Assessing Need for Transesophageal Echocardiography in Clinically Improving Patients at Risk for Infective Endocarditis: A Preliminary Retrospective Cohort Study in a Community Based Health System

Assessing Need for Transesophageal Echocardiography in Clinically Improving Patients at Risk for Infective Endocarditis: A Preliminary Retrospective Cohort Study in a Community Based Health System | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing Need for Transesophageal Echocardiography in Clinically Improving Patients at Risk for Infective Endocarditis: A Preliminary Retrospective Cohort Study in a Community Based Health System Tyler Lee, Abhinav Nair This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7042094/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Transesophageal echocardiogram is the preferred imaging modality for definitive diagnosis of infective endocarditis. However, some cases don’t always necessitate its use, especially among non-surgical, clinically improving patients on antibiotics. Methods A preliminary retrospective cohort study was performed on 134 patients within a 2-hospital community-based health system from March 2024 to June 2024. Results 68 were male (50.7%) and 66 were female (49.3%) with median age of 71 years. 41% of patients were treated with predetermined long-term antibiotics for infective endocarditis, and 71% of those were non-surgical candidates and clinically improving (defervesced in less than 3 days/remained afebrile and had resolving/resolved white blood count) . Transesophageal echocardiogram use did not significantly change predetermined long-term antibiotic management among non-surgical, clinically improving patients. Predetermined long-term antibiotic treatment was found to be significantly associated with patients having a definitive infective endocarditis diagnosis (p < 0.001). Repeat positive sets of blood cultures and failure to defervesce less than 3 days were shown to be significant clinical predictors of infective endocarditis (p < 0.001 and p = 0.015 respectively) and increased transesophageal echocardiography use (p < 0.001 and p = 0.045 respectively). Conclusions Overall, the study suggests that transesophageal echocardiography may not be necessary in non-surgically indicated clinically improving patients at risk for infective endocarditis, as management did not significantly change. However, if objective guidance is needed for transesophageal echocardiogram use, repeating positive blood cultures for gram positive organisms and failure to defervesce in less than 3 days may be useful. blood cultures defervescence infective endocarditis predetermined antibiotics transesophageal echocardiogram transthoracic echocardiogram INTRODUCTION Infective endocarditis (IE) is an inflammatory condition of the endocardium or valves of the heart secondary to an infective microorganism. The vast majority of IE cases stem from gram-positive cocci (GPC) and tends to affect those more with preexisting prosthetic valves, cardiac devices, and rheumatic heart diseases at a much higher proportion compared to those with normal, native, healthy hearts. The latest 2015 AHA national guidelines recommend that a transthoracic echocardiogram (TTE) always be used among low-risk patients with low clinical suspicion of IE. The decision for transesophageal echocardiogram (TEE) use, however, is more complex. According to the guidelines, low-risk patients were described as patients with fever and previously known valvular dysfunction with no other concerns for IE. TEE is only utilized if (1) initial TTE is negative, but there is still increased suspicion of IE based on clinical course or (2) have TTE high-risk features. High risk patients were described as patients with prosthetic heart valves, congenital heart diseases, previous endocarditis, new valvular murmur, heart failure, intravenous drug use (IVDU), or other concerns for endocarditis. Those at high risk are recommended to be evaluated with an initial TTE followed by a TEE as soon as possible [ 1 ]. Clinical suspicion remains a key subjective variable in escalating imaging to TEE from a TTE. In fact, one meta-analysis on diagnostic accuracy of TTE using TEE as a reference standard use concluded that subsequent TEE is “almost always required” in the workup of IE due to TTE having potential to miss many vegetative findings. They discussed that TEE use was only questionable when patients were without prosthetic valves and only demonstrated negative findings on optimal quality TTE studies, as these were shown to decrease the likelihood of IE [ 2 ]. There have been multiple studies in literature where there is growing evidence that routine echocardiography may not be obligatory for every case of suspected IE, including TEE [ 3 – 17 ]. Although TEEs are generally safe, they come with small but significant risks including esophageal damage and anesthesia exposure. The risks increase among elderly patients with increasing comorbidities. Compared to TTEs, TEEs require more resources to coordinate and perform. The decision to escalate cardiac imaging to TEE from TTE is coming into question as there is discordance with use and guideline recommendations, especially with the increasing use of non-invasive imaging modalities such as cardiac computed tomography and positron emission tomography. This preliminary study aims to assess the use of TEE on clinically improving patients with suspected IE and its effect on overall management. METHODS A preliminary retrospective cohort study was performed within the Jefferson Abington health system comprising of a community teaching hospital (Abington Memorial Hospital) and a community hospital (Abington Lansdale Hospital) from March 2024 to June 2024. Inclusion criteria for the study involved those who had 2 separate positive blood culture results (1 set) for gram positive cocci and were over the age of 18 years. Those excluded (14 patients) had insufficient data/workup for the study, specifically those who transitioned to comfort measures, expired early on admission, or transferred to another hospital. Data was collected by code and manual chart review through electronic medical records (EMR). Informed consent was not obtained as t he Jefferson IRB allowed conduction of study without a consent form or HIPAA authorization form. The primary measure was quantifying change in antibiotic treatment/overall management post TEE. Secondary measures included definitive IE diagnosis, possible IE diagnosis, and TEE use. Both definitive and possible IE diagnosis criteria were derived from the AHA 2015 IE guidelines and Modified Duke Criteria. Definitive IE diagnosis was made if the patient met 2 major criteria or 1 major plus 3 minor criteria. Possible IE diagnosis was made if the patient met 1 major plus 1 minor criterion or 3 minor criteria. Definitive and possible IE diagnoses were objectively made through a chart review investigation. Clinically improving patients were objectified by defervescing in less than 3 days or remaining afebrile AND showed a downtrending/normal white blood count (WBC). Predetermined long-term antibiotics (PTLA) were defined as starting IE treatment for 4–6 weeks prior to TEE use. Statistical Methods Descriptive statistics were used to summarize findings using mean and standard deviation, median and interquartile ranges. For quantitative analysis, chi-square tests were done to assess for significant associations between variables. T-tests were used to assess significant differences. To exclude bias in data selection, a third-party coder compiled all patients within the study timeframe who met the inclusion criteria mentioned above. To exclude data collection and analysis bias, the data sheet was reviewed by authors and third-party coder. RESULTS Patient Demographics A total of 148 patients met the criteria for the study, however 134 patients were ultimately analyzed. Of those analyzed, 68 were male (50.7%) and 66 were female (49.3%). The top 3 races among patients were White (n = 97, 72.3%), Black (n = 28, 20.9%), and Asian (n = 6, 4.5%). The median age and length of stay was 71 years (IQR = 22.75) and 9 days (IQR = 10) respectively. 20 (14.9%) patients expired during hospitalization. Of the 134 patients, 67 (50.0%) had at least 1 IE risk factor with the top 3 risk factors being cardio-structural abnormality (n = 54, 40.3%), chronic intravenous catheter (n = 22, 16.4%), and intracardiac device (n = 11, 8.2%) ( Table 1 ). Table 1 Patient Demographics Total (n) % Sex Male 68 50.7% Female 66 49.3% Race White 97 72.4% Black 28 20.9% Hispanic 3 2.2% Asian 6 4.5% IE Risk Factors Cardio-structural Abnormality* 54 40.3% Chronic Intravenous Catheter Present** 22 16.4% Intracardiac Device 11 8.2% Intravenous Drug Use 5 3.7% Prosthetic Heart Valve 5 3.7% Previous Infective Endocarditis 2 1.5% Blood Culture and Clinical Findings All patients in the study had positive GPC growth in at least 2 separate blood cultures (1 set). Half of the patients grew Coagulase-negative Staphylococci (n = 67, 50.0%), with the next most being Staphylococcus aureus (n = 38, 28.4%), and third being Streptococcus viridans (n = 17, 12.7%). The staphylococcus aureus group had the most definitive (7/13, 53.8%) and possible (36/59, 61.0%) diagnoses of IE as well as the most amount of TEE use (13/21, 61.9%). 48 (35.8%) patients had at least 1 repeat positive blood culture set following the initial positive blood culture set ( Table 2 ). Table 2 Blood Culture Data with TEE Use and Infective Endocarditis Diagnosis Total (n) Repeat positive blood culture sets (n) Days of positive blood cultures (n) TEE Use (n) Definitive IE Dx (n) Possible IE DX (n) Staphylococcus aureus * * * MSSA 28 71 49 7 6 26 MRSA 10 46 40 6 1 10 Streptococcus viridans S. mitis group 7 7 0 1 1 3 S. mutans 3 3 0 1 1 2 S. constellatus 3 3 1 0 0 2 S. gorodornii 2 3 0 2 1 2 S. anginosus 2 2 0 0 0 2 Enterococcus E. faecalis 10 33 23 1 2 10 VRE 2 5 7 0 0 0 CoNS ** ** ** S. epidermidis 41 47 9 2 1 1 S. hominis 12 12 0 1 0 1 S. capitis 7 7 0 0 0 0 S. haemolyticus 3 4 1 0 0 0 S. pettenkoferi 3 3 0 0 0 0 S. saccarolyticus 1 1 0 0 0 0 73 (54.5%) patients had a fever, and 61 (45.5%) patients were afebrile at the time of positive blood cultures. Of the patients with a fever, 58 (79.5%) defervesced in less than 3 days. 116 (86.6%) had a normal or downtrending WBC count after initial elevation. 13 (9.7%) patients had a definitive diagnosis of IE and 59 (44.0%) had a possible diagnosis of IE. TTE and TEE Use All TEE operators were certified by the National Board of Echocardiography in labs accredited by the Intersocietal Accreditation Commission. Imaging modalities included TTE and TEE, where a total of 99 (73.9%) patients received a TTE and 21 (15.7%) patients received a TEE. Nearly all patients who received a TEE had a TTE already done during the same admission (n = 20, 95.2%). TTEs did show positive valvular vegetations in 8.1% (8/99) of patients, concerning for IE. However, worsened functional findings on TTE did not predict IE or TEE use. TEE showed 15.0% (3/20) valvular vegetations findings when a TTE was inconclusive, although patients were already noted to be on definitive IE treatment. TTE [ X 2 (1, n = 134) = 32.52, p < 0.001, φ = 0.49] and TEE [ X 2 (1, n = 134) = 12.70, p < 0.001, φ = 0.30] use significantly dropped when blood cultures were positive for coagulase-negative staphylococcus. TEE use did not significantly prolong hospital length of stay. Predictors of IE or TEE Use Of the non-Modified Duke Criteria variables, significant predictors of definitive IE diagnosis were repeat positive sets of blood cultures [ X 2 (1, n = 134) = 14.90, p < 0.001, φ = 0.33] and PLTA treatment [ X 2 (1, n = 134) = 15.63, p < 0.001, φ = 0.34]. Predictors of possible IE diagnosis were repeat positive sets of blood cultures [ X 2 (1, n = 134) = 62.97, p < 0.001, φ = 0.68], failure to defervesce less than 3 days [ X 2 (1, n = 134) = 5.88, p = 0.015, φ = 0.20], and PLTA treatment [ X 2 (1, n = 134) = 64.96, p < 0.001, φ = 0.69] ( Table 3 ). Table 3 Predictors of TEE Use and Infective Endocarditis Diagnosis TEE Use (p value) Definitive IE Dx (p value) Possible IE Dx (p value) Non-Modified Duke Criteria Variables Repeat Positive Blood Cultures < 0.01 < 0.01 < 0.01 Failure to Defervesce Less than 3 days 0.045 0.67 0.015 Unresolving/Uptrending WBC 0.56 0.28 0.28 Planned Longterm Antibiotics < 0.01 < 0.01 < 0.01 Modified Duke Criteria Variables Cardio-structural Abnormality* 0.45 < 0.01 0.01 Intracardiac Device 0.048 0.03 < 0.01 Intravenous Drug Use < 0.01 0.01 0.05 Prosthetic Heart Valve < 0.01 0.42 0.46 Previous IE Diagnosis 0.80 < 0.01 0.22 Significant predictors of TEE use were history of prosthetic valves [ X 2 (1, n = 134) = 7.72, p = 0.005, φ = 0.24], history of intracardiac devices [ X 2 (1, n = 134) = 3.88, p = 0.048, φ = 0.17], history of intravenous drug use [ X 2 (1, n = 134) = 7.72, p = 0.005, φ = 0.24], repeat positive sets of blood cultures [ X 2 (1, n = 134) = 13.73, p < 0.001, φ = 0.32], failure to defervesce less than 3 days [ X 2 (1, n = 134) = 3.98, p = 0.045, φ = 0.17], and PLTA treatment [ X 2 (1, n = 134) = 12.71, p < 0.001, φ = 0.30] ( Table 3 ). Those who had a TEE done had significantly more repeat sets of positive blood cultures than those who did not undergo TEE evaluation [TEE 3.04 (SD 2.41) vs without TEE 1.61 (SD 1.15), t(132) = 2.47, p = 0.01, 95% CI [1.33, 1.52]]. Similarly, the number of days of positive blood cultures was seen significantly more in patients who received a TEE [TEE 2.61 (SD 3.16) vs without TEE 0.66 (SD 1.34), t(132) = 2.57, p = 0.011, 95% CI [1.82, 2.07]]. Culture data showed that Staphylococcus aureus was significantly associated with an increased number of definitive IE diagnoses [ X 2 (1, n = 134) = 4.60, p = 0.031, φ = 0.18], possible IE diagnoses [ X 2 (1, n = 134) = 55.34, p < 0.001, φ = 0.64], and TEE use [ X 2 (1, n = 134) = 13.79, p = 0.005, φ = 0.32]. In contrast, CoNS was shown to have a significantly lower number of definitive IE diagnoses, possible IE diagnoses, and TEE use. ( Table 2 ). There were no significant demographic predictors of IE or TEE use. WBC trends did not have any significant associations with IE or TEE use. Effects On Overall Management Nearly all patients were treated at some point during their admission with antibiotic therapy (n = 130, 97.0%) with 41.0% (55/134) patients having PLTA treatment of 4 to 6 weeks for suspected IE. 71% (39/55) on PLTA treatment were non-surgical candidates and clinically improving (defervesced in less than 3 days/remained afebrile AND had resolving/resolved WBC) and 30.7% (12/39) received a TEE. TEE use did not significantly change PLTA management among non-surgical, clinically improving patients [ X 2 (1, n = 39) = 4.74, p = 0.066, φ = 0.18)]. Of the total 134 patients, 21 patients had a TEE. Only 4 (19.0%) had their long-term antibiotic or overall treatment adjusted with only 1 seen by cardiothoracic surgery (no recommendations for surgery). Even with new TEE vegetative findings not found initially on TTE, no significant impact was made on PLTA treatment overall [ X 2 (1, n = 21) = 1.86, p = 0.171, φ = 0.11]. DISCUSSION S. aureus was shown to be the most common microorganism associated with the highest amount of TTE and TEE use and definitive IE diagnosis. Conversely, the CoNS group showed opposite trends as many of these blood cultures were thought to be contaminants where no further management was pursued. In addition to the culprit microorganism, clinical management was most influenced by the presence or absence of persistent bacteremia. The lack of repeat GPC growth almost always impacted clinical judgment in assessing for potential blood culture contaminants. As shown in our study, negative repeat blood cultures were the primary reason for the halted IE workup, especially in patients growing CoNS. However, we also showed that repeat positive blood cultures for GPC can provide significant insight to other aspects of IE management that go beyond differentiating microorganism contaminants. In a community hospital setting, we found that the objective clinical factors (not included in the Modified Duke Criteria) including (1) repeat positive blood cultures and (2) failure to defervesce in less than 3 days appeared to have significant association with TEE use. In fact, definitive IE diagnoses were even found to be significantly associated with increased repeating blood cultures and lack of defervescence. These two objective factors/data points confer a higher likelihood of IE and may provide clarifying guidance on the decision to pursue TEE. Failure to defervesce in less than 3 days along with persistent bacteremia can be utilized in conjunction with the Modified Dukes Criteria to guide clinical management in this patient population. In addition to repeating positive blood cultures and failure to defervesce, this study suggests clinicians in this cohort appeared to be directing TEE use toward high-risk IE patients (history of prosthetic valves, intracardiac devices, and IVDU) as recommended by AHA 2015 guidelines. These findings help to objectify the subjectivity of TEE use and low TEE use yield in this study. TTE remains the first line of imaging for IE. TEE can be helpful in assisting with IE diagnosis when TTE is inconclusive, but the question of whether TEE would change IE management is always considered. In this study, whether or not patients received a TEE, PTLA treatment remained unchanged. Even in cases where new valvular vegetations appeared on TEE (initially missed on TTE), there was no significant change in PTLA treatment. To note, it was observed that PLTA treatment was being directed to those with definitive and possible IE diagnoses before TEE was considered or utilized. These findings suggest the insignificant change in PTLA treatment and overall IE management post TEE. Several limitations were acknowledged when conducting this study. We acknowledge that multiple TTE/TEE operators and echocardiography reading clinicians may have various views and interpretations of the images without standardized criteria, leading to unavoidable selection bias and possible inconsistent results. Also, data was collected through manual chart review notes (more than objective ICD-10 code retrieval). This was attributed to inconsistent documentation of diagnoses from various providers in EMR coding. The significant extent of manual chart review limited the size of the study population as well, which subsequently lowered the power of the statistical analysis. Patients also may have had multiple problems contributing to their clinical picture affecting fever and WBC trends, especially with some patients requiring ICU admission. CONCLUSION Staphylococcus aureus remains the most common organism to cause IE with the majority of TEEs used belonging to this group. Objective data outside the Modified Duke Criteria including (1) repeating positive blood cultures and (2) failure of defervescence may provide guidance in TEE use as they may have potential to be significant predictors of IE diagnosis. Managment of suspected IE was shown to be generally sufficient before the use of TEE, as only a small number of patients had their management changed post-TEE. Overall, the study suggests that transesophageal echocardiography may not be necessary in non-surgically indicated clinically improving patients at risk for infective endocarditis, as management did not significantly change. However, if objective guidance is needed for transesophageal echocardiogram use, repeating positive blood cultures for gram positive organisms and failure to defervesce in less than 3 days may be useful. This preliminary study provides the foundation for future studies with a larger patient population and motive to assess TEE use in clinically improving patients at risk for IE in major academic hospital settings. Abbreviations AHA American Heart Association CoNS Coagulase negative staphylococcus EMR Electronic medical record GPC Gram positive cocci ICD 10 – International Classification of Disease IE Infective endocarditis ICU Intensive care unit IVDU Intravenous drug use TEE Transesophageal echocardiogram TTE Transthoracic echocardiogram Predetermined long term antibiotic – PLTA WBC White blood cell Declarations Ethics approval and consent to participate: The study was submitted and approved by Jefferson IRB. The study conducted adhered to the Declaration of Helsinki. Informed consent was not obtained as t he Jefferson IRB allowed conduction of study without a consent form or HIPAA authorization form. (IRB#: iRISID-2024-0730). Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request Competing Interests: The authors declare that they have no competing interests Funding: Not applicable Authors' contributions : T.L. designed study, cured data, analyzed data, designed tables, wrote main manuscript text, and reviewed manuscript. A.N. conceptualized study, supervised study, validated data, and reviewed manuscript. Acknowledgements: This work was greatly supported by David H Wiener M.D. for his insight on echocardiography References Baddour LM, Wilson WR, Bayer AS, for Healthcare Professionals From the American Heart Association. 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Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYBACNv7mBhAtByIOPCBGC5/EQaCWBAZjsJYEYrTIMSSCtSSC7SJKCxvDwcYHH38cTp8fdvgh0BY7Od0GQlqYG5sNZyQczt14O80AqCXZ2OwAYVvapHlAWmYngLQcSNxGWEti++8/CYfTDWenfyBaSxszQ8LhBHnpHGJtkTjYLNmTlm64QTqn4ECCARF+ke9vPvjhh421vPzs9M0fPlTYyRHUAgXNDAZglQbEKQeBOgb5BuJVj4JRMApGwQgDAGz1SNizQJ/EAAAAAElFTkSuQmCC","orcid":"","institution":"Jefferson Abington Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tyler","middleName":"","lastName":"Lee","suffix":""},{"id":518690780,"identity":"b7d1cf59-970e-4b4a-b524-bc0ab05f021b","order_by":1,"name":"Abhinav Nair","email":"","orcid":"","institution":"Jefferson Abington Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abhinav","middleName":"","lastName":"Nair","suffix":""}],"badges":[],"createdAt":"2025-07-04 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17:43:16","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":99861,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7042094/v1/65159a82a104e4ade839f239.html"},{"id":92203522,"identity":"33c87880-fdd7-4792-b78b-515e3a22e56a","added_by":"auto","created_at":"2025-09-25 17:51:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":694133,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7042094/v1/f22f147e-d0f5-4aa9-9a56-851981a2de09.pdf"},{"id":92203250,"identity":"b999283c-a122-43be-ba2a-f09b538651cb","added_by":"auto","created_at":"2025-09-25 17:43:16","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":783908,"visible":true,"origin":"","legend":"","description":"","filename":"IEresearchdatacollectionMarchJune2024BMC.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7042094/v1/9aa344af05a6f42164f773a5.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing Need for Transesophageal Echocardiography in Clinically Improving Patients at Risk for Infective Endocarditis: A Preliminary Retrospective Cohort Study in a Community Based Health System","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eInfective endocarditis (IE) is an inflammatory condition of the endocardium or valves of the heart secondary to an infective microorganism. The vast majority of IE cases stem from gram-positive cocci (GPC) and tends to affect those more with preexisting prosthetic valves, cardiac devices, and rheumatic heart diseases at a much higher proportion compared to those with normal, native, healthy hearts.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e The latest 2015 AHA national guidelines recommend that a transthoracic echocardiogram (TTE) always be used among low-risk patients with low clinical suspicion of IE. The decision for transesophageal echocardiogram (TEE) use, however, is more complex. According to the guidelines, low-risk patients were described as patients with fever and previously known valvular dysfunction with no other concerns for IE. TEE is only utilized if (1) initial TTE is negative, but there is still increased suspicion of IE based on clinical course or (2) have TTE high-risk features. High risk patients were described as patients with prosthetic heart valves, congenital heart diseases, previous endocarditis, new valvular murmur, heart failure, intravenous drug use (IVDU), or other concerns for endocarditis. Those at high risk are recommended to be evaluated with an initial TTE followed by a TEE as soon as possible\u003c/span\u003e [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eClinical suspicion remains a key subjective variable in escalating imaging to TEE from a TTE. In fact, one meta-analysis on diagnostic accuracy of TTE using TEE as a reference standard use concluded that subsequent TEE is \u0026ldquo;almost always required\u0026rdquo; in the workup of IE due to TTE having potential to miss many vegetative findings. They discussed that TEE use was only questionable when patients were without prosthetic valves and only demonstrated negative findings on optimal quality TTE studies, as these were shown to decrease the likelihood of IE\u003c/span\u003e [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThere have been multiple studies in literature where there is growing evidence that routine echocardiography may not be obligatory for every case of suspected IE, including TEE\u003c/span\u003e [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAlthough TEEs are generally safe, they come with small but significant risks including esophageal damage and anesthesia exposure. The risks increase among elderly patients with increasing comorbidities. Compared to TTEs, TEEs require more resources to coordinate and perform. The decision to escalate cardiac imaging to TEE from TTE is coming into question as there is discordance with use and guideline recommendations, especially with the increasing use of non-invasive imaging modalities such as cardiac computed tomography and positron emission tomography. This preliminary study aims to assess the use of TEE on clinically improving patients with suspected IE and its effect on overall management.\u003c/span\u003e\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA preliminary retrospective cohort study was performed within the Jefferson Abington health system comprising of a community teaching hospital (Abington Memorial Hospital) and a community hospital (Abington Lansdale Hospital) from March 2024 to June 2024. Inclusion criteria for the study involved those who had 2 separate positive blood culture results (1 set) for gram positive cocci and were over the age of 18 years. Those excluded (14 patients) had insufficient data/workup for the study, specifically those who transitioned to comfort measures, expired early on admission, or transferred to another hospital. Data was collected by code and manual chart review through electronic medical records (EMR). Informed consent was not obtained as\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003et\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehe Jefferson IRB allowed conduction of study without a consent form or HIPAA authorization form.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe primary measure was quantifying change in antibiotic treatment/overall management post TEE. Secondary measures included definitive IE diagnosis, possible IE diagnosis, and TEE use. Both definitive and possible IE diagnosis criteria were derived from the AHA 2015 IE guidelines and Modified Duke Criteria. Definitive IE diagnosis was made if the patient met 2 major criteria or 1 major plus 3 minor criteria. Possible IE diagnosis was made if the patient met 1 major plus 1 minor criterion or 3 minor criteria. Definitive and possible IE diagnoses were objectively made through a chart review investigation. Clinically improving patients were objectified by defervescing in less than 3 days or remaining afebrile AND showed a downtrending/normal white blood count (WBC). Predetermined long-term antibiotics (PTLA) were defined as starting IE treatment for 4\u0026ndash;6 weeks prior to TEE use.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eStatistical Methods\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDescriptive statistics were used to summarize findings using mean and standard deviation, median and interquartile ranges. For quantitative analysis, chi-square tests were done to assess for significant associations between variables. T-tests were used to assess significant differences. To exclude bias in data selection, a third-party coder compiled all patients within the study timeframe who met the inclusion criteria mentioned above. To exclude data collection and analysis bias, the data sheet was reviewed by authors and third-party coder.\u003c/span\u003e\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ePatient Demographics\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of 148 patients met the criteria for the study, however 134 patients were ultimately analyzed. Of those analyzed, 68 were male (50.7%) and 66 were female (49.3%). The top 3 races among patients were White (n\u0026thinsp;=\u0026thinsp;97, 72.3%), Black (n\u0026thinsp;=\u0026thinsp;28, 20.9%), and Asian (n\u0026thinsp;=\u0026thinsp;6, 4.5%). The median age and length of stay was 71 years (IQR\u0026thinsp;=\u0026thinsp;22.75) and 9 days (IQR\u0026thinsp;=\u0026thinsp;10) respectively. 20 (14.9%) patients expired during hospitalization. Of the 134 patients, 67 (50.0%) had at least 1 IE risk factor with the top 3 risk factors being cardio-structural abnormality (n\u0026thinsp;=\u0026thinsp;54, 40.3%), chronic intravenous catheter (n\u0026thinsp;=\u0026thinsp;22, 16.4%), and intracardiac device (n\u0026thinsp;=\u0026thinsp;11, 8.2%) (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePatient Demographics\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIE Risk Factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCardio-structural Abnormality*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic Intravenous Catheter Present**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntracardiac Device\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntravenous Drug Use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProsthetic Heart Valve\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious Infective Endocarditis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eBlood Culture and Clinical Findings\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAll patients in the study had positive GPC growth in at least 2 separate blood cultures (1 set). Half of the patients grew Coagulase-negative Staphylococci (n\u0026thinsp;=\u0026thinsp;67, 50.0%), with the next most being Staphylococcus aureus (n\u0026thinsp;=\u0026thinsp;38, 28.4%), and third being Streptococcus viridans (n\u0026thinsp;=\u0026thinsp;17, 12.7%). The staphylococcus aureus group had the most definitive (7/13, 53.8%) and possible (36/59, 61.0%) diagnoses of IE as well as the most amount of TEE use (13/21, 61.9%). 48 (35.8%) patients had at least 1 repeat positive blood culture set following the initial positive blood culture set (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eBlood Culture Data with TEE Use and Infective Endocarditis Diagnosis\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRepeat positive blood culture sets\u003c/p\u003e\u003cp\u003e(n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDays of positive blood cultures\u003c/p\u003e\u003cp\u003e(n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTEE Use\u003c/p\u003e\u003cp\u003e(n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDefinitive IE Dx\u003c/p\u003e\u003cp\u003e(n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePossible IE DX\u003c/p\u003e\u003cp\u003e(n)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStaphylococcus aureus\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMSSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMRSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStreptococcus viridans\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. mitis group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. mutans\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. constellatus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. gorodornii\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. anginosus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEnterococcus\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eE. faecalis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVRE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCoNS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. epidermidis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. hominis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. capitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. haemolyticus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. pettenkoferi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. saccarolyticus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e73 (54.5%) patients had a fever, and 61 (45.5%) patients were afebrile at the time of positive blood cultures. Of the patients with a fever, 58 (79.5%) defervesced in less than 3 days. 116 (86.6%) had a normal or downtrending WBC count after initial elevation. 13 (9.7%) patients had a definitive diagnosis of IE and 59 (44.0%) had a possible diagnosis of IE.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eTTE and TEE Use\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAll TEE operators were certified by the National Board of Echocardiography in labs accredited by the Intersocietal Accreditation Commission. Imaging modalities included TTE and TEE, where a total of 99 (73.9%) patients received a TTE and 21 (15.7%) patients received a TEE. Nearly all patients who received a TEE had a TTE already done during the same admission (n\u0026thinsp;=\u0026thinsp;20, 95.2%). TTEs did show positive valvular vegetations in 8.1% (8/99) of patients, concerning for IE. However, worsened functional findings on TTE did not predict IE or TEE use. TEE showed 15.0% (3/20) valvular vegetations findings when a TTE was inconclusive, although patients were already noted to be on definitive IE treatment. TTE [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;32.52, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, φ\u0026thinsp;=\u0026thinsp;0.49] and TEE [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;12.70, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, φ\u0026thinsp;=\u0026thinsp;0.30] use significantly dropped when blood cultures were positive for coagulase-negative staphylococcus. TEE use did not significantly prolong hospital length of stay.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ePredictors of IE or TEE Use\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOf the non-Modified Duke Criteria variables, significant predictors of definitive IE diagnosis were repeat positive sets of blood cultures [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;14.90, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, φ\u0026thinsp;=\u0026thinsp;0.33] and PLTA treatment [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;15.63, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, φ\u0026thinsp;=\u0026thinsp;0.34]. Predictors of possible IE diagnosis were repeat positive sets of blood cultures [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;62.97, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, φ\u0026thinsp;=\u0026thinsp;0.68], failure to defervesce less than 3 days [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;5.88, p\u0026thinsp;=\u0026thinsp;0.015, φ\u0026thinsp;=\u0026thinsp;0.20], and PLTA treatment [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;64.96, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, φ\u0026thinsp;=\u0026thinsp;0.69] (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePredictors of TEE Use and Infective Endocarditis Diagnosis\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTEE Use\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(p value)\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDefinitive IE Dx\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(p value)\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePossible IE Dx\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(p value)\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNon-Modified Duke Criteria Variables\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRepeat Positive Blood Cultures\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFailure to Defervesce Less than 3 days\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.045\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.67\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.015\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eUnresolving/Uptrending WBC\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.56\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.28\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.28\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePlanned Longterm Antibiotics\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eModified Duke Criteria Variables\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCardio-structural Abnormality*\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.45\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIntracardiac Device\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.048\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.03\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIntravenous Drug Use\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.05\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eProsthetic Heart Valve\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.42\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.46\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePrevious IE Diagnosis\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.80\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e0.22\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSignificant predictors of TEE use were history of prosthetic valves [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;7.72, p\u0026thinsp;=\u0026thinsp;0.005, φ\u0026thinsp;=\u0026thinsp;0.24], history of intracardiac devices [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;3.88, p\u0026thinsp;=\u0026thinsp;0.048, φ\u0026thinsp;=\u0026thinsp;0.17], history of intravenous drug use [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;7.72, p\u0026thinsp;=\u0026thinsp;0.005, φ\u0026thinsp;=\u0026thinsp;0.24], repeat positive sets of blood cultures [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;13.73, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, φ\u0026thinsp;=\u0026thinsp;0.32], failure to defervesce less than 3 days [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;3.98, p\u0026thinsp;=\u0026thinsp;0.045, φ\u0026thinsp;=\u0026thinsp;0.17], and PLTA treatment [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;12.71, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, φ\u0026thinsp;=\u0026thinsp;0.30] (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThose who had a TEE done had significantly more repeat sets of positive blood cultures than those who did not undergo TEE evaluation [TEE 3.04 (SD 2.41) vs without TEE 1.61 (SD 1.15), t(132)\u0026thinsp;=\u0026thinsp;2.47, p\u0026thinsp;=\u0026thinsp;0.01, 95% CI [1.33, 1.52]]. Similarly, the number of days of positive blood cultures was seen significantly more in patients who received a TEE [TEE 2.61 (SD 3.16) vs without TEE 0.66 (SD 1.34), t(132)\u0026thinsp;=\u0026thinsp;2.57, p\u0026thinsp;=\u0026thinsp;0.011, 95% CI [1.82, 2.07]].\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCulture data showed that Staphylococcus aureus was significantly associated with an increased number of definitive IE diagnoses [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;4.60, p\u0026thinsp;=\u0026thinsp;0.031, φ\u0026thinsp;=\u0026thinsp;0.18], possible IE diagnoses [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;55.34, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, φ\u0026thinsp;=\u0026thinsp;0.64], and TEE use [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;134)\u0026thinsp;=\u0026thinsp;13.79, p\u0026thinsp;=\u0026thinsp;0.005, φ\u0026thinsp;=\u0026thinsp;0.32]. In contrast, CoNS was shown to have a significantly lower number of definitive IE diagnoses, possible IE diagnoses, and TEE use. (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e). There were no significant demographic predictors of IE or TEE use. WBC trends did not have any significant associations with IE or TEE use.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eEffects On Overall Management\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNearly all patients were treated at some point during their admission with antibiotic therapy (n\u0026thinsp;=\u0026thinsp;130, 97.0%) with 41.0% (55/134) patients having PLTA treatment of 4 to 6 weeks for suspected IE.\u003c/span\u003e 71% (39/55) on PLTA treatment were non-surgical candidates and clinically improving \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(defervesced in less than 3 days/remained afebrile AND had resolving/resolved WBC) and\u003c/span\u003e 30.7% (12/39) received a TEE. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTEE use did not significantly change PLTA management among non-surgical, clinically improving patients [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;39)\u0026thinsp;=\u0026thinsp;4.74, p\u0026thinsp;=\u0026thinsp;0.066, φ\u0026thinsp;=\u0026thinsp;0.18)].\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOf the total 134 patients, 21 patients had a TEE. Only 4 (19.0%) had their long-term antibiotic or overall treatment adjusted with only 1 seen by cardiothoracic surgery (no recommendations for surgery). Even with new TEE vegetative findings not found initially on TTE, no significant impact was made on PLTA treatment overall [\u003c/span\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eX\u003c/span\u003e\u003csup\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(1, n\u0026thinsp;=\u0026thinsp;21)\u0026thinsp;=\u0026thinsp;1.86, p\u0026thinsp;=\u0026thinsp;0.171, φ\u0026thinsp;=\u0026thinsp;0.11].\u003c/span\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eS. aureus was shown to be the most common microorganism associated with the highest amount of TTE and TEE use and definitive IE diagnosis. Conversely, the CoNS group showed opposite trends as many of these blood cultures were thought to be contaminants where no further management was pursued. In addition to the culprit microorganism, clinical management was most influenced by the presence or absence of persistent bacteremia. The lack of repeat GPC growth almost always impacted clinical judgment in assessing for potential blood culture contaminants. As shown in our study, negative repeat blood cultures were the primary reason for the halted IE workup, especially in patients growing CoNS. However, we also showed that repeat positive blood cultures for GPC can provide significant insight to other aspects of IE management that go beyond differentiating microorganism contaminants.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIn a community hospital setting, we found that the objective clinical factors (not included in the Modified Duke Criteria) including (1) repeat positive blood cultures and (2) failure to defervesce in less than 3 days appeared to have significant association with TEE use. In fact, definitive IE diagnoses were even found to be significantly associated with increased repeating blood cultures and lack of defervescence. These two objective factors/data points confer a higher likelihood of IE and may provide clarifying guidance on the decision to pursue TEE. Failure to defervesce in less than 3 days along with persistent bacteremia can be utilized in conjunction with the Modified Dukes Criteria to guide clinical management in this patient population. In addition to repeating positive blood cultures and failure to defervesce, this study suggests clinicians in this cohort appeared to be directing TEE use toward high-risk IE patients (history of prosthetic valves, intracardiac devices, and IVDU) as recommended by AHA 2015 guidelines. These findings help to objectify the subjectivity of TEE use and low TEE use yield in this study.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTTE remains the first line of imaging for IE. TEE can be helpful in assisting with IE diagnosis when TTE is inconclusive, but the question of whether TEE would change IE management is always considered. In this study, whether or not patients received a TEE, PTLA treatment remained unchanged. Even in cases where new valvular vegetations appeared on TEE (initially missed on TTE), there was no significant change in PTLA treatment. To note, it was observed that PLTA treatment was being directed to those with definitive and possible IE diagnoses before TEE was considered or utilized. These findings suggest the insignificant change in PTLA treatment and overall IE management post TEE.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSeveral limitations were acknowledged when conducting this study. We acknowledge that multiple TTE/TEE operators and echocardiography reading clinicians may have various views and interpretations of the images without standardized criteria, leading to unavoidable selection bias and possible inconsistent results. Also, data was collected through manual chart review notes (more than objective ICD-10 code retrieval). This was attributed to inconsistent documentation of diagnoses from various providers in EMR coding. The significant extent of manual chart review limited the size of the study population as well, which subsequently lowered the power of the statistical analysis. Patients also may have had multiple problems contributing to their clinical picture affecting fever and WBC trends, especially with some patients requiring ICU admission.\u003c/span\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eStaphylococcus aureus remains the most common organism to cause IE with the majority of TEEs used belonging to this group. Objective data outside the Modified Duke Criteria including (1) repeating positive blood cultures and (2) failure of defervescence may provide guidance in TEE use as they may have potential to be significant predictors of IE diagnosis. Managment of suspected IE was shown to be generally sufficient before the use of TEE, as only a small number of patients had their management changed post-TEE. Overall, the study suggests that transesophageal echocardiography may not be necessary in non-surgically indicated clinically improving patients at risk for infective endocarditis, as management did not significantly change. However, if objective guidance is needed for transesophageal echocardiogram use, repeating positive blood cultures for gram positive organisms and failure to defervesce in less than 3 days may be useful. This preliminary study provides the foundation for future studies with a larger patient population and motive to assess TEE use in clinically improving patients at risk for IE in major academic hospital settings.\u003c/span\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAHA\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAmerican Heart Association\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCoNS\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCoagulase negative staphylococcus\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEMR\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eElectronic medical record\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eGPC\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eGram positive cocci\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eICD\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eInternational Classification of Disease\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIE\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eInfective endocarditis\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eICU\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIntensive care unit\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIVDU\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIntravenous drug use\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTEE\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTransesophageal echocardiogram\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTTE\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTransthoracic echocardiogram\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePredetermined long\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eterm antibiotic\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePLTA\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eWBC\u003c/span\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eWhite blood cell\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study was submitted and approved by Jefferson IRB. The study conducted adhered to the Declaration of Helsinki. Informed consent was not obtained as\u003cstrong\u003e\u0026nbsp;t\u003c/strong\u003ehe Jefferson IRB allowed conduction of study without a consent form or HIPAA authorization form. (IRB#: iRISID-2024-0730).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e: T.L. designed study, cured data, analyzed data, designed tables, wrote main manuscript text, and reviewed manuscript. A.N. conceptualized study, supervised study, validated data, and reviewed manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThis work was greatly supported by David H Wiener M.D. for his insight on echocardiography\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBaddour LM, Wilson WR, Bayer AS, for Healthcare Professionals From the American Heart Association. American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement. Circulation. 2015;132(15):1435-86. doi: 10.1161/CIR.0000000000000296. Epub 2015 Sep 15. Erratum in: Circulation. 2015;132(17):e215. 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Open Forum Infect Dis. 2016;3(4):ofw204. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ofid/ofw204\u003c/span\u003e\u003cspan address=\"10.1093/ofid/ofw204\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 27833929; PMCID: PMC5102142.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoseph JP, Meddows TR, Webster DP et al. Prioritizing echocardiography in Staphylococcus aureus bacteraemia. J Antimicrob Chemother. 2013;68(2):444-9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jac/dks408\u003c/span\u003e\u003cspan address=\"10.1093/jac/dks408\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2012 Oct 30. PMID: 23111851.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndersen MH, Holle SLK, Klein CF, et al. Risk for infective endocarditis in bacteremia with Gram positive cocci. Infection. 2020;48(6):905\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s15010-020-01504-6\u003c/span\u003e\u003cspan address=\"10.1007/s15010-020-01504-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2020 Aug 25. PMID: 32844380.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeriot G, Yeoh J, Street A, Ratnam I. Echocardiography has minimal yield and may not be warranted in Staphylococcus aureus bacteremia without clinical risk factors for endocarditis. Eur J Clin Microbiol Infect Dis. 2015;34(6):1231\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10096-015-2352-7\u003c/span\u003e\u003cspan address=\"10.1007/s10096-015-2352-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2015 Feb 26. PMID: 25717023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaasch AJ, Fowler VG Jr, Rieg S, et al. Use of a simple criteria set for guiding echocardiography in nosocomial Staphylococcus aureus bacteremia. Clin Infect Dis. 2011;53(1):1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/cid/cir320\u003c/span\u003e\u003cspan address=\"10.1093/cid/cir320\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 21653295; PMCID: PMC3149212.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePalraj BR, Baddour LM, Hess EP, et al. Predicting Risk of Endocarditis Using a Clinical Tool (PREDICT): Scoring System to Guide Use of Echocardiography in the Management of Staphylococcus aureus Bacteremia. Clin Infect Dis. 2015;61(1):18\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/cid/civ235\u003c/span\u003e\u003cspan address=\"10.1093/cid/civ235\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2015 Mar 25. PMID: 25810284; PMCID: PMC4542912.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhatib R, Sharma M. Echocardiography is dispensable in uncomplicated Staphylococcus aureus bacteremia. Med (Baltim). 2013;92(3):182\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MD.0b013e318294a710\u003c/span\u003e\u003cspan address=\"10.1097/MD.0b013e318294a710\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 23619238; PMCID: PMC4553989.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePigrau C, Rodr\u0026iacute;guez D, Planes AM, et al. Management of catheter-related Staphylococcus aureus bacteremia: when may sonographic study be unnecessary? Eur J Clin Microbiol Infect Dis. 2003;22(12):713\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10096-003-1041-0\u003c/span\u003e\u003cspan address=\"10.1007/s10096-003-1041-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2003 Nov 6. PMID: 14605943.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGow N, Lowe BS, Freeman J, Roberts S. The role of echocardiography in Staphylococcus aureus bacteraemia at Auckland City Hospital. N Z Med J. 2015;128(1416):28\u0026ndash;35. PMID: 26117673.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoseph JP, Meddows TR, Webster DP, et al. Prioritizing echocardiography in Staphylococcus aureus bacteraemia. J Antimicrob Chemother. 2013;68(2):444\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jac/dks408\u003c/span\u003e\u003cspan address=\"10.1093/jac/dks408\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2012 Oct 30. PMID: 23111851.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRasmussen RV, H\u0026oslash;st U, Arpi M, et al. Prevalence of infective endocarditis in patients with Staphylococcus aureus bacteraemia: the value of screening with echocardiography. Eur J Echocardiogr. 2011;12(6):414\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ejechocard/jer023\u003c/span\u003e\u003cspan address=\"10.1093/ejechocard/jer023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 21685200; PMCID: PMC3117467.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede la Buitron P, Tandon P, Qureshi W, et al. Simplified risk stratification criteria for identification of patients with MRSA bacteremia at low risk of infective endocarditis: implications for avoiding routine transesophageal echocardiography in MRSA bacteremia. Eur J Clin Microbiol Infect Dis. 2016;35(2):261\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10096-015-2539-y\u003c/span\u003e\u003cspan address=\"10.1007/s10096-015-2539-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2015 Dec 16. PMID: 26676855; PMCID: PMC4724372.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTubiana S, Duval X, Alla F, Selton-Suty C, et al. The VIRSTA score, a prediction score to estimate risk of infective endocarditis and determine priority for echocardiography in patients with Staphylococcus aureus bacteremia. J Infect. 2016;72(5):544\u0026ndash;53. Epub 2016 Feb 22. PMID: 26916042.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarton T, Moir S, Rehmani H, Woolley I, Korman TM, Stuart RL. Low rates of endocarditis in healthcare-associated Staphylococcus aureus bacteremia suggest that echocardiography might not always be required. Eur J Clin Microbiol Infect Dis. 2016;35(1):49\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10096-015-2505-8\u003c/span\u003e\u003cspan address=\"10.1007/s10096-015-2505-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 26490139.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Hal SJ, Mathur G, Kelly J, Aronis C, Cranney GB, Jones PD. The role of transthoracic echocardiography in excluding left sided infective endocarditis in Staphylococcus aureus bacteraemia. J Infect. 2005;51(3):218\u0026thinsp;\u0026ndash;\u0026thinsp;21. doi: 10.1016/j.jinf.2005.01.011. PMID: 16230219.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"blood cultures, defervescence, infective endocarditis, predetermined antibiotics, transesophageal echocardiogram, transthoracic echocardiogram","lastPublishedDoi":"10.21203/rs.3.rs-7042094/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7042094/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTransesophageal echocardiogram is the preferred imaging modality for definitive diagnosis of infective endocarditis. However, some cases don\u0026rsquo;t always necessitate its use, especially among non-surgical, clinically improving patients on antibiotics.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA preliminary retrospective cohort study was performed on 134 patients within a 2-hospital community-based health system from March 2024 to June 2024.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e68 were male (50.7%) and 66 were female (49.3%) with median age of 71 years.\u003c/span\u003e 41% of patients were treated with predetermined long-term antibiotics for infective endocarditis, and 71% of those were non-surgical candidates and clinically improving \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(defervesced in less than 3 days/remained afebrile and had resolving/resolved white blood count)\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTransesophageal echocardiogram use did not significantly change predetermined long-term antibiotic management among non-surgical, clinically improving patients. Predetermined long-term antibiotic treatment was found to be significantly associated with patients having a definitive infective endocarditis diagnosis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Repeat positive sets of blood cultures and failure to defervesce less than 3 days were shown to be significant clinical predictors of infective endocarditis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and p\u0026thinsp;=\u0026thinsp;0.015 respectively) and increased transesophageal echocardiography use (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and p\u0026thinsp;=\u0026thinsp;0.045 respectively).\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOverall, the study suggests that transesophageal echocardiography may not be necessary in non-surgically indicated clinically improving patients at risk for infective endocarditis, as management did not significantly change. However, if objective guidance is needed for transesophageal echocardiogram use, repeating positive blood cultures for gram positive organisms and failure to defervesce in less than 3 days may be useful.\u003c/span\u003e\u003c/p\u003e","manuscriptTitle":"Assessing Need for Transesophageal Echocardiography in Clinically Improving Patients at Risk for Infective Endocarditis: A Preliminary Retrospective Cohort Study in a Community Based Health System","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-25 17:43:11","doi":"10.21203/rs.3.rs-7042094/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"136157488051699060151070089868680385850","date":"2025-09-21T22:04:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152077516493071363215298252154024145722","date":"2025-09-17T11:34:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-12T11:22:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-02T19:23:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-17T12:35:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-17T01:52:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2025-07-17T01:48:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a83aeaae-1ba0-457f-81ea-5dcb0656e3f4","owner":[],"postedDate":"September 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-25T17:43:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-25 17:43:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7042094","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7042094","identity":"rs-7042094","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}