Forgoing transesophageal echocardiogram in selected patients with complicated Staphylococcus aureus bacteremia.

Infective endocarditis (IE) has been increasingly recognized as an important complication of Staphylococcus aureus bacteremia (SAB), leading to a low threshold for echocardiography and extended treatment with anti-staphylococcal agents. However, outside of IE, many indications for prolonged anti-staphylococcal therapy courses are present. We sought to determine the frequency in which findings from a transesophageal echocardiogram (TEE) changed clinical SAB management in a large Canadian health region. Residents (> 18 years) with SAB from 2012 to 2014 who underwent transthoracic echocardiogram (TTE) and TEE were assessed. Patients potentially benefiting from an extended course of anti-staphylococcal agents were defined a priori. Patient demographics, treatment (including surgical), and clinical outcomes were extracted and evaluated. Of the 705 episodes of SAB that underwent a screening echocardiogram, 203 episodes underwent both a TTE and TEE, of which 92.1% (187/203) contained an a priori indication for extended anti-staphylococcal therapy. Regardless of TEE results, actual duration of therapy did not differ in SAB episodes that had ≥ 1 extended anti-staphylococcal therapy criteria (36.7 days, IQR 23.4-48.6 vs. 43.8 days, IQR 33.3-49.5, p = 0.17). Additionally, there were no cases in which TEE was utilized as the sole reason to shorten duration of therapy or proceed to surgery for those with SAB. Routine performance of TEE may be unnecessary in all SAB as many patients have pre-existing indications for extended anti-staphylococcal therapy independent of TEE findings. An algorithm to selectively identify cases of SAB that would benefit from TEE can reduce resource and equipment expenditure and patient risks associated with TEE.

Infectious diseases consultation improves key performance metrics in the management of Staphylococcus aureus bacteremia: A multicentre cohort study.

Background: Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality. We sought to identify factors associated with infectious diseases consultation (IDC) and understand how IDC associates with SAB patient management and outcomes. Methods: A multicentre retrospective study was performed between 2012 and 2014 in a large Canadian Health Zone in order to determine factors associated with IDC and performance of key quality of care determinants in SAB management and clinical outcomes. Factors subject to quality of care determinants were established a priori and studied for associations with IDC and 30-day all-cause mortality using multivariable analysis. Results: Of 961 SAB episodes experienced by 892 adult patients, 605 episodes received an IDC. Patients receiving IDC were more likely to have prosthetic valves and joints and to have community-acquired and known sources of SAB, but increasing age decreased IDC occurrence. IDC was the strongest independent predictor for quality of care performance metrics, including repeat blood cultures and echocardiography. Mortality at 30 days was 20% in the cohort, and protective factors included IDC, achievement of source control, targeted therapy within 48 hours, and follow-up blood cultures but not the performance of echocardiography. Conclusions: There were significant gaps between the treatments and investigations that patients actually received for SAB and what is considered the optimal management of their condition. IDC is associated with improved attainment of targeted SAB quality of care determinants and reduced mortality rates. Based on our findings, we propose a policy of mandatory IDC for all cases of SAB to improve patient management and outcomes.

Historique: La bactériémie à Staphylococcus aureus (BSA) provoque une morbidité et une mortalité marquées. Les auteurs ont cherché à déterminer les facteurs associés aux consultations en infectiologie (CeI) et à comprendre le lien entre ces consultations et la prise en charge et le pronostic des patients atteints d'une BSA. Méthodologie: Entre 2012 et 2014, les auteurs ont réalisé une étude rétrospective multicentrique dans une grande zone de santé canadienne afin de déterminer les facteurs associés aux CeI et l'exécution des principaux déterminants de la qualité des soins dans la prise en charge et les résultats cliniques de la BSA. Au moyen d'une analyse multivariée, ils ont établi a priori les facteurs soumis aux déterminants de la qualité des soins et les ont étudiés pour les associer aux CeI et à la mortalité toutes causes confondues au bout de 30 jours. Résultats: Sur les 961 épisodes de BSA qu'ont vécus 892 patients adultes, 605 ont donné lieu à une CeI. Les patients dirigés vers une telle consultation étaient plus susceptibles d'avoir reçu des valvules et des articulations artificielles et de souffrir d'une BSA d'origine communautaire ou d'une autre source connue, mais ces consultations diminuaient avec le vieillissement. Les CeI étaient le meilleur prédicteur indépendant de mesures démontrant la qualité des soins, y compris des hémocultures et des échocardiographies répétées. La mortalité au bout de 30 jours s'élevait à 20 % dans la cohorte, et les facteurs protecteurs incluaient les CeI, la réalisation du contrôle des sources, un traitement ciblé dans les 48 heures et des hémocultures de suivi, mais pas des échocardiographies. Conclusions: Les auteurs ont constaté un écart important entre les traitements et les explorations que les patients ont subis en raison de leur BSA et ce qui est considéré comme une prise en charge optimale de leur maladie. La CeI s'associe à une meilleure réalisation des déterminants de la qualité des soins ciblés et d'un taux de mortalité réduit pour la BSA. D'après leurs constatations, les auteurs proposent que la CeI soit obligatoire en cas de BSA, afin d'améliorer la prise en charge et le pronostic des patients.

Guidelines for the provision of echocardiography in Canada: recommendations of a joint Canadian Cardiovascular Society/Canadian Society of Echocardiography Consensus Panel.

Recognizing the central role of echocardiographic examinations in the assessment of most cardiac disorders and the need to ensure the provision of these services in a highly reliable, timely, economical and safe manner, the Canadian Cardiovascular Society and Canadian Society of Echocardiography undertook a comprehensive review of all aspects influencing the provision of echocardiographic services in Canada. Five regional panels were established to develop preliminary recommendations in the five component areas, which included the echocardiographic examination, the echocardiographic laboratory and report, the physician, the sonographer and indications for examinations. Membership in the panels was structured to recognize the regional professional diversity of individuals involved in the provision of echocardiography. In addition, a focus group of cardiac sonograhers was recruited to review aspects of the document impacting on sonographer responsibilities and qualification. The document is intended to be used as a comprehensive and practical reference for all of those involved in the provision of echocardiography in Canada.