Reply to Naucler and Berge

TO THE EDITOR—We thank Dr Naucler and Dr Berge for their interest in our study [1]. They have raised interesting questions regarding our publication, and we provide the following responses [2]. The first question is about the utility of a 2-staged algorithm for the use of transesophageal echocardiography (TEE) in patients with Staphylococcus aureus bacteremia (SAB). We designed the 2-stage algorithm with the following rationale. Day 1 score is designed to have a higher specificity at the expense of sensitivity, as the goal of an initial TEE is to identify high-risk patients in whom TEE could potentially identify complications that may necessitate early surgical intervention. Dr Naucler and Dr Berge are correct that we assumed that the sensitivity of TEE is influenced by the time from onset of bacteremia. Even though the timing of TEE in patients with SAB is unclear, there is a concern that if TEE is performed too early in the clinical presentation, one could potential miss cases of infective endocarditis [3]. Day 5 score is designed to have higher sensitivity at the expense of specificity. For patients with day 1 score of <4, it would be wise to defer TEE until day 5. TEE is recommended 5–7 days after the onset of bacteremia to minimize false negative results [4]. Even in patients who undergo early TEE, many experts and guidelines recommend performing repeat TEE in 7–10 days if initial TEE is negative and clinical suspicion persists [4]. The second question is to clarify how the 2-staged algorithm is influenced by the removal of cardiovascular implantable electronic device (CIED). In our institution, intraoperative TEE is performed after removal of CIED. If TEE is negative and a patient continues to have persistent bacteremia, repeat TEE is performed.