202 Chapter 9 the hypervirulent USA300 MRSA clone were similar among the two sexes despite the higher rates of MRSA infection in women overall. Although transthoracic echocardiography use was similar between sexes, TEE was performed significantly less often in female than male patients, a finding that is consistent with previous reports [32,33]. Furthermore, a shorter median duration of antibiotics was prescribed in female compared with male patients. It is unclear whether these differences reflect a sex-driven bias in management or simply the fact that men in our study had higher rates of metastatic infection, and thus more often a true indication for TEE and prolonged therapy. Alternately, it is also possible that the higher rate of metastatic infection identified in male patients may reflect the higher rate of diagnostic testing with TEE and other modalities. A limitation of our study is the setting: a single academic centre in a region with high MRSA prevalence, making the results less generalizable to some other settings. Our study could have been underpowered to detect a small sex difference. A large meta-analysis would be helpful to determine smaller differences. Also, only the first episode of bacteraemia was considered; therefore, a bias towards less severe SAB is possible. Another potential limitation is the long period of time during which the study was conducted, starting back in the nineties. Awareness of sex differences has increased over the years in many medical fields. However, because we found consistent results on sex differences in all time periods, this does not seem to be of important influence in our study. The increasing overall mortality over time is remarkable, and we hypothesize that the increasing tertiary care function of Duke University Hospital and the introduction of informed consent, which provides the possibility for patients to refuse participation, may be contributing factors. Finally, although sex assigned at birth was reported in the SABG-PCS, gender was not. People assigned female at birth and people identifying as women may comprise clinically distinct populations with different effects on health [12,34]. In conclusion, significant differences between females and males exist in patient, disease and management characteristics of SAB. Whereas some differences may be because of fixed biological distinctions or can be explained by different disease manifestations, others warrant further research to determine whether a sex-driven bias exists. Despite the multiple differences, women and men in this large cohort of patients with SAB have a similar mortality risk.
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