New Tool Guides Echocardiography Decision-Making in Bacteremia

Ultrasound machine
Ultrasound machine
Echocardiography is used to diagnose infective endocarditis, but it is not known which patients with non-beta-hemolytic streptococci bacteremia should undergo echocardiography.

Among patients with non-beta-hemolytic streptococci bacteremia, a new screening measure, the HANDOC score (heart murmur or auscultation, [a]etiology, number of cultures, duration of symptoms, only 1 species, and community-acquired infection), was created and validated to identify patients with a low risk for infectious endocarditis, allowing echocardiography to be omitted, according to the results of research published in Clinical Infectious Diseases.

In a retrospective chart review, 1 cohort of patients (n=339) with non-beta-hemolytic streptococci bacteremia were evaluated to determine factors predictive of infective endocarditis. The HANDOC score was developed using these data and was validated in a second cohort of patients (n=399) with non-beta-hemolytic streptococci bacteremia.

Among the 339 patients in the first cohort, 26 cases of infective endocarditis were identified, and 197 cases could be excluded.

The researchers found that the following factors could discriminate between cases of infective endocarditis and cases without: the presence of heart murmur or valve disease; etiology of Streptococcus mutans, S bovis, S sanguinis, or S anginosus; ≥2 positive blood cultures; ≥7 days of symptoms; single species growing in blood cultures; and community-acquired infection. These factors were combined to form the HANDOC score.

In the first cohort, a cut-off between 2 and 3 points had a sensitivity of 100% and specificity of 73%. In the second cohort, the sensitivity was 100% and the specificity was 76%.

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In an interview with Infectious Disease Advisor, Torgny Sunnerhagen, doctoral student in the Division of Infection Medicine at Lund University in Sweden, and lead author on the study, explained that the study results were important “because until now, there has been no systematic way of deciding whether or not to perform infective endocarditis investigations in cases of bacteremia with non-beta-hemolytic streptococci, leaving it up to the attending physician.”

He concluded that “a prospective study, possibly in a different setting, would be of great value for evaluating the HANDOC score in clinical practice.”


Sunnerhagen T, Törnell A, Vikbrant M, Nilson B, Rasmussen M. HANDOC – a handy score to determine the need for echocardiography in non-beta-hemolytic streptococcal bacteremia [published online October 10, 2017]. Clin Infect Dis. doi: 10.1093/cid/cix880