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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Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B, Miro JM, Mulder BJ, Plonska-Gosciniak E, Price S, Roos-Hesselink J, Snygg-Martin U, Thuny F, Tornos Mas P, Vilacosta I, Zamorano JL; Document Reviewers, Erol Ç, Nihoyannopoulos P, Aboyans V, Agewall S, Athanassopoulos G, Aytekin S, Benzer W, Bueno H, Broekhuizen L, Carerj S, Cosyns B, De Backer J, De Bonis M, Dimopoulos K, Donal E, Drexel H, Flachskampf FA, Hall R, Halvorsen S, Hoen B, Kirchhof P, Lainscak M, Leite-Moreira AF, Lip GY, Mestres CA, Piepoli MF, Punjabi PP, Rapezzi C, Rosenhek R, Siebens K, Tamargo J, Walker DM (2015) 2015 ESC guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 36(44):3075–3128
Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, Barsic B, Lockhart PB, Gewitz MH, Levison ME, Bolger AF, Steckelberg JM, Baltimore RS, Fink AM, O’Gara P, Taubert KA; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council (2015) Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation 132(15):1435–1486
Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, Talan DA, Chambers HF (2011) Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis 52(3):285–292
Murray RJ (2005) Staphylococcus aureus infective endocarditis: diagnosis and management guidelines. Intern Med J 35(Suppl 2):S25–S44
Goto M, Schweizer ML, Vaughan-Sarrazin MS, Perencevich EN, Livorsi DJ, Diekema DJ, Richardson KK, Beck BF, Alexander B, Ohl ME (2017) Association of evidence-based care processes with mortality in Staphylococcus aureus bacteremia at Veterans Health Administration hospitals, 2003–2014. JAMA Intern Med 177(10):1489–1497
Paulsen J, Solligård E, Damås JK, DeWan A, Åsvold BO, Bracken MB (2016) The impact of infectious disease specialist consultation for Staphylococcus aureus bloodstream infections: a systematic review. Open Forum Infect Dis 3(2):ofw048
Vogel M, Schmitz RP, Hagel S, Pletz MW, Gagelmann N, Scherag A, Schlattmann P, Brunkhorst FM (2016) Infectious disease consultation for Staphylococcus aureus bacteremia—a systematic review and meta-analysis. J Infect 72(1):19–28
Holden E, Bashir A, Das I, Morton H, Steadman CD, Nightingale P, Steeds RP, David MD (2014) Staphylococcus aureus bacteraemia in a UK tertiary referral centre: a ‘transoesophageal echocardiogram for all’ policy. J Antimicrob Chemother 69(7):1960–1965
Young H, Knepper BC, Price CS, Heard S, Jenkins TC (2016) Clinical reasoning of infectious diseases physicians behind the use or nonuse of transesophageal echocardiography in Staphylococcus aureus bacteremia. Open Forum Infect Dis 3(4):ofw204
Tubiana S, Duval X, Alla F, Selton-Suty C, Tattevin P, Delahaye F, Piroth L, Chirouze C, Lavigne JP, Erpelding ML, Hoen B, Vandenesch F, Iung B, Le Moing V; VIRSTA/AEPEI Study Group (2016) The VIRSTA score, a prediction score to estimate risk of infective endocarditis and determine priority for echocardiography in patients with Staphylococcus aureus bacteremia. J Infect 72(5):544–553
Heriot G, Yeoh J, Street A, Ratnam I (2015) Echocardiography has minimal yield and may not be warranted in Staphylococcus aureus bacteremia without clinical risk factors for endocarditis. Eur J Clin Microbiol Infect Dis 34(6):1231–1236
Barton T, Moir S, Rehmani H, Woolley I, Korman TM, Stuart RL (2016) Low rates of endocarditis in healthcare-associated Staphylococcus aureus bacteremia suggest that echocardiography might not always be required. Eur J Clin Microbiol Infect Dis 35(1):49–55
Van Hal SJ, Mathur G, Kelly J, Aronis C, Cranney GB, Jones PD (2005) The role of transthoracic echocardiography in excluding left sided infective endocarditis in Staphylococcus aureus bacteraemia. J Infect 51(3):218–221
Incani A, Hair C, Purnell P, O’Brien DP, Cheng AC, Appelbe A, Athan E (2013) Staphylococcus aureus bacteraemia: evaluation of the role of transoesophageal echocardiography in identifying clinically unsuspected endocarditis. Eur J Clin Microbiol Infect Dis 32(8):1003–1008
Bai AD, Steinberg M, Showler A, Burry L, Bhatia RS, Tomlinson GA, Bell CM, Morris AM (2017) Diagnostic accuracy of transthoracic echocardiography for infective endocarditis findings using transesophageal echocardiography as the reference standard: a meta-analysis. J Am Soc Echocardiogr 30(7):639–646.e8
Stoddard MF, Longaker RA (1993) The safety of transesophageal echocardiography in the elderly. Am Heart J 125(5 Pt 1):1358–1362
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This work was supported by the Australian Government Research Training Program, Monash University Faculty of Medicine, Nursing and Health Sciences (GSH) and an Australian National Health and Medical Research Council Career Development Fellowship (SYCT, #1065736).
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Heriot, G.S., Tong, S.Y.C., Cheng, A.C. et al. Clinical variation in the use of echocardiography in Staphylococcus aureus bacteraemia: a multi-centre cohort study. Eur J Clin Microbiol Infect Dis 37, 469–474 (2018). https://doi.org/10.1007/s10096-018-3192-z
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DOI: https://doi.org/10.1007/s10096-018-3192-z