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ROLE OF ECHOCARDIOGRAPHY IN
EVALUATION OF PATIENTS WITH
STAPHYLOCOCCUS AUREUS BACTEREMIA:
EXPERIENCE IN 103 PATIENTS
FOWLERVG JR, ET AL. J AM COLL CARDIOL. 1997; 30(4):1072-8.
SALT-E: OVMC LANDMARKTRIALS SERIES
2016
ACCESS THIS ONLINE: HTTP://TINYURL.COM/SALTE5
QUESTION BEING ASKED
• What is the relative diagnostic value of the two echo modalities (TTE and
TEE) compared with traditional clinical variables for detecting infectious
endocarditis (IE) in patients with Staph aureus bacteremia (SAB)
• For diagnosis of Infective Endocarditis (IE), is TEE necessary over TTE?
BACKGROUND
 The reported incidence of infective endocarditis (IE) in patients with
Staphylococcus aureus bacteremia (SAB) varies widely depending on the patient
population and has been reported to be anywhere from 5% to 64%.
 Distinguishing patients with uncomplicated SAB from those with IE is
therapeutically and prognostically important, but often difficult
STUDY DESIGN
 Time Frame 1994 -1996
 Location: Duke University Medical Center
 Number of Study Subjects: N=103 patients
 Intervention:
 Each Patient underwent both transthoracic (TTE) echocardiography and transesophageal (TEE)
echocardiography to find evidence of IE
• Each patient was examined byTTE andTEE within 5.7 ± 3.4 days of the first positive blood culture.
• The mean interval betweenTTE andTEE was 2.5 ± 4.0 days.
 Inclusion Criteria:
 Presented with fever and ≥ to 1 positive blood culture
 Exclusion Criteria:
 Age <18 years old, polymicrobial infection, neutropenia (WBC <1), death before blood cx turning
positive, outpatient status
 Follow-up time: 12 weeks
PRIMARY OUTCOME
 In patients with Staph aureus bacteremia, traditional predictors of endocarditis were of minimal
value in establishing a diagnosis.
• Clinical evidence of IE was rare, occurring in only 7 (7%) of 103 patients. Of these seven patients,
five had peripheral emboli and two developed new murmurs
 Transthoracic echocardiography was negative for IE in 77, indeterminate in 19 and positive for
vegetations in 7 patients.
• TTE could not detect abscess or leaflet perforation, which are other findings consistent with IE.
 TEE was significantly more sensitive for detecting vegetations compared withTTE (p = 0.004) and
identified vegetations in 22 patients, aortic root abscess in 2, valve perforation (anterior leaflet) in
1 and new severe valvular regurgitation in 1 patient.
• No vegetation seen on TTE was missed byTEE and no single category of findings accounted for the
increased diagnostic yield provided byTEE.
PRIMARY OUTCOME
 The sensitivity ofTTE for detecting IE was 32%, and the specificity was 100%.
 The addition of TEE increased the sensitivity to 100%
• The incremental yield provided byTEE was predominantly due to its ability to detect
small vegetations and intracardiac complications such as abscesses.
 TEE evidence of IE was equally likely among patients with negative compared
with indeterminate TTE results.
• Thus, the incremental yield of TEE cannot be predicted on the basis of the TTE results
SECONDARY OUTCOME
 Patient outcome at 12 weeks – Cure, relapse, death due to SAB, death due to
underlying disease
 At follow-up (12 weeks), cure of staphylococcal infection occurred in a similar
percentage of patients with and without IE (77% and 75%, respectively).
 Death due to sepsis was significantly more likely among patients with IE (4 of 26
[15%]) than among those without IE (2 of 77 [3%]) (p = 0.03).
BOTTOM LINE
 TEE detected evidence of clinically unsuspected IE in a high percentage of
patients with SAB and was more sensitive than either clinical findings orTTE for
this purpose.
 TEE is essential to establish the diagnosis of IE and to detect associated
complications (abscesses and valve perforation).Therefore, the test should be
considered part of the early evaluation of patients with SAB
DISCUSSION QUESTIONS
 What is the primary end point of this study?
 What is the sensitivity when using both TTE andTEE?
 Can TTE detect abscess and leaflet perforation?
 How does indeterminate and negativeTTE result affectTEE?

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SALT-E 5

  • 1. ROLE OF ECHOCARDIOGRAPHY IN EVALUATION OF PATIENTS WITH STAPHYLOCOCCUS AUREUS BACTEREMIA: EXPERIENCE IN 103 PATIENTS FOWLERVG JR, ET AL. J AM COLL CARDIOL. 1997; 30(4):1072-8. SALT-E: OVMC LANDMARKTRIALS SERIES 2016 ACCESS THIS ONLINE: HTTP://TINYURL.COM/SALTE5
  • 2. QUESTION BEING ASKED • What is the relative diagnostic value of the two echo modalities (TTE and TEE) compared with traditional clinical variables for detecting infectious endocarditis (IE) in patients with Staph aureus bacteremia (SAB) • For diagnosis of Infective Endocarditis (IE), is TEE necessary over TTE?
  • 3. BACKGROUND  The reported incidence of infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB) varies widely depending on the patient population and has been reported to be anywhere from 5% to 64%.  Distinguishing patients with uncomplicated SAB from those with IE is therapeutically and prognostically important, but often difficult
  • 4. STUDY DESIGN  Time Frame 1994 -1996  Location: Duke University Medical Center  Number of Study Subjects: N=103 patients  Intervention:  Each Patient underwent both transthoracic (TTE) echocardiography and transesophageal (TEE) echocardiography to find evidence of IE • Each patient was examined byTTE andTEE within 5.7 ± 3.4 days of the first positive blood culture. • The mean interval betweenTTE andTEE was 2.5 ± 4.0 days.  Inclusion Criteria:  Presented with fever and ≥ to 1 positive blood culture  Exclusion Criteria:  Age <18 years old, polymicrobial infection, neutropenia (WBC <1), death before blood cx turning positive, outpatient status  Follow-up time: 12 weeks
  • 5. PRIMARY OUTCOME  In patients with Staph aureus bacteremia, traditional predictors of endocarditis were of minimal value in establishing a diagnosis. • Clinical evidence of IE was rare, occurring in only 7 (7%) of 103 patients. Of these seven patients, five had peripheral emboli and two developed new murmurs  Transthoracic echocardiography was negative for IE in 77, indeterminate in 19 and positive for vegetations in 7 patients. • TTE could not detect abscess or leaflet perforation, which are other findings consistent with IE.  TEE was significantly more sensitive for detecting vegetations compared withTTE (p = 0.004) and identified vegetations in 22 patients, aortic root abscess in 2, valve perforation (anterior leaflet) in 1 and new severe valvular regurgitation in 1 patient. • No vegetation seen on TTE was missed byTEE and no single category of findings accounted for the increased diagnostic yield provided byTEE.
  • 6. PRIMARY OUTCOME  The sensitivity ofTTE for detecting IE was 32%, and the specificity was 100%.  The addition of TEE increased the sensitivity to 100% • The incremental yield provided byTEE was predominantly due to its ability to detect small vegetations and intracardiac complications such as abscesses.  TEE evidence of IE was equally likely among patients with negative compared with indeterminate TTE results. • Thus, the incremental yield of TEE cannot be predicted on the basis of the TTE results
  • 7. SECONDARY OUTCOME  Patient outcome at 12 weeks – Cure, relapse, death due to SAB, death due to underlying disease  At follow-up (12 weeks), cure of staphylococcal infection occurred in a similar percentage of patients with and without IE (77% and 75%, respectively).  Death due to sepsis was significantly more likely among patients with IE (4 of 26 [15%]) than among those without IE (2 of 77 [3%]) (p = 0.03).
  • 8. BOTTOM LINE  TEE detected evidence of clinically unsuspected IE in a high percentage of patients with SAB and was more sensitive than either clinical findings orTTE for this purpose.  TEE is essential to establish the diagnosis of IE and to detect associated complications (abscesses and valve perforation).Therefore, the test should be considered part of the early evaluation of patients with SAB
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  • 11. DISCUSSION QUESTIONS  What is the primary end point of this study?  What is the sensitivity when using both TTE andTEE?  Can TTE detect abscess and leaflet perforation?  How does indeterminate and negativeTTE result affectTEE?