title: Staphylococcus aureus bacteraemia in a UK tertiary referral centre: a 'transoesophageal echocardiogram for all' policy.
abstract: OBJECTIVE
  Infective endocarditis (IE) is a feared complication in up to 38% of cases of Staphylococcus aureus bacteraemia (SAB). BSAC guidelines recommend echocardiography in all cases of SAB. The aim of this study was to determine the incidence of IE in SAB using transoesophageal echocardiography (TOE) as the first step in diagnostic imaging. This study also sought to identify clinical predictors that could improve stratification of those with and without IE.
  
  
  METHODS
  A guideline was implemented that any SAB resulted in the microbiology department (i) recommending that the patient be referred for TOE and (ii) notifying the echocardiography department, resulting in streamlined listing of the patient for TOE. All cases of SAB were then assessed prospectively at University Hospitals Birmingham NHS Foundation Trust between September 2011 and October 2012. Previously identified risk factors for complicated S. aureus bacteraemia were recorded.
  
  
  RESULTS
  There were 98 SAB episodes in total. TOE was performed in 58 (59%) with a further 22 episodes imaged by transthoracic echocardiography alone. IE was diagnosed overall in 13 (16%) cases investigated with echocardiography. No risk factor for IE other than presence of a cardiac device was detected in this group (P = 0.013).
  
  
  CONCLUSIONS
  The rate of IE found in SAB is high when TOE is performed first line. There are no clear risk factors to improve yield or the type of echocardiography to be performed. Echocardiography should be performed in all cases and TOE should be considered where it is expected to influence management, as long as local resources allow.
authors.affiliation: Microbiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Holden
authors.affiliation: Cardiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Bashir
authors.affiliation: Microbiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Ira
authors.initials: I
authors.lastname: Das
authors.affiliation: Microbiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Hugh
authors.initials: H
authors.lastname: Morton
authors.affiliation: Cardiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Steadman
authors.affiliation: Wellcome Trust Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Nightingale
authors.affiliation: Cardiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Richard P
authors.initials: RP
authors.lastname: Steeds
authors.affiliation: Microbiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK miruna.david@uhb.nhs.uk.
authors.forename: Miruna D
authors.initials: MD
authors.lastname: David
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016470:Bacteremia / Q000150:complications* / Q000382:microbiology / Q000473:pathology; D017548:Echocardiography, Transesophageal / Q000379:methods* / Q000706:statistics & numerical data; D004696:Endocarditis / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology / Q000473:pathology; D005260:Female; D006291:Health Policy; D006785:Hospitals, University; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D013203:Staphylococcal Infections / Q000175:diagnosis* / Q000382:microbiology / Q000473:pathology; D013211:Staphylococcus aureus / Q000302:isolation & purification*; D062606:Tertiary Care Centers; D006113:United Kingdom; D055815:Young Adult
keywords: bloodstream infections; endocarditis; medical decision making; patient outcomes