What are the odds of doing a Transesophageal Echocardiogram (TEE) rather than a standard echocardiogram for a patient with candidemia?

Echocardiography Strategy for Candidemia

For patients with candidemia, proceed directly to transesophageal echocardiography (TEE) rather than relying on transthoracic echocardiography (TTE) alone, as Candida infective endocarditis (CIE) occurs in at least 4.2% of candidemic patients and is frequently clinically unsuspected. 1

Why TEE is Essential in Candidemia

The evidence strongly supports systematic echocardiographic screening in candidemia, with TEE being the superior modality:

• CIE prevalence is significant: At least 4.2% of all candidemic patients have Candida infective endocarditis, and among those who undergo echocardiographic evaluation, the rate is 5.9% 1

• Clinical suspicion is unreliable: In one prospective study, CIE was clinically unsuspected in 3 of 11 confirmed cases (27%), meaning you cannot rely on clinical judgment alone to determine who needs imaging 1

• TTE misses most cases: TTE suggested infective endocarditis in only 5 of 172 patients (2.9%), while TEE was positive in 10 of 87 patients (11.5%) 1

The Diagnostic Performance Gap

TEE dramatically outperforms TTE for detecting endocarditis:

• Sensitivity: TEE achieves >90% sensitivity for detecting intracardiac lesions associated with infective endocarditis, compared to 75% for TTE 2

• Small vegetations: TEE identifies significantly more small vegetations (<1 cm) than TTE (12/12 vs 5/12, p=0.02) 3

• Negative predictive value: TEE has up to 98.6% negative predictive value in suspected infective endocarditis 2, 4

• Perivalvular complications: TEE identifies all periannular complications (9/9) compared to only 2/9 by TTE (p=0.001) 3

Clinical Algorithm for Candidemia

Step 1: Assess candidemia severity and patient stability

• If patient is critically/terminally ill or has died when cultures become positive, echocardiography may not be feasible 1
• Otherwise, proceed to Step 2

Step 2: Perform TEE as the primary imaging modality

• TEE should be performed systematically in all suitable candidates with candidemia 1
• Do not rely on TTE alone, as it has only 2.9% detection rate compared to TEE's 11.5% 1

Step 3: If TEE is negative but clinical suspicion persists

• Repeat TEE after 3-5 days if clinical course is worrisome during early treatment 2
• A negative TEE never completely rules out infective endocarditis 2

Important Caveats

Why TTE is insufficient in candidemia:

• TTE has limited sensitivity (70% for native valves, 50% for prosthetic valves) compared to TEE's 96% and 92% respectively 5
• In the candidemia-specific study, TTE suggested IE in only 2.9% of patients while TEE detected it in 11.5% 1
• TTE particularly struggles with small vegetations and perivalvular complications 3

When TTE might be considered first:

• Current general endocarditis guidelines recommend starting with TTE in suspected IE 2
• However, the candidemia-specific evidence suggests this approach misses too many cases 1
• If TTE is performed first and is negative, TEE must follow immediately in candidemia patients given the high false-negative rate 1

Prosthetic valves require TEE:

• TEE is mandatory for any prosthetic valve with candidemia, as TTE sensitivity drops to only 50% 4, 6
• TEE achieves approximately 90% sensitivity for prosthetic valve endocarditis 4

Mortality and Morbidity Considerations

The decision to use TEE directly impacts outcomes:

• Intracardiac abscess detected on echocardiography is an independent predictor of both in-hospital mortality and 1-year mortality 2, 6
• Valve perforation on echocardiography independently predicts 1-year mortality 2, 6
• Left ventricular ejection fraction <40% combined with intracardiac abscess predicts in-hospital mortality 2, 6
• Early detection of these complications through TEE allows for timely surgical intervention when indicated 2