Adrienne Showler1, Lisa Burry2, Anthony D Bai3, Marilyn Steinberg4, Daniel R Ricciuto5, Tania Fernandes6, Anna Chiu6, Sumit Raybardhan7, Michelle Science8, Eshan Fernando9, Chaim M Bell10, Andrew M Morris11. 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.
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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