What risk of endocarditis is low enough to justify the omission of transoesophageal echocardiography in Staphylococcus aureus bacteraemia? A narrative review

G. S. Heriot, S. Y.C. Tong, A. C. Cheng, D. Liew

    Research output: Contribution to journalArticleResearchpeer-review

    Abstract

    Background: Recent criteria which can identify patients with Staphylococcus aureus bacteraemia (SAB) who are at very low risk of endocarditis raise the question of whether transoesophageal echocardiography (TOE) is appropriate for these patients. 

    Aims: To estimate the probability of occult endocarditis complicating SAB below which a TOE-guided treatment strategy no longer offers the best 180-day survival, and to examine the key uncertainties affecting this result. 

    Sources: Estimates of the parameters required to calculate the Pauker–Kassirer testing threshold were identified from studies published prior to 1 June 2017 using a composite search strategy that involved a systematic search for relevant controlled trials and guidelines, followed by a non-systematic iterative search of the observational literature. 

    Content: Estimates of the necessary parameters were generally consistent across the literature with the exception of the procedural mortality of TOE. In our base-case scenario (TOE mortality 0.1%), the testing threshold for TOE in apparently uncomplicated SAB was a 1.1% probability of occult endocarditis. Sensitivity analyses revealed that the procedural mortality of TOE was a key uncertainty affecting estimates of the testing threshold. 

    Implications: None of the available clinical tools can place patients with SAB below this probability of endocarditis with 95% confidence. Future work in this area should concentrate on improving the precision of these tools and on exploring the value of alternative echocardiography strategies. In addition, a better understanding of the harms of TOE is required to ensure that recommendations regarding the role of this investigation in the management of patients with SAB are appropriate.

    Original languageEnglish
    Pages (from-to)1251-1256
    Number of pages6
    JournalClinical Microbiology and Infection
    Volume24
    Issue number12
    DOIs
    Publication statusPublished - Dec 2018

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    Transesophageal Echocardiography
    Bacteremia
    Endocarditis
    Staphylococcus aureus
    Uncertainty
    Mortality
    Echocardiography
    Guidelines
    Survival

    Cite this

    @article{0a4a869da6c1433fb95ed9bdf5e4e9f4,
    title = "What risk of endocarditis is low enough to justify the omission of transoesophageal echocardiography in Staphylococcus aureus bacteraemia? A narrative review",
    abstract = "Background: Recent criteria which can identify patients with Staphylococcus aureus bacteraemia (SAB) who are at very low risk of endocarditis raise the question of whether transoesophageal echocardiography (TOE) is appropriate for these patients. Aims: To estimate the probability of occult endocarditis complicating SAB below which a TOE-guided treatment strategy no longer offers the best 180-day survival, and to examine the key uncertainties affecting this result. Sources: Estimates of the parameters required to calculate the Pauker–Kassirer testing threshold were identified from studies published prior to 1 June 2017 using a composite search strategy that involved a systematic search for relevant controlled trials and guidelines, followed by a non-systematic iterative search of the observational literature. Content: Estimates of the necessary parameters were generally consistent across the literature with the exception of the procedural mortality of TOE. In our base-case scenario (TOE mortality 0.1{\%}), the testing threshold for TOE in apparently uncomplicated SAB was a 1.1{\%} probability of occult endocarditis. Sensitivity analyses revealed that the procedural mortality of TOE was a key uncertainty affecting estimates of the testing threshold. Implications: None of the available clinical tools can place patients with SAB below this probability of endocarditis with 95{\%} confidence. Future work in this area should concentrate on improving the precision of these tools and on exploring the value of alternative echocardiography strategies. In addition, a better understanding of the harms of TOE is required to ensure that recommendations regarding the role of this investigation in the management of patients with SAB are appropriate.",
    keywords = "Endocarditis, Staphylococcus aureus bacteraemia, TOE, transoesophageal echocardiography",
    author = "Heriot, {G. S.} and Tong, {S. Y.C.} and Cheng, {A. C.} and D. Liew",
    year = "2018",
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    language = "English",
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    What risk of endocarditis is low enough to justify the omission of transoesophageal echocardiography in Staphylococcus aureus bacteraemia? A narrative review. / Heriot, G. S.; Tong, S. Y.C.; Cheng, A. C.; Liew, D.

    In: Clinical Microbiology and Infection, Vol. 24, No. 12, 12.2018, p. 1251-1256.

    Research output: Contribution to journalArticleResearchpeer-review

    TY - JOUR

    T1 - What risk of endocarditis is low enough to justify the omission of transoesophageal echocardiography in Staphylococcus aureus bacteraemia? A narrative review

    AU - Heriot, G. S.

    AU - Tong, S. Y.C.

    AU - Cheng, A. C.

    AU - Liew, D.

    PY - 2018/12

    Y1 - 2018/12

    N2 - Background: Recent criteria which can identify patients with Staphylococcus aureus bacteraemia (SAB) who are at very low risk of endocarditis raise the question of whether transoesophageal echocardiography (TOE) is appropriate for these patients. Aims: To estimate the probability of occult endocarditis complicating SAB below which a TOE-guided treatment strategy no longer offers the best 180-day survival, and to examine the key uncertainties affecting this result. Sources: Estimates of the parameters required to calculate the Pauker–Kassirer testing threshold were identified from studies published prior to 1 June 2017 using a composite search strategy that involved a systematic search for relevant controlled trials and guidelines, followed by a non-systematic iterative search of the observational literature. Content: Estimates of the necessary parameters were generally consistent across the literature with the exception of the procedural mortality of TOE. In our base-case scenario (TOE mortality 0.1%), the testing threshold for TOE in apparently uncomplicated SAB was a 1.1% probability of occult endocarditis. Sensitivity analyses revealed that the procedural mortality of TOE was a key uncertainty affecting estimates of the testing threshold. Implications: None of the available clinical tools can place patients with SAB below this probability of endocarditis with 95% confidence. Future work in this area should concentrate on improving the precision of these tools and on exploring the value of alternative echocardiography strategies. In addition, a better understanding of the harms of TOE is required to ensure that recommendations regarding the role of this investigation in the management of patients with SAB are appropriate.

    AB - Background: Recent criteria which can identify patients with Staphylococcus aureus bacteraemia (SAB) who are at very low risk of endocarditis raise the question of whether transoesophageal echocardiography (TOE) is appropriate for these patients. Aims: To estimate the probability of occult endocarditis complicating SAB below which a TOE-guided treatment strategy no longer offers the best 180-day survival, and to examine the key uncertainties affecting this result. Sources: Estimates of the parameters required to calculate the Pauker–Kassirer testing threshold were identified from studies published prior to 1 June 2017 using a composite search strategy that involved a systematic search for relevant controlled trials and guidelines, followed by a non-systematic iterative search of the observational literature. Content: Estimates of the necessary parameters were generally consistent across the literature with the exception of the procedural mortality of TOE. In our base-case scenario (TOE mortality 0.1%), the testing threshold for TOE in apparently uncomplicated SAB was a 1.1% probability of occult endocarditis. Sensitivity analyses revealed that the procedural mortality of TOE was a key uncertainty affecting estimates of the testing threshold. Implications: None of the available clinical tools can place patients with SAB below this probability of endocarditis with 95% confidence. Future work in this area should concentrate on improving the precision of these tools and on exploring the value of alternative echocardiography strategies. In addition, a better understanding of the harms of TOE is required to ensure that recommendations regarding the role of this investigation in the management of patients with SAB are appropriate.

    KW - Endocarditis

    KW - Staphylococcus aureus bacteraemia

    KW - TOE

    KW - transoesophageal echocardiography

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    U2 - 10.1016/j.cmi.2018.03.027

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    JO - Clinical Microbiology and Infection

    JF - Clinical Microbiology and Infection

    SN - 1198-743X

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    ER -