 83.0%; p<0.001), and at least 2 weeks of parenteral therapy (83.5% vs 92.9%; p=0.014) were observed after introduction of the bundle. There were no significant differences in rates 30-day mortality (18.6% vs. 20.5%; p=0.596), but there was a reduction in episodes of relapsed infection in the post-intervention cohort (7.4% vs 1.3%; p=0.004). Conclusion An integrated care bundle for the management of S. aureus bacteraemia resulted in increased use of quality of care indicators and infectious diseases review and improved patient outcome.
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Affiliation(s)
- Jared Green
- Department of Infectious Diseases, Christchurch Hospital, New Zealand
| | - Julia Howard
- Department of Microbiology, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Avinesh Shankar
- Department of General Medicine, Christchurch Hospital, New Zealand
| | - Richard Clinghan
- Department of Microbiology, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Tessa Luff
- Department of General Medicine, Christchurch Hospital, New Zealand
| | - Mark Birch
- Department of Infectious Diseases, Christchurch Hospital, New Zealand.,Department of General Medicine, Christchurch Hospital, New Zealand
| | - Alan Pithie
- Department of Infectious Diseases, Christchurch Hospital, New Zealand.,Department of General Medicine, Christchurch Hospital, New Zealand
| | - Anja Werno
- Department of Microbiology, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Sarah Metcalf
- Department of Infectious Diseases, Christchurch Hospital, New Zealand.,Department of General Medicine, Christchurch Hospital, New Zealand
| | - Stephen Chambers
- Department of Infectious Diseases, Christchurch Hospital, New Zealand.,Department of Pathology, University of Otago, Christchurch, New Zealand
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7
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Kim CJ, Song KH, Choe PG, Park WB, Kim ES, Park KU, Kim NJ, Park KH, Kwak YG, Cheon S, Jang HC, Kim YK, Lee SH, Kiem SM, Lee S, Kim HB, Oh MD. The microbiological characteristics of Staphylococcus aureus isolated from patients with native valve infective endocarditis. Virulence 2020; 10:948-956. [PMID: 31718473 PMCID: PMC8647854 DOI: 10.1080/21505594.2019.1685631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The microbiological characteristics of Staphylococcus aureus causing infective endocarditis (IE) have not been investigated thoroughly. We compared the characteristics of S. aureus isolates from patients with and without IE. Cases of S. aureus bacteremia (SAB) were collected from 10 hospitals over 7 years. Cases of native valve IE were matched with non-IE controls according to the following criteria: central-line-associated infection, community-acquired infection, methicillin susceptibility, and if possible, the primary site of infection. Genes coding virulence factors were analyzed using multiplex polymerase chain reactions. Fibrinogen and fibronectin-binding properties were assessed using in vitro binding assays. The fibronectin-binding protein A gene (fnbpA) was sequenced. Of 2,365 cases of SAB, 92 had IE. After matching, 37 pairs of S. aureus isolates from the IE cases and non-IE controls were compared; fnbpA was detected in 91.9% of the IE isolates and 100% of the non-IE isolates (p = 0.24). While the fibrinogen binding ratio was similar (1.07 ± 0.33 vs. 1.08 ± 0.26, p = 0.89), the fibronectin-binding ratio was significantly higher in the IE-group (1.31 ± 0.42 vs. 1.06 ± 0.31, p = 0.01). The proportions of major single-nucleotide polymorphisms in fnbpA were as follows: E652D (2.9% vs. 2.7%), H782Q (65.6% vs. 60.6%), and K786N (65.6% vs. 72.7%). The fibronectin-binding ratio was positively correlated with the number of SNPs present in IE cases (p < 0.001) but not in the non-IE controls (p = 0.124). Fibronectin-binding might play a key role in SAB IE. However, the degree of binding may be mediated by genetic variability between isolates.
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Affiliation(s)
- Chung-Jong Kim
- Department of Internal Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyoung Un Park
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung-Hwa Park
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Yee Gyung Kwak
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Shinhye Cheon
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejon, Republic of Korea
| | - Hee-Chang Jang
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Young Keun Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Sun Hee Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Sung-Min Kiem
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, South Korea
| | - Shinwon Lee
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, South Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myoung-Don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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8
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Abu Saleh O, Fida M, Asbury K, Narichania A, Sotello D, Bosch W, Vikram HR, Palraj R, Lahr B, Baddour LM, Sohail MR. Prospective Validation of PREDICT and its Impact on the Transesophageal Echocardiography Use in Management of Staphylococcus aureus Bacteremia. Clin Infect Dis 2020; 73:e1745-e1753. [PMID: 32569366 DOI: 10.1093/cid/ciaa844] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 06/18/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Infective 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 benefit the most from undergoing TEE. The current prospective investigation aims to validate this score. METHODS We prospectively screened all consecutive adults (≥18 years) hospitalized with SAB at three Mayo Clinic sites between January 2015 and March 2017. RESULTS Of 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 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. CONCLUSION We 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.
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Affiliation(s)
- Omar Abu Saleh
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Madiha Fida
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Kara Asbury
- Division of Infectious Diseases, Mayo Clinic Phoenix, Arizona
| | | | - David Sotello
- Division of Infectious Diseases, Mayo Clinic Jacksonville, Florida
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic Jacksonville, Florida
| | | | - Raj Palraj
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Brian Lahr
- Department of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - M Rizwan Sohail
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Rochester, Minnesota.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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9
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Lam JC, Gregson DB, Robinson S, Somayaji R, Welikovitch L, Conly JM, Parkins MD. Infectious diseases consultation improves key performance metrics in the management of Staphylococcus aureus bacteremia: A multicentre cohort study. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2019; 4:24-32. [PMID: 36338780 PMCID: PMC9603189 DOI: 10.3138/jammi.2018-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 11/21/2018] [Indexed: 06/16/2023]
Abstract
BACKGROUND Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality. We sought to identify factors associated with infectious diseases consultation (IDC) and understand how IDC associates with SAB patient management and outcomes. METHODS A multicentre retrospective study was performed between 2012 and 2014 in a large Canadian Health Zone in order to determine factors associated with IDC and performance of key quality of care determinants in SAB management and clinical outcomes. Factors subject to quality of care determinants were established a priori and studied for associations with IDC and 30-day all-cause mortality using multivariable analysis. RESULTS Of 961 SAB episodes experienced by 892 adult patients, 605 episodes received an IDC. Patients receiving IDC were more likely to have prosthetic valves and joints and to have community-acquired and known sources of SAB, but increasing age decreased IDC occurrence. IDC was the strongest independent predictor for quality of care performance metrics, including repeat blood cultures and echocardiography. Mortality at 30 days was 20% in the cohort, and protective factors included IDC, achievement of source control, targeted therapy within 48 hours, and follow-up blood cultures but not the performance of echocardiography. CONCLUSIONS There were significant gaps between the treatments and investigations that patients actually received for SAB and what is considered the optimal management of their condition. IDC is associated with improved attainment of targeted SAB quality of care determinants and reduced mortality rates. Based on our findings, we propose a policy of mandatory IDC for all cases of SAB to improve patient management and outcomes.
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Affiliation(s)
- John C Lam
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel B Gregson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Calgary Laboratory Services, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Disease, University of Calgary, Calgary, Alberta, Canada
| | - Stephen Robinson
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Disease, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Lisa Welikovitch
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - John M Conly
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Disease, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Parkins
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Disease, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
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Bolhuis K, Bakker LJ, Keijer JT, de Vries PJ. Implementing a hospital-wide protocol for Staphylococcus aureus bacteremia. Eur J Clin Microbiol Infect Dis 2018; 37:1553-1562. [PMID: 29855842 PMCID: PMC6061069 DOI: 10.1007/s10096-018-3284-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/13/2018] [Indexed: 02/06/2023]
Abstract
Staphylococcus aureus bacteraemia (SAB) is associated with high-mortality and complication rates. A multidisciplinary approach is needed to predict, detect and treat complications. In this pre- and post-intervention study, we investigated the effects of a hospital-wide protocol for diagnosis, classification and treatment of SAB. It was hypothesized that complications and endocarditis would be better identified and treated. Medical records of SAB patients admitted in 2011 and 2012 (pre) were analysed. In 2013, a protocol, describing risk factors, diagnostic classification and recommended treatment, was implemented. In 2014 and 2015 (post), SAB patients were followed prospectively. Transthoracic (TTE) or transoesophageal cardiac ultrasound (TEE) was chosen following a decision tree. A resident internal medicine acted as contact person. Pre-intervention, 98 patients were eligible for analysis compared to 85 patients post-intervention. Age and number of risk factors were slightly higher post-intervention; other baseline characteristics were similar. Most SAB-patients were classified as complicated (89 and 82% pre- and post-intervention, respectively). Follow-up blood cultures drawn within 2 days after initiating treatment increased from 51 to 85%. Cardiac ultrasounds increased from 44 to 83% for TTE and 13 to 24% for TEE. Endocarditis was more frequently diagnosed (4 vs. 12%). Additionally, duration of antibiotic therapy increased. The 3-month mortality did not change significantly (33% pre-intervention vs. 35% post-intervention; p > 0.05). Introduction of a hospital-wide protocol for SAB management increased standard of care, created awareness among clinicians to properly classify SAB, search for endocarditis and adapt duration of antibiotic treatment. Mortality did not decrease.
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Affiliation(s)
- K Bolhuis
- Department of Internal Medicine, Academic Medical Center, Meijbergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - L J Bakker
- Department of Medical Microbiology, Tergooi Hospital, Van Riebeeckweg 212, 1213 XZ, Hilversum, The Netherlands
| | - J T Keijer
- Department of Cardiology, Tergooi Hospital, Van Riebeeckweg 212, 1213 XZ, Hilversum, The Netherlands
| | - P J de Vries
- Department of Internal Medicine, Tergooi Hospital, Van Riebeeckweg 212, 1213 XZ, Hilversum, The Netherlands
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11
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Loh Z, Estacio O, Grigg A, Holmes NE, Chong G, Hawkes EA. Echocardiography has low utility in cancer patients with Staphylococcus aureus bacteraemia: findings from a retrospective study. Support Care Cancer 2018; 26:3083-3089. [PMID: 29564624 DOI: 10.1007/s00520-018-4162-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
AIM To describe the incidence of infective endocarditis (IE) detected on echocardiography in cancer patients with confirmed Staphylococcus aureus bacteraemia (SAB). METHODS We retrospectively identified 95 cases of SAB in cancer patients from January 2007-March 2016. Echocardiography was ordered at the discretion of the treating team, and positive findings defined according to the Modified Duke Criteria. Complicated bacteraemia was defined by prolonged bacteraemia, presence of intracardiac device/prosthetic valve, or signs of metastatic infection. RESULTS Major predisposing risk factors for IE (intracardiac device, prosthetic valve, valvular disease, diabetes mellitus, renal dialysis) were present in 27% of cases. Fifty-one of 95 (54%) had a central venous catheter and 17 (18%) patients had complicated bacteraemia. Echocardiography was performed in 75/95 (79%) episodes, with transthoracic echocardiography (TTE) alone in 56, transoesophageal echocardiography (TOE) alone in 4 and both in 15. Echocardiography was diagnostic for IE in 2 patients (1 TTE, 1 TOE), including one result that led to the diagnosis of IE in a clinically unsuspected case. Four further cases of IE were diagnosed on clinical findings, resulting in an overall rate of IE of 6% (6/95). Five of these cases occurred in patients with complicated bacteraemia or ≥ 1 risk factor for IE. No patient was readmitted due to IE. CONCLUSION IE is infrequent in cancer patients with uncomplicated SAB and no risk factors for IE. Performing echocardiography routinely in all cancer patients with SAB rarely alters diagnosis or affects antibiotic management and therefore should be reserved for patients with specific risk factors.
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Affiliation(s)
- Zoe Loh
- Department of Medical Oncology & Clinical Haematology, Olivia Newton John Cancer Research and Wellness Centre, Austin Health, Heidelberg, Victoria, Australia. .,The University of Melbourne, Parkville, Victoria, Australia.
| | - Ortis Estacio
- The University of Melbourne, Parkville, Victoria, Australia
| | - Andrew Grigg
- Department of Medical Oncology & Clinical Haematology, Olivia Newton John Cancer Research and Wellness Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Geoff Chong
- Department of Medical Oncology & Clinical Haematology, Olivia Newton John Cancer Research and Wellness Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Eliza A Hawkes
- Department of Medical Oncology & Clinical Haematology, Olivia Newton John Cancer Research and Wellness Centre, Austin Health, Heidelberg, Victoria, Australia.,Eastern Health, Box Hill, Victoria, Australia
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12
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Bai A, Steinberg M, Bell C, Morris A. Reply to the Letter to the Editor—Clinical prediction rules used to rule out endocarditis must be assessed against a sensitive reference standard. Clin Microbiol Infect 2018; 24:317-320. [DOI: 10.1016/j.cmi.2017.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/30/2022]
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13
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Heriot GS, Tong SYC, Cheng AC, Thevarajan I, Levinson MR, Visvanathan K, Liew D. Clinical variation in the use of echocardiography in Staphylococcus aureus bacteraemia: a multi-centre cohort study. Eur J Clin Microbiol Infect Dis 2018; 37:469-474. [PMID: 29357050 DOI: 10.1007/s10096-018-3192-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/11/2018] [Indexed: 01/04/2023]
Abstract
The objective of this investigation was to assess whether between-hospital variation in echocardiography usage for patients with Staphylococcus aureus bacteraemia (SAB) is explained by differences in patients' pre-test probability of endocarditis. This was a retrospective cohort study at three neighbouring hospitals in Australia. Consecutive episodes of SAB were reviewed for the presence of three endocarditis risk factors (community onset, prolonged bacteraemia and the presence of an intracardiac prosthetic device) and the performance and results of all echocardiography studies within 30 days. Multivariate logistic regression was used to examine the effect of hospital site on the performance of (i) transoesophageal and (ii) transthoracic echocardiography controlling for major endocarditis risk factors. Significant variation in echocardiography usage was demonstrated between sites in a total cohort of 1167 episodes of SAB. None of the three sites were found to exhibit echocardiography usage that could be considered consistent with current guidelines, and each differed from the guidelines in different ways. Hospital site, rather than endocarditis risk factors, was the strongest predictor of transthoracic echocardiography use; however, the use of transoesophageal echocardiography was strongly predicted by endocarditis risk factors. Variation in echocardiography use between these hospitals is not adequately explained by differences in the risk factor profile of their SAB cohorts.
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Affiliation(s)
- George S Heriot
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia. .,Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Australia. .,Infectious Diseases Unit, St Vincent's Hospital Melbourne, Melbourne, Australia.
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Australia.,Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Australia.,Menzies School of Health Research, Darwin, Australia
| | - Allen C Cheng
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.,Department of Infectious Diseases, Alfred Health, Melbourne, Australia.,Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Australia
| | - Irani Thevarajan
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Australia
| | - Michele R Levinson
- Cabrini-Monash Department of Medicine, Monash University, Melbourne, Australia
| | - Kumar Visvanathan
- Infectious Diseases Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Danny Liew
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.
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Asgeirsson H, Thalme A, Weiland O. Staphylococcus aureus bacteraemia and endocarditis - epidemiology and outcome: a review. Infect Dis (Lond) 2017; 50:175-192. [PMID: 29105519 DOI: 10.1080/23744235.2017.1392039] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To review the epidemiology of Staphylococcus aureus bacteraemia (SAB) and endocarditis (SAE), and discuss the short- and long-term outcome. Materials and methods: A literature review of the epidemiology of SAB and SAE. RESULTS The reported incidence of SAB in Western countries is 16-41/100,000 person-years. Increasing incidence has been observed in many regions, in Iceland by 27% during 1995-2008. The increase is believed to depend on changes in population risk factors and possibly better and more frequent utilization of diagnostic procedures. S. aureus is now the leading causes of infective endocarditis (IE) in many regions of the world. It accounts for 15-40% of all IE cases, and the majority of cases in people who inject drugs (PWID). Recently, the incidence of SAE in PWID in Stockholm, Sweden, was found to be 2.5/1000 person-years, with an in-hospital mortality of 2.5% in PWID as compared to 15% in non-drug users. The 30-day mortality associated with SAB amounts to 15-25% among adults in Western countries, but is lower in children (0-9%). Mortality associated with SAE is high (generally 20-30% in-hospital mortality), and symptomatic cerebral embolizations are common (12-35%). The 1-year mortality reported after SAB and SAE is 19-62% and reflects deaths from underlying diseases and complications caused by the infection. In a subset of SAE cases, valvular heart surgery is needed (15-45%), but active intravenous drug use seems to be a reason to refrain from surgery. Despite its importance, there are insufficient data on the optimal management of SAB and SAE, especially on the required duration of antibiotic therapy. Conclusions: The epidemiology of SAB and SAE has been changing in the past decades. They still carry a substantial morbidity and mortality. Intensified studies on treatment are warranted for improving patient outcome.
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Affiliation(s)
- Hilmir Asgeirsson
- a Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden.,b Unit of Infectious Diseases, Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden
| | - Anders Thalme
- a Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Ola Weiland
- a Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden.,b Unit of Infectious Diseases, Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden
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15
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Bai AD, Agarwal A, Steinberg M, Showler A, Burry L, Tomlinson GA, Bell CM, Morris AM. Clinical predictors and clinical prediction rules to estimate initial patient risk for infective endocarditis in Staphylococcus aureus bacteraemia: a systematic review and meta-analysis. Clin Microbiol Infect 2017; 23:900-906. [PMID: 28487168 DOI: 10.1016/j.cmi.2017.04.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/18/2017] [Accepted: 04/25/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVES We conducted a meta-analysis to summarize diagnostic properties of risk factors and clinical prediction rules for diagnosing infective endocarditis (IE) in Staphylococcus aureus bacteraemia (SAB). METHODS We searched MEDLINE, Embase, and the Cochrane Database from inception to 6 January 2016 to identify studies evaluating risk factors and clinical prediction rules for IE in SAB patients. Pooled estimates of diagnostic properties for main risk factors were calculated using a bivariate random effects model. RESULTS Of 962 articles identified, 30 studies were included. These involved 16 538 SAB patients including 1572 IE cases. Risk factors with positive likelihood ratio (PLR) greater than 5 included embolic events (PLR 12.7, 95% CI 9.2-17.7), pacemakers (PLR 9.7, 95% CI 3.7-21.2), history of previous IE (PLR 8.2, 95% CI 3.1-22.0), prosthetic valves (PLR 5.7, 95% CI 3.2-9.5), and intravenous drug use (PLR 5.2, 95% CI 3.8-6.9). The only clinical factor with negative likelihood ratio (NLR) less than 0.5 was documented clearance of bacteraemia within 72 hours (NLR range 0.32-0.35). Of the nine published clinical prediction rules for ruling out IE, five had an NLR below 0.1. CONCLUSIONS SAB patients with high-risk features (embolic events, pacemakers, prosthetic valves, previous IE, or intravenous drug use) should undergo a trans-esophageal echocardiography (TEE) for IE. Clinical prediction rules show promise in safely ruling out endocarditis, but require validation in future studies.
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Affiliation(s)
- A D Bai
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - A Agarwal
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - M Steinberg
- Sinai Health System, Toronto, Ontario, Canada
| | - A Showler
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - L Burry
- Sinai Health System, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - G A Tomlinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - C M Bell
- Sinai Health System, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - A M Morris
- Sinai Health System, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada.
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Barton T, Moir S, Rehmani H, Woolley I, Korman TM, Stuart RL. Low rates of endocarditis in healthcare-associated Staphylococcus aureus bacteremia suggest that echocardiography might not always be required. Eur J Clin Microbiol Infect Dis 2016; 35:49-55. [PMID: 26490139 DOI: 10.1007/s10096-015-2505-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 10/05/2015] [Indexed: 12/20/2022]
Abstract
Healthcare-associated Staphylococcus aureus bacteremia (HA-SAB) is an increasingly frequently observed complication of medical treatment. Current guidelines recommend evaluation with echocardiography and preferably transesophageal echocardiography for the exclusion of infectious endocarditis (IE). We performed a retrospective analysis of all patients with HA-SAB between 1 January 2007 and 31 July 2012. Patients were divided into those with a high degree of clinical suspicion of IE (prosthetic intracardiac device, hemodialysis or positive blood cultures for 4 days or more) or those with a low degree of clinical suspicion of IE (absence of high-risk features based on previous literature as strong indicators of endocarditis). Three hundred and fifty-eight patients with HA-SAB were evaluated to determine the prevalence of IE, including 298 (83 %) who had echocardiography. Fourteen patients (4 %) had a final diagnosis of IE after echocardiography. In the group with a high degree of clinical suspicion 11 out of 84 patients (13 %) had IE. In the group with a low degree of clinical suspicion group 3 out 274 patients (1.1 %) had IE. HA-SAB has a low rate of IE, especially in the absence of high-risk features such as prolonged bacteremia, intracardiac prosthetic devices, and hemodialysis. Echocardiographic imaging in this low-risk population of patients is rarely helpful and may generally be avoided, although careful clinical follow-up is warranted. Patients with HA-SAB who have mechanical valves, intracardiac devices, prolonged bacteremia or dialysis dependency have a high incidence of IE and should be evaluated thoroughly using echocardiography.
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17
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Utilization of Echocardiography in Patients With Staphylococcus aureus Bacteremia at Two Large Canadian Hospitals. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2016. [DOI: 10.1097/ipc.0000000000000345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Gough A, Clay K, Williams A, Jackson S, Prendergast B. Infective endocarditis in the military patient. J ROY ARMY MED CORPS 2015; 161:283-7. [PMID: 26243804 DOI: 10.1136/jramc-2015-000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 06/29/2015] [Indexed: 11/03/2022]
Abstract
Infective endocarditis (IE) is a potentially fatal cardiac infection associated with an inhospital mortality rate of up to 22%. Fifty per cent of IE cases develop in patients with no known history of valve disease. It is therefore important to remain vigilant to the possibility of the diagnosis in patients with a febrile illness and unknown source. From a military perspective, our patients are unique due to the breadth of pathogens they are exposed to, and blood-culture-negative IE is a risk. In particular, there should be awareness of Coxiella burnetii as a possible causative pathogen. In this review we incorporate the latest consensus from systematic reviews and publications identified by a literature search through Medline. We describe the diagnosis and management of IE with particular reference to the military population.
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Affiliation(s)
- Andrew Gough
- Neurology department, Defence Medical Rehabilitation Centre (DMRC), Epsom, UK
| | - K Clay
- Department of Academic Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - A Williams
- Cardiology Department, Royal Gwent Hospital, Newport, UK
| | - S Jackson
- Directorate of Manning (Army), Marlborough Lines, Andover, UK
| | - B Prendergast
- Department of Cardiology, Guy's and St Thomas' Hospitals, London, UK
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Use of Transthoracic Echocardiography in the Management of Low-Risk Staphylococcus aureus Bacteremia: Results From a Retrospective Multicenter Cohort Study. JACC Cardiovasc Imaging 2015; 8:924-31. [PMID: 26189120 DOI: 10.1016/j.jcmg.2015.02.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 02/01/2015] [Accepted: 02/05/2015] [Indexed: 11/20/2022]
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.
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Diagnosis and treatment of bacteremia and endocarditis due to Staphylococcus aureus. A clinical guideline from the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC). Enferm Infecc Microbiol Clin 2015; 33:625.e1-625.e23. [PMID: 25937457 DOI: 10.1016/j.eimc.2015.03.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 03/16/2015] [Indexed: 01/30/2023]
Abstract
Both bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. The prognosis may darken not infrequently, especially in the presence of intracardiac devices or methicillin-resistance. Indeed, the optimization of the antimicrobial therapy is a key step in the outcome of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and -resistant isolates has led to the research of novel therapeutic schemes. Specifically, the interest raised in recent years on the new antimicrobials with activity against methicillin-resistant staphylococci has been also extended to infections caused by susceptible strains, which still carry the most important burden of infection. Recent clinical and experimental research has focused in the activity of new combinations of antimicrobials, their indication and role still being debatable. Also, the impact of an appropriate empirical antimicrobial treatment has acquired relevance in recent years. Finally, it is noteworthy the impact of the implementation of a systematic bundle of measures for improving the outcome. The aim of this clinical guideline is to provide an ensemble of recommendations in order to improve the treatment and prognosis of bacteremia and infective endocarditis caused by S. aureus, in accordance to the latest evidence published.
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Abstract
IMPORTANCE Several management strategies may improve outcomes in patients with Staphylococcus aureus bacteremia. OBJECTIVES 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. EVIDENCE REVIEW 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. FINDINGS 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%]). CONCLUSIONS AND RELEVANCE 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.
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Affiliation(s)
- Thomas L. Holland
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Christopher Arnold
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
| | - Vance G. Fowler
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Clinical Research Institute, Duke University, Durham, NC
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