Real-world effectiveness of infection prevention interventions for reducing procedure-related cardiac device infections: Insights from the veterans affairs clinical assessment reporting and tracking program

An Approach to Cardiac Implantable Electronic Device Pocket Infections: From Prevention to Diagnosis and Management

Cardiac implantable electronic device (CIED) infections are a highly morbid and potentially fatal complication of CIED implantation. Prompt diagnosis is paramount to the proper management of such infections. This review seeks to highlight the pathophysiology, risk factors, diagnostic approach, and prevention strategies for CIED infection, with an emphasis on pocket infection. Management will be discussed in detail, with complete device removal representing the standard of case, but with conservative management representing a potential alternative for patients at high risk for extraction. The high prevalence of CIED in the cardiac population renders understanding of this subject essential for the practicing clinician.

The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation

INTRODUCTION

The International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety.

MATERIALS AND METHODS

Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant.

RESULTS

The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.

CONCLUSIONS

The NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

Cardiovascular implantable electronic device lead safety: Harnessing real-world remote monitoring data for medical device evaluation

BACKGROUND

Current methods to identify cardiovascular implantable electronic device lead failure include postapproval studies, which may be limited in scope, participant numbers, and attrition; studies relying on administrative codes, which lack specificity; and voluntary adverse event reporting, which cannot determine incidence or attribution to the lead.

OBJECTIVE

The purpose of this study was to determine whether adjudicated remote monitoring (RM) data can address these limitations and augment lead safety evaluation.

METHODS

Among 48,191 actively monitored patients with a cardiovascular implantable electronic device, we identified RM transmissions signifying incident lead abnormalities and, separately, identified all leads abandoned or extracted between April 1, 2019, and April 1, 2021. We queried electronic health record and Medicare fee-for-service claims data to determine whether patients had administrative codes for lead failure. We verified lead failure through manual electronic health record review.

RESULTS

Of the 48,191 patients, 1170 (2.4%) had incident lead abnormalities detected by RM. Of these, 409 patients had administrative codes for lead failure, and 233 of these 409 patients (57.0%) had structural lead failure verified through chart review. Of the 761 patients without administrative codes, 167 (21.9%) had structural lead failure verified through chart review. Thus, 400 patients with RM transmissions suggestive of lead abnormalities (34.2%) had structural lead failure. In addition, 200 patients without preceding abnormal RM transmissions had leads abandoned or extracted for structural failure, making the total lead failure cohort 600 patients (66.7% with RM abnormalities, 33.3% without). Patients with isolated right atrial or left ventricular lead failure were less likely to have lead replacement and administrative codes reflective of lead failure.

CONCLUSION

RM may strengthen real-world assessment of lead failure, particularly for leads where patients do not undergo replacement.

[Global and national trends in the evolution of infective endocarditis]

For the recent 20 years, substantial changes have occurred in all aspects of infectious endocarditis (IE), the evolution of risk factors, modernization of diagnostic methods, therapeutic and preventive approaches. The global trends are characterized by increased IE morbidity among people older than 65 who use intravenous psychoactive drugs. The epidemiological trend is represented by reduced roles of chronic rheumatic heart disease and congenital heart defects, increased proportion of IE associated with medical care, valve replacement, installation of intracardiac devices, and increased contribution of Staphylococcus spp. and Enterococcus spp. to the IE etiology. Additional visualization methods (fluorodeoxyglucose positron emission tomography with 18F-fludesoxyglucose (18F-FDG PET-CT), labeled white blood cell single-photon emission computed tomography (SPECT), and modernization of the etiological diagnostic algorithm for determining the true pathogen (immunochemistry, polymerase chain reaction, sequencing) also become increasingly important. The COVID-19 pandemic has also adversely contributed to the IE epidemiology. New prospects of treatment have emerged, such as bacteriophages, lysins, oral antibacterial therapy, minimally invasive surgical strategies (percutaneous mechanical aspiration), endovascular mechanical embolectomy. The physicians' compliance with clinical guidelines (CG) is low, which contributes to the high rate of adverse outcomes of IE, while simple adherence to the CG together with more frequent use of surgical treatment doubles survival. Systematic adherence to CG, timely prevention and implementation of the Endocarditis Team into practice play the decisive role in a favorable prognosis of dynamically changing IE. This article presents the authors' own data that confirm the evolutionary trends of current IE.

[Surgical basics of cardiac implantable electronic device implantation from skin incision through closure]

Implantation of pacemakers is generally considered a "minor intervention". Younger colleagues obtain their skills from experienced ones; ideally not just over the course of one or two interventions under surveillance but until a certain level of confidence is achieved. In Germany, certification is still optional. The German Cardiology Society (DSC, "Deutsche Gesellschaft für Kardiologie") provides expertise courses to obtain basic knowledge of pacemaker therapy; the GCS/GSCVS has been offering certification modules since 2013 to acquire fundamental knowledge from experts and basic technical skills by simulator training. The present article illustrates the major aspects of pacemaker implantation procedures and some avoidable pitfalls.

The utility of postoperative systemic antibiotic prophylaxis following cardiovascular implantable electronic device implantation: A systematic review and meta-analysis

BACKGROUND

There is insufficient evidence regarding postoperative systemic antibiotic prophylaxis use for more than 24 hours following cardiovascular implantable electronic devices (CIED) implantation and its impact on infection prevention. However, this strategy remains a common practice in many institutions.

METHODS

We conducted a systematic review and meta-analysis including studies that compared the outcomes of patients: 1) who received preoperative plus 24 hours or more of postoperative antibiotic prophylaxis (intervention group); and 2) who received either preoperative only or preoperative plus less than 24 hours of antibiotic prophylaxis (control group). Risk of bias was assessed with ROBINS-I and ROB-2 tools. Risk ratio (RR) was pooled using random-effect meta-analyses with inverse variance method.

RESULTS

Eight studies that included two randomized controlled trials (RCTs) and six cohort studies with a total of 26,187 patients were included in the analysis. Overall, there were no differences in outcomes between the two groups, which included rates of CIED infection (RR 0.77, 95% CI 0.42, 1.42), mortality (RR 1.19, 95% CI 0.69, 2.06), pocket hematoma (RR 1.15, 95% CI 0.44, 3.00) or reintervention (RR 0.87, 95% CI 0.22, 3.46). Of note, the results were primarily impacted by the larger RCT.

CONCLUSIONS

There was no benefit of postoperative antibiotic prophylaxis for more than 24 hours following CIED implantation in the current systematic review and meta-analysis. This supports the practice advocated by current guidelines which foster antibiotic stewardship and may result in reductions of adverse drug events, selection for antibiotic resistance, and financial costs of prolonged postoperative antibiotic prophylaxis. This article is protected by copyright. All rights reserved.

Epidemiology of infective endocarditis: novel aspects in the twenty-first century

INTRODUCTION

The epidemiology of infective endocarditis (IE) in this millennium has changed with emergence of new risk factors and reemergence of others. This, coupled with modifications in national guidelines in the setting of a pandemic, prompted an address of the topic.

AREAS COVERED

Our goal is to provide a contemporary review of IE epidemiology considering changing incidence of rheumatic heart disease (RHD), cardiac device implantation, and injection drug use (IDU), with SARS-CoV-2 pandemic as the backdrop.

METHODS

PubMed and Google Scholar were used to identify studies of interest.

EXPERT OPINION

Our experience over the past two decades verifies the notion that there is not one 'textbook' profile of IE. Multiple factors have dramatically impacted IE epidemiology, and these factors differ, based, in part on geography. RHD has declined in many areas of the world, whereas implanted cardiovascular devices-related IE has grown exponentially. Perhaps the most influential, at least in areas of the United States, is injection drug use complicating the opioid epidemic. Healthy younger individuals contracting a potentially life-threatening infection has been tragic. In the past year, epidemiological changes due to the COVID-19 pandemic have also occurred. No doubt, changes will characterize IE in the future and serial review of the topic is warranted.

Impact of Choice of Prophylaxis on the Microbiology of Cardiac Implantable Electronic Device Infections: Insights From the Prevention of Arrhythmia Device Infection Trial (PADIT)

Background

The Prevention of Arrhythmia Device Infection Trial (PADIT) investigated whether intensification of perioperative prophylaxis could prevent cardiac implantable electronic device (CIED) infections. Compared with a single dose of cefazolin, the perioperative administration of cefazolin, vancomycin, bacitracin, and cephalexin did not significantly decrease the risk of infection. Our objective was to compare the microbiology of infections between study arms in PADIT.

Methods

This was a post hoc analysis. Differences between study arms in the microbiology of infections were assessed at the level of individual patients and at the level of microorganisms using the Fisher exact test.

Results

Overall, 209 microorganisms were reported from 177 patients. The most common microorganisms were coagulase-negative staphylococci (CoNS; 82/209 [39.2%]) and S. aureus (75/209 [35.9%]). There was a significantly lower proportion of CoNS in the incremental arm compared with the standard arm (30.1% vs 46.6%; P = .04). However, there was no significant difference between study arms in the frequency of recovery of other microorganisms. In terms of antimicrobial susceptibility, 26.5% of microorganisms were resistant to cefazolin. CoNS were more likely to be cefazolin-resistant in the incremental arm (52.2% vs 26.8%, respectively; P = .05). However, there was no difference between study arms in terms of infections in which the main pathogen was sensitive to cefazolin (77.8% vs 64.3%; P = .10) or vancomycin (90.8% vs 90.2%; P = .90).

Conclusions

Intensification of the prophylaxis led to significant changes in the microbiology of infections, despite the absence of a decrease in the overall risk of infections. These findings provide important insight on the physiopathology of CIED infections.

Trial registration

NCT01002911.

Antimicrobial Resistance and Molecular Epidemiological Characteristics of Methicillin-Resistant and Susceptible Staphylococcal Isolates from Oral Cavity of Dental Patients and Staff in Northern Japan

The acquisition of drug resistance and virulence by staphylococcal species colonizing humans is a growing public health concern. The present study was conducted to investigate the prevalence, antimicrobial resistance and genetic characteristics of Staphylococcus isolates from the oral cavity and skin (hand) of systemically healthy subjects with dental disease and dental staff in northern Japan. Among a total of 133 subjects (91 patients and 42 staff), 87 coagulase-positive Staphylococcus (83 S. aureus/4 S. argenteus) and 162 coagulase-negative Staphylococcus (CoNS) isolates were recovered from 59 (44.4%) and 95 (71.4%) subjects, respectively. Three oral isolates were methicillin-resistant S. aureus (MRSA) (3.6%, 3/83) that were genotyped as ST8-SCCmec-IVl, ST4775(CC1)-SCCmec-IVa and ST6562(CC8)-SCCmec-IVa. Remarkably, the ST6562 isolate harbored PVL genes on ΦSa2usa and type I ACME (arginine catabolic mobile element). Four methicillin-susceptible isolates were identified as S. argenteus belonging to ST1223 and ST2250, which harbored enterotoxin genes egc-2 and sey, respectively. Among the fourteen CoNS species identified, methicillin-resistant (MR) isolates were detected in five species (11 isolates, 13.3% of CoNS), with S. saprophyticus and S. haemolyticus being the most common. ACME was prevalent in only S. epidermidis and S. capitis. These findings indicated the potential distribution of USA300 clone-like MRSA, toxigenic S. argenteus and MR-CoNS in the oral cavity of dental patients.

A Review of Cardiac Implantable Electronic Device Infections for the Practicing Electrophysiologist

Cardiovascular implantable electronic device (CIED) infections are morbid, costly, and difficult to manage. This review explores the pathophysiology, diagnosis, and management of CIED infections. Diagnostic accuracy has been improved through increased awareness and improved imaging strategies. Pocket or bloodstream infection with virulent organisms often requires complete system extraction. Emerging prophylactic interventions and novel devices have expanded preventative strategies and options for re-implantation. A clear and nuanced understanding of CIED infection is important to the practicing electrophysiologist.

Novel Method to Flag Cardiac Implantable Device Infections by Integrating Text Mining With Structured Data in the Veterans Health Administration's Electronic Medical Record

IMPORTANCE

Health care-associated infections (HAIs) are preventable, harmful, and costly; however, few resources are dedicated to infection surveillance of nonsurgical procedures, particularly cardiovascular implantable electronic device (CIED) procedures.

OBJECTIVE

To develop a method that includes text mining of electronic clinical notes to reliably and efficiently measure HAIs for CIED procedures.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter, national cohort study using electronic medical record data for patients undergoing CIED procedures in Veterans Health Administration (VA) facilities for fiscal years (FYs) 2016 and 2017, an algorithm to flag cases with a true CIED-related infection based on structured (eg, microbiology orders, vital signs) and free text diagnostic and therapeutic data (eg, procedure notes, discharge summaries, microbiology results) was developed and validated. Procedure data were divided into development and validation data sets. Criterion validity (ie, positive predictive validity [PPV], sensitivity, and specificity) was assessed via criterion-standard manual medical record review.

EXPOSURES

CIED procedure.

MAIN OUTCOMES AND MEASURES

The concordance between medical record review and the study algorithm with respect to the presence or absence of a CIED infection. CIED infection in the algorithm included 90-day mortality, congestive heart failure and nonmetastatic tumor comorbidities, CIED or surgical site infection International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes, antibiotic treatment of Staphylococci, a microbiology test of a cardiac specimen, and text documentation of infection in specific clinical notes (eg, cardiology, infectious diseases, inpatient discharge summaries).

RESULTS

The algorithm sample consisted of 19 212 CIED procedures; 15 077 patients (78.5%) were White individuals, 1487 (15.5%) were African American; 18 766 (97.7%) were men. The mean (SD) age in our sample was 71.8 (10.6) years. The infection detection threshold of predicted probability was set to greater than 0.10 and the algorithm flagged 276 of 9606 (2.9%) cases in the development data set (9606 procedures); PPV in this group was 41.4% (95% CI, 31.6%-51.8%). In the validation set (9606 procedures), at predicted probability 0.10 or more the algorithm PPV was 43.5% (95% CI, 37.1%-50.2%), and overall sensitivity and specificity were 94.4% (95% CI, 88.2%-97.9%) and 48.8% (95% CI, 42.6%-55.1%), respectively.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the method of combining structured and text data in VA electronic medical records can be used to expand infection surveillance beyond traditional boundaries to include outpatient and procedural areas.

Screening the nose, throat and the naso-pharynx for methicillin-resistant Staphylococcus aureus: a pilot study

Patients who carry nasal methicillin-resistant Staphylococcus aureus (MRSA) may also harbour MRSA in the oro-pharyngeal cavity. However, the naso-oro-pharyngeal co-carriage is infrequently assessed. The incidence of concurrent MRSA carriage of the naso-oro-pharynx was ascertained, and the sensitivity of two methods, a throat swab and a phosphate buffered saline (PBS) oral rinse, for MRSA detection was investigated. Among nasal MRSA carriers, 80% harboured MRSA in the oro-pharynx. Among these patients, 15% had MRSA detected in the oro-pharynx and not in the throat. Oro-pharyngeal colonisation represents a significant reservoir to persistence as well as nasal recolonisation. Decolonisation methods effective in reducing oro-pharyngeal MRSA in addition to nasal carriage should be investigated.

Factors influencing uptake of evidence-based antimicrobial prophylaxis guidelines for electrophysiology procedures

BACKGROUND

Clinical guidelines support early discontinuation of antimicrobials after cardiac device procedures; however, prolonged courses of antimicrobials are common.

METHODS

We conducted semistructured interviews with 13 electrophysiologists representing diverse geographic and clinical settings of care to identify perceived barriers and facilitators to discontinuing postprocedure antimicrobial prophylaxis as part of a formative evaluation prior to implementing a program to improve uptake of guideline recommendations. A directed content analysis approach was used to map responses to the Implementation Outcomes Framework.

RESULTS

Data indicated that electrophysiologists were not willing to stop postprocedural antimicrobials, indicating a lack of acceptability of clinical guidelines. Feasibility, fidelity, cost, and appropriateness were also frequently cited. Factors associated with prolonged antimicrobial prescribing included beliefs about lack of harm and possible benefit. There was a strong "cultural inertia" to conform to institutional normative practices. Reasons for conforming ranged from streamlining processes for clinical staff and concerns about being perceived as an "outlier."

CONCLUSIONS

Institutional culture and beliefs about consequences of cardiac device infections versus antimicrobial use appeared to be major drivers of current practice. The desire to promote institutional standardization suggests that strategies to enhance implementation of prophylaxis guidelines must include facility-level changes, rather than interventions directed only at individual-providers.

Development and Validation of a Semi-Automated Surveillance Algorithm for Cardiac Device Infections: Insights from the VA CART program

Procedure-related cardiac electronic implantable device (CIED) infections have high morbidity and mortality, highlighting the urgent need for infection prevention efforts to include electrophysiology procedures. We developed and validated a semi-automated algorithm based on structured electronic health records data to reliably identify CIED infections. A sample of CIED procedures entered into the Veterans' Health Administration Clinical Assessment Reporting and Tracking program from FY 2008-2015 was reviewed for the presence of CIED infection. This sample was then randomly divided into training (2/3) validation sets (1/3). The training set was used to develop a detection algorithm containing structured variables mapped from the clinical pathways of CIED infection. Performance of this algorithm was evaluated using the validation set. 2,107 unique CIED procedures from a cohort of 5,753 underwent manual review; 97 CIED infections (4.6%) were identified. Variables strongly associated with true infections included presence of a microbiology order, billing codes for surgical site infections and post-procedural antibiotic prescriptions. The combined algorithm to detect infection demonstrated high c-statistic (0.95; 95% confidence interval: 0.92-0.98), sensitivity (87.9%) and specificity (90.3%) in the validation data. Structured variables derived from clinical pathways can guide development of a semi-automated detection tool to surveil for CIED infection.

Novel methodology to measure pre-procedure antimicrobial prophylaxis: integrating text searches with structured data from the Veterans Health Administration's electronic medical record

Background

Antimicrobial prophylaxis is an evidence-proven strategy for reducing procedure-related infections; however, measuring this key quality metric typically requires manual review, due to the way antimicrobial prophylaxis is documented in the electronic medical record (EMR). Our objective was to electronically measure compliance with antimicrobial prophylaxis using both structured and unstructured data from the Veterans Health Administration (VA) EMR. We developed this methodology for cardiac device implantation procedures.

Methods

With clinician input and review of clinical guidelines, we developed a list of antimicrobial names recommended for the prevention of cardiac device infection. We trained the algorithm using existing fiscal year (FY) 2008–15 data from the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP), which contains manually determined information about antimicrobial prophylaxis. We merged CART-EP data with EMR data and programmed statistical software to flag an antimicrobial orders or drug fills from structured data fields in the EMR and hits on text string searches of antimicrobial names documented in clinician’s notes. We iteratively tested combinations of these data elements to optimize an algorithm to accurately classify antimicrobial use. The final algorithm was validated in a national cohort of VA cardiac device procedures from FY2016–2017. Discordant cases underwent expert manual review to identify reasons for algorithm misclassification.

Results

The CART-EP dataset included 2102 procedures at 38 VA facilities with manually identified antimicrobial prophylaxis in 2056 cases (97.8%). The final algorithm combining structured EMR fields and text note search results correctly classified 2048 of the CART-EP cases (97.4%). In the validation sample, the algorithm measured compliance with antimicrobial prophylaxis in 16,606 of 18,903 cardiac device procedures (87.8%). Misclassification was due to EMR documentation issues, such as antimicrobial prophylaxis documented only in hand-written clinician notes in a format that cannot be electronically searched.

Conclusions

We developed a methodology with high accuracy to measure guideline concordant use of antimicrobial prophylaxis before cardiac device procedures using data fields present in modern EMRs. This method can replace manual review in quality measurement in the VA and other healthcare systems with EMRs; further, this method could be adapted to measure compliance in other procedural areas where antimicrobial prophylaxis is recommended.