280 - Description of Transesophageal Echocardiography Prescribing Practices in non-Staphylococcus aureus Bacteremia with Application of Scoring Systems

Background: In non-S. aureus gram-positive bacteremia (non-SAB), practices of obtaining transesophageal echocardiography (TEE) are mixed despite the availability of scoring systems in certain organisms (DENOVA for E. faecalis, HANDOC for non-beta hemolytic streptococci) that provide recommendations for TEE with scores 3 or higher. This study aimed to analyze the application of DENOVA and HANDOC scoring systems to coagulase-negative Staphylococci (CoNS), Enterococcus spp. and Streptococcus spp. in relation to TEE prescribing practices.

Methods: A retrospective, observational study was conducted at two tertiary care hospitals including patients with ≥1 positive blood culture for Enterococcus spp. or Streptococcus spp., or ≥2 positive blood cultures for CoNS with matching susceptibilities between November 2017 and November 2019. The primary outcome compared DENOVA and HANDOC scores in patients who received TEE vs. those who did not. Secondary outcomes included DENOVA and HANDOC scores in subgroup populations, adherence to DENOVA/HANDOC scoring systems, treatment characteristics, and patient outcomes.

Results: Of the 310 patients included, 96 (31%) underwent TEE and 214 (69%) did not. Fewer patients in the TEE group underwent transthoracic echocardiography: 29.2% vs. 69.9%, p< 0.01. Infectious Diseases providers were involved in all patients that underwent TEE. Median scores were significantly higher in all patients who underwent TEE; DENOVA: 2 (1-3) vs. 1 (1-2), p< 0.01; HANDOC: 3 (3-4) vs. 3 (2-3), p< 0.01. DENOVA and HANDOC scores were significantly higher in the TEE group in Enterococcus spp. and Streptococcus spp., respectively; overall adherence to scoring system recommendations in these groups was less than 60%.  HANDOC score was higher in the TEE group for patients with CoNS and 87.5% of these patients with score ≥3 had endocarditis (versus 50% with DENOVA score). More patients in the TEE group had endocarditis 46.9% vs. 6.5%, p< 0.01.

Conclusion: DENOVA and HANDOC scores were significantly higher among TEE patients, but areas of improvement exist in relation to overutilization of TEE and development of scoring system for CoNS. Efforts to improve TEE utilization should be coordinated with Infectious Disease providers.