Timing of Patient Management Decisions Relative to Echocardiography in Staphylococcus aureus Bacteremia: A Single-Center Retrospective Analysis

BACKGROUND: In patients with Staphylococcus aureus bacteremia (SAB), endocarditis evaluation includes transthoracic echocardiography (TTE) and, in patients at increased risk of endocarditis, subsequent transesophageal echocardiography (TEE). Whether performing TTE before TEE influences clinicians’ decision making has not been well studied in patients deemed to warrant TEE. METHODS: In this retrospective case series, we studied clinician behavior at a large Veterans Affairs medical center regarding the care of adult patients diagnosed with SAB who completed both TTE and TEE (n = 206 episodes of SAB). The timing of key patient management decisions was compared to the timing of the patient’s TTE and TEE. It was inferred whether each management decision could have been informed by TTE alone versus TTE plus subsequent TEE. Management decisions included the following: documentation of antibiotic treatment duration, initiation of synergistic antibiotics, consultation of relevant specialists, ordering of relevant imaging studies, and performance of valve surgery or cardiac device explanation. RESULTS: The primary outcome (any of the above 5 management decisions taking place) occurred after completion of TTE but before TEE in 13 SAB episodes (6.3%). The primary outcome occurred after completion of both TTE and TEE in 178 SAB episodes (86.4%). Documentation of antibiotic treatment duration accounted for the large majority of observed management decisions. CONCLUSIONS: Among patients with SAB who are deemed to warrant TEE for endocarditis evaluation, TTE results alone rarely prompt clinical management decisions.