Trends in the use of echocardiography in patients with Staphylococcus aureus bacteremia: an analysis using the Nationwide Inpatient Sample data.

BACKGROUND: Infective endocarditis occurs in approximately 10%-30% of patients with Staphylococcus aureus bacteremia (SaB). Guidelines recommend echocardiography in patients with SaB and risk factors for infective endocarditis in the absence of any obvious source of infection. Herein, we explored the trends in the use of echocardiography in patients with SaB and its relationship to outcomes using a large national database. METHOD: All patients with a principal discharge diagnosis of SaB were identified using the National Inpatient Sample database from 2001 to 2014. Procedure code 88.72 was used to identify echocardiography. Logistic regression models were estimated to identify the year-over-year trends in echocardiogram, predictors of use, and association with mortality. RESULTS: From 2001 to 2014, there were 668 423 hospitalizations with SaB diagnosis and 86 387 (12.9%) had echocardiogram. The rate of echocardiography increased from 10.7% in 2001 to 15.2% in 2014 (ptrend  < 0.001). Major predictors of echocardiogram usage were younger age, male gender, presence of sepsis, valvular or congenital heart disease, prosthetic heart valve (PHV), cardiac implantable electronic device (CIED), hemodialysis, and drug abuse. The adjusted rates of echocardiography increased from approximately 10% to 15% in hospitalizations without risk factors for IE while for high-risk groups like PHV and CIED it remained constant at 30% and 19%, respectively. Echocardiography was associated with 31% lower odds of in-hospital mortality. CONCLUSION: The increase in echocardiography rate was largely attributable to increased use in those without risk factors while usage in those with PHV and CIED remained much lower than expected. Echocardiography use was associated with lower risk-adjusted mortality. These findings require further study and confirmation.

Meta-analysis of Randomized Controlled Trials on Patent Foramen Ovale Closure Versus Medical Therapy for Secondary Prevention of Cryptogenic Stroke.

The optimal management of patients with cryptogenic stroke (CS) and patent foramen ovale (PFO) remains controversial. We conducted a meta-analysis to assess the effect of PFO closure for secondary prevention of stroke on patients with CS. We searched the literature for randomized control trials assessing the recurrence of stroke after PFO closure compared with medical therapy (antiplatelet and/or anticoagulation). Five randomized control trials with a total of 3,440 patients were included. The mean age was 45.2 ± 9.7 years and follow-up duration ranged from 2.0 to 5.9 years. PFO closure significantly reduced the risk of stroke compared with the medical therapy (2.8% vs 5.8%; relative risk [RR] 0.48, confidence interval [CI] 0.27 to 0.87, p = 0.01, I2 = 56%). The number needed to treat for stroke prevention was 10.5. PFO closure was associated with an increased risk of atrial fibrillation compared with medical therapy (4.2% vs 0.7%; RR 4.55, CI 2.16 to 9.6, p = 0.0001, I2 = 25%). There was no significant difference in all-cause mortality (RR 1.33, CI 0.56 to 3.16, p = 0.52, I2 = 0%), as well as no difference in bleeding risk between the 2 groups (RR 0.94, CI 0.49 to 1.83, p = 0.86, I2 = 29%). In conclusion, our meta-analysis demonstrates that PFO closure is associated with significantly lower risk of recurrent stroke in patients with PFO and CS compared with medical therapy. However, atrial fibrillation was more common among closure patients.

Murine typhus and febrile illness, Nepal.

Murine typhus was diagnosed by PCR in 50 (7%) of 756 adults with febrile illness seeking treatment at Patan Hospital in Kathmandu, Nepal. Of patients with murine typhus, 64% were women, 86% were residents of Kathmandu, and 90% were unwell during the winter. No characteristics clearly distinguished typhus patients from those with blood culture-positive enteric fever.

Emergence of Salmonella enterica serotype Paratyphi A as a major cause of enteric fever in Kathmandu, Nepal.

We performed pulsed-field gel electrophoresis (XbaI) on 114 bloodstream isolates of Salmonella enterica serotype Paratyphi A and S. enterica serotype Typhi collected from febrile patients in Kathmandu, Nepal. Of the 56 S. Paratyphi A isolates, 51 (91%) were indistinguishable, which suggests the emergence of a single clone. In contrast, only 21 (36%) of the 58 S. Typhi isolates exhibited a common genotype, which is consistent with endemic disease from multiple sources.

The etiology of febrile illness in adults presenting to Patan hospital in Kathmandu, Nepal.

In Nepal, many infections remain poorly characterized, partly due to limited diagnostic facilities. We studied consecutive febrile adults presenting to a general hospital in Kathmandu, Nepal. Of the 876 patients enrolled, enteric fever and pneumonia were the most common clinical diagnoses. Putative pathogens were identified in 323 (37%) patients, the most common being Salmonella enterica serotype Typhi and S. enterica serotype Paratyphi A (117), Rickettsia typhi (97), Streptococcus pneumoniae (53), Leptospira spp. (36), and Orientia tsutsugamushi (28). Approximately half of the Salmonella isolates were resistant to nalidixic acid. No clinical predictors were identified to reliably distinguish between the different infections. These findings confirm the heavy burden of enteric fever and pneumonia in Kathmandu, and highlight the importance of murine typhus, scrub typhus, and leptospirosis. Given the lack of reliable clinical predictors, the development of cheap and accurate diagnostic tests are likely to be of great clinical utility in this setting.