From the Guidelines
Not all End-Stage Renal Disease (ESRD) patients with bacteremia require a Transesophageal Echocardiogram (TEE). The decision to perform a TEE should be individualized based on specific clinical factors, as suggested by the most recent guidelines and studies 1.
Clinical Factors for TEE
TEE is generally recommended for ESRD patients with bacteremia who have:
- Persistent positive blood cultures despite appropriate antibiotic therapy
- Staphylococcus aureus bacteremia (particularly MRSA)
- Unexplained fever lasting more than 48-72 hours on appropriate antibiotics
- Clinical signs of endocarditis (new murmur, embolic phenomena)
- Indwelling catheters or devices
For low-risk bacteremia cases with prompt clinical improvement on antibiotics and no concerning features, a TEE may not be necessary, as supported by studies 1.
Rationale for Selective TEE Use
The rationale behind selective TEE use is that while ESRD patients have a higher risk of infective endocarditis due to frequent vascular access, immune dysfunction, and calcific valvular disease, performing TEE on all bacteremic ESRD patients would expose many to an invasive procedure with potential complications without clear benefit, as noted in the guidelines 1. Clinical judgment should guide this decision, weighing the probability of endocarditis against the risks of the procedure.
Evidence-Based Recommendation
Based on the most recent and highest quality study 1, TEE should be performed in ESRD patients with bacteremia who have a high probability of endocarditis or those with clinical signs suggestive of endocarditis, as it has been shown to have a high sensitivity and specificity for detecting vegetations and perivalvular complications. However, for patients with low-risk bacteremia and no concerning features, a more conservative approach may be taken, reserving TEE for those who do not respond to initial antibiotic therapy or who develop signs of endocarditis.
From the Research
ESRD Patients with Bacteremia and TEE
- Not all End-Stage Renal Disease (ESRD) patients with bacteremia require a Transesophageal Echocardiogram (TEE) 2.
- The decision to perform a TEE should be based on individual patient risk factors and clinical presentation 3, 4.
- TEE is more sensitive than Transthoracic Echocardiography (TTE) in detecting valvular vegetations and diagnosing infective endocarditis (IE) 3, 4, 5.
- However, TEE may not be necessary in all cases of Staphylococcus aureus bacteremia (SAB), especially if there are pre-existing indications for extended anti-staphylococcal therapy independent of TEE findings 2.
Risk Factors and TEE
- Patients with SAB and certain risk factors, such as older age, may be more likely to benefit from TEE 4.
- TEE may be more useful in patients with complicated SAB or those who are at high risk for IE 3, 4.
- The American Society of Echocardiography (ASE) has developed appropriate use criteria for TEE, which can help guide decision-making 6.
Clinical Implications
- The results of a TEE can influence treatment duration and lead to valve surgery in some cases 3.
- However, the routine performance of TEE may be unnecessary in all SAB cases, and an algorithm to selectively identify cases that would benefit from TEE can reduce resource and equipment expenditure and patient risks associated with TEE 2.