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Trump T, Mitchell K, Werner Z, Duenas-Garcia O, Shapiro R, Zaslau S. Assessing the effectiveness of antimicrobial pouch use for infection prevention in sacral neuromodulation. Int Urogynecol J 2023; 34:2513-2517. [PMID: 37222739 DOI: 10.1007/s00192-023-05570-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/22/2023] [Indexed: 05/25/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Sacral neuromodulation (SNM) is a commonly performed procedure for various conditions. Infection rates range as high as 10% and often require operative explantation with resultant increased cost and morbidity. Pouches impregnated with antibiotic have been utilized in cardiovascular procedures with decreasing infectious complications. TYRX is an antibiotic pouch utilizing minocycline and rifampin manufactured by Medtronic. The objective of this study is to investigate the utility of antimicrobial pouches for patients undergoing SNM. METHODS We retrospectively analyzed our patients undergoing SNM using an antimicrobial pouch and compared them with a historic cohort. Additional variables of interest included post-operative infection, diagnosis of diabetes, weight, and revision case or virgin implant. RESULTS A total of 170 cases were identified, ranging from March 2017 to November 2022. Overall infection rate was 2.9% with 0 in the antimicrobial pouch cohort (0%) versus 5 in the historic cohort (5.5%; p = 0.04). Groups were similar in terms of body habitus. The group receiving an antimicrobial pouch was noted to be older with a higher percentage of female patients. 85 patients received an antimicrobial pouch and 85 did not. Of the infections, 4 occurred in revision cases (6.9%) and 1 in a virgin implant (0.9%; p = 0.03). No difference was noted in infection rate with regard to a diagnosis of diabetes or body habitus. CONCLUSION The use of antimicrobial pouches in SNM is associated with a decreased rate of infectious complications. Revision cases displayed a higher rate of infectious complications.
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Affiliation(s)
- Tyler Trump
- Department of Urology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506, USA.
| | - Katharina Mitchell
- Department of Urology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506, USA
| | - Zachary Werner
- Department of Urology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506, USA
| | - Omar Duenas-Garcia
- Department of Obstetrics and Gynecology, West Virginia University, Morgantown, WV, USA
| | - Robert Shapiro
- Department of Obstetrics and Gynecology, West Virginia University, Morgantown, WV, USA
| | - Stanley Zaslau
- Department of Urology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506, USA
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Senaratne JM, Wijesundera J, Chhetri U, Beaudette D, Sander A, Hanninen M, Gulamhusein S, Senaratne M. Reduced incidence of CIED infections with peri- and post-operative antibiotic use in CRT-P/D and ICD procedures. Medicine (Baltimore) 2022; 101:e30944. [PMID: 36221436 PMCID: PMC9542667 DOI: 10.1097/md.0000000000030944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Higher cardiac implantable electronic device (CIED) infection incidence has been observed with cardiac resynchronization therapy pacemaker/defibrillator (CRT-P/D) and implantable cardioverter defibrillator (ICD) devices compared to traditional pacemakers with a 1.2% rate reported at 1 year. CIED infection management has high morbidity/mortality. A previous study from this institution demonstrated significantly reduced CIED infection rate when peri/post-operative antibiotics were given for traditional pacemaker procedures. The present study examines CIED infection incidence following peri/post-operative antibiotics during CRT-P/D and ICD procedures. All patients who underwent CRT-P/D and ICD procedures from 1996 to 2015 received IV cephalexin/clindamycin pre- and 8-hours post-procedure followed by 5 days of oral therapy. There were 427 procedures (CRT-P = 146 (34.2%); CRT-D = 142 (33.3%); ICD = 139 (32.6%)). Mean age at time of procedure was 61.6 years. Mean follow-up duration was 4.26 years. CIED infection occurred in 6 patients (ICD = 4, CRT-P = 1, CRT-D = 1), amounting to a rate of 4.96/1000 device-years in total. Times to CIED infection from procedure were: 1.7, 3.5, 6.7, 7.3, 7.9 and 9.2 years. Five out of 6 infections occurred in patients with repeat procedures. This study demonstrates that administration of peri- followed by post-operative antibiotics during CRT-P/D and ICD procedures is associated with a very low rate of CIED infection. This rate of 4.96 infections per 1000 device-years compares favorably to contemporary rates of 8.9 infections per 1000 device-years. Most CIED infections occur late and well-beyond the 1-year follow-up of the Prevention of Arrhythmia Device Infection Trial, the largest trial on this question. This approach should be considered pending a definitive trial.
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Affiliation(s)
- Janek Manoj Senaratne
- Division of Cardiology, University of Alberta, Edmonton, Canada
- Division of Cardiology, Grey Nuns Hospital, Edmonton, Canada
- Department of Medicine, University of Alberta, Edmonton, Canada
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
- * Correspondence: Janek Senaratne, Department of Medicine, University of Alberta, 2939-66 Street NW, Edmonton, AB T6K 4C1, Canada (e-mail: )
| | | | - Usha Chhetri
- Division of Cardiology, Grey Nuns Hospital, Edmonton, Canada
| | - Diane Beaudette
- Division of Cardiology, Grey Nuns Hospital, Edmonton, Canada
| | - Andrea Sander
- Division of Cardiology, Grey Nuns Hospital, Edmonton, Canada
| | - Mike Hanninen
- Division of Cardiology, Grey Nuns Hospital, Edmonton, Canada
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Mano Senaratne
- Division of Cardiology, Grey Nuns Hospital, Edmonton, Canada
- Department of Medicine, University of Alberta, Edmonton, Canada
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Chesdachai S, Go JR, Hassett LC, Baddour LM, DeSimone DC. The utility of postoperative systemic antibiotic prophylaxis following cardiovascular implantable electronic device implantation: A systematic review and meta-analysis. Pacing Clin Electrophysiol 2022; 45:940-949. [PMID: 35819103 DOI: 10.1111/pace.14561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/08/2022] [Accepted: 06/26/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Supavit Chesdachai
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John R Go
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Larry M Baddour
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel C DeSimone
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
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Almonte M, Huston T, Yee SL, Karimaei R, Hort A, Rawlins M, Seet J, Nizich Z, McLellan D, Stobie P, Czarniak P, Chalmers L. Adherence to antimicrobial prophylaxis guidelines in cardiac implantable electronic device procedures in two Australian teaching hospitals. AUST HEALTH REV 2021; 45:761-770. [PMID: 34470697 DOI: 10.1071/ah21046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/25/2021] [Indexed: 11/23/2022]
Abstract
Objective This study investigated antibiotic prophylaxis (AP) guideline adherence and the cardiac implantable electronic device (CIED) infection rate in two major Australian public teaching hospitals. Methods In a retrospective observational study, the medical records of patients who underwent CIED procedures between January and December 2017 were reviewed (Hospital A, n = 400 procedures; Hospital B, n = 198 procedures). Adherence to AP guidelines was assessed regarding drug, dose, timing, route and frequency. Infection was identified using follow-up documentation. Results AP was administered in 582 of 598 procedures (97.3%). Full guideline adherence was observed in 33.9% of procedures (203/598) and differed significantly between Hospitals A and B (47.3% vs 7.1%, respectively; P < 0.001). Common reasons for non-adherence were the timing of administration (42.3% vs 60.6% non-adherent in Hospitals A and B, respectively; P < 0.001) and repeat dosing (19.3% vs 78.8% non-adherent in Hospitals A and B, respectively; P < 0.001). Twenty infections were identified over 626.6 patient-years of follow-up (mean (±s.d.) follow-up 1.0 ± 0.3 years). The infection rate was 3.19 per 100 patient-years (P = 0.99 between hospitals). Two devices were removed due to infection; no patients died from CIED infection. Conclusions Although the rate of serious CIED infection was low, there was evidence of highly variable and suboptimal antibiotic use, and potential overuse of AP. What is known about the topic? Previous Australian studies have revealed high rates of inappropriate surgical AP. CIED infections are potentially life threatening, but can be avoided through effective use of AP. However, prolonged durations of AP in this setting may also result in complications, including Clostridioides difficile infection. What does this paper add? This study, the first to our knowledge to focus specifically on adherence to Australian guidelines for AP in CIED procedures, highlighted several common issues between AP in this setting and surgical and procedural AP more broadly. 'Early' and 'late' dose administration and extended post-procedural AP were common. Only 34% of prescriptions fully adhered to the guidelines; practices varied significantly between the two hospitals. What are the implications for practitioners? There is a clear need for institution-specific antimicrobial stewardship strategies to optimise AP in CIED procedures, aligned with the Antimicrobial Stewardship Clinical Care Standard. Patients are being placed at potentially avoidable risk of both complications of extended durations of AP and CIED infection, although the rate of serious CIED infection was low. A standardised approach to surveillance of CIED infections and prospective multisite audits of AP in CIED procedures using a validated tool, such as the Surgical National Antimicrobial Prescribing Survey, are recommended to better inform evidence-based practice. Potential strategies to optimise guideline adherence include prescribing support in patients with immediate penicillin hypersensitivity or methicillin-resistant Staphylococcus aureus colonisation, optimising the in-patient location of drug administration to promote timely dosing, limiting inappropriate post-procedural prophylaxis and routine S. aureus screening and decolonisation.
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Affiliation(s)
- Monique Almonte
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia. ; ; ; ; and Present address: Northlands Pharmacy, Balcatta, WA, Australia
| | - Taylor Huston
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia. ; ; ; ; and Present address: TerryWhite Chemmart Leeming, Leeming, WA, Australia
| | - Sok Ling Yee
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia. ; ; ; ; and Present address: Pharmacy Alliance, Albany, WA, Australia
| | - Roya Karimaei
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia. ; ; ; ; and Present address: Pharmacy 777 Lynwood, Lynwood, WA, Australia
| | - Adam Hort
- Pharmacy Department, Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, WA, Australia. ;
| | - Matthew Rawlins
- Pharmacy Department, Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, WA, Australia. ;
| | - Jason Seet
- Pharmacy Department, Sir Charles Gairdner Hospital, North Metropolitan Health Service, Nedlands, WA, Australia. ;
| | - Zachiah Nizich
- Pharmacy Department, Sir Charles Gairdner Hospital, North Metropolitan Health Service, Nedlands, WA, Australia. ;
| | - Duncan McLellan
- Infectious Diseases Department, Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, WA, Australia.
| | - Paul Stobie
- Department of Cardiovascular Medicine, North Metropolitan Health Service, Nedlands, WA, Australia.
| | - Petra Czarniak
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia. ; ; ; ; and Present address: Curtin Medical School, Curtin University, Bentley, WA, Australia.
| | - Leanne Chalmers
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia. ; ; ; ; and Present address: Curtin Medical School, Curtin University, Bentley, WA, Australia. ; and Corresponding author.
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Feng XF, Yang LC, Tan LZ, Li YG. Risk factor analysis of device-related infections: value of re-sampling method on the real-world imbalanced dataset. BMC Med Inform Decis Mak 2019; 19:185. [PMID: 31511006 PMCID: PMC6737640 DOI: 10.1186/s12911-019-0899-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 08/20/2019] [Indexed: 12/05/2022] Open
Abstract
Background The incidence of cardiac implantable electronic device infection (CIEDI) is low and usually belongs to the typical imbalanced dataset. We sought to describe our experience on the management of the imbalanced CIEDI dataset. Methods Database from two centers of patients undergoing device implantation from 2001 to 2016 were reviewed retrospectively. Re-sampling technique was used to improve the classifier accuracy. Results CIEDI was identified in 28 out of 4959 procedures (0.56%); a high imbalance existed in the sizes of the patient profiles. In univariate analyses, replacement procedure and male were significantly associated with an increase in CIEDI: (53.6% vs. 23.4, 0.8% vs. 0.3%, P < 0.01). Multivariate logistic regression analysis showed that gender (odds ratio, OR = 3.503), age (OR = 1.032), replacement procedure (OR = 3.503), and use of antibiotics (OR = 0.250) remained as independent predictors of CIEDI (all P < 0.05) after adjustment for diabetes, post-operation fever, and device style, device company. There were 616 under-sampled cases and 123 over-sampled cases in the analyzed cohort after re-sampling. The re-sampling and bootstrap results were robust and largely like the analysis results prior re-sampling method, while use of antibiotics lost the predicting capacity for CIEDI after re-sampling technique (P > 0.05). Conclusion The application of re-sampling techniques can generate useful synthetic samples for the classification of imbalanced data and improve the accuracy of predicting efficacy of CIEDI. The peri-operative assessment should be intensified in male and aged patients as well as patients receiving replacement procedures for the risk of CIEDI.
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Affiliation(s)
- Xiang-Fei Feng
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665#, KongJiang Road, Shanghai, 200092, China.
| | - Ling-Chao Yang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665#, KongJiang Road, Shanghai, 200092, China
| | - Li-Zhuang Tan
- School of Electronics and Information Engineering, Beijing Jiaotong University, Beijing, China
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665#, KongJiang Road, Shanghai, 200092, China.
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6
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Kabulski GM, Northup A, Wiggins BS. Postoperative Antibiotic Prophylaxis Following Cardiac Implantable Electronic Device Placement. J Innov Card Rhythm Manag 2019; 10:3777-3784. [PMID: 32477744 PMCID: PMC7252755 DOI: 10.19102/icrm.2019.100804] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/19/2019] [Indexed: 02/01/2023] Open
Abstract
Infections related to cardiac implantable electronic device (CIED) placement are associated with poor clinical outcomes. As such, preprocedural prophylactic antibiotic therapy is indicated for all patients prior to device insertion. However, the available data are less clear on the impact of postprocedural antibiotic therapy on rates of CIED infection when used in addition to preprocedural therapy. This is single-center, retrospective cohort study of 913 patients who underwent CIED-related procedures between October 2010 and August 2014 sought to compare the rate of CIED infections in patients receiving only preprocedural antibiotics with those receiving both preprocedural and postprocedural antibiotics. Univariate analysis was used to detect independent risk factors for CIED infection. After excluding patients receiving concomitant antibiotics for other conditions, those undergoing CIED extraction alone, and those with a lack of follow-up data and/or adequate documentation of clinical encounters, 569 patients were identified for inclusion in the final analysis. The majority of patients who received postprocedural antibiotics received three to five days of therapy, with the most common antibiotic used being cephalexin. There was no statistically significant difference in the incidence of infection between patients who did and did not receive postoperative antibiotics (4.5% versus 6.1%; p = 0.398). In a multivariate analysis, the use of postprocedural antibiotic therapy was not a significant risk factor for infection (adjusted odds ratio: 0.692; 95% confidence interval: 0.314–1.525; p = 0.361). It is therefore reasonable to withhold prescribing postoperative antibiotics in patients following CIED implantation. Individualized risk factor evaluation of patient comorbidities and procedural characteristics may be needed to aid in determining whether postoperative antibiotics are reasonable in different patients. The validity of these findings is contingent on further confirmation via a prospective, randomized clinical trial.
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Affiliation(s)
- Galen M Kabulski
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA.,College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Amanda Northup
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Barbara S Wiggins
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA.,College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
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Abstract
BACKGROUND AND OBJECTIVES Due to the widespread indications for device implants and the population aging, right-sided infective endocarditis (RSIE) epidemiology has dramatically changed, being nowadays, cardiac device carriers the main affected group. The aim of this work is to describe the epidemiology, clinical profile and outcomes of RSIE in cardiac device carriers. PATIENTS AND METHODS We included definitive infective endocarditis episodes consecutively diagnosed in 3 tertiary centers from March 1995 to September 2014. A retrospective analysis of 85 variables, one-year follow up and univariate analysis of in-hospital mortality was conducted. RESULTS Among 1,182 episodes, 100 cardiac device carriers presented with RSIE (8.5%). Mean age±SD was 67±14 years. Staphylococcus spp. were the main causative microorganisms (coagulase-negative 44%, aureus 31%) and 37% were methicillin-resistant. Cardiac devices were removed in 95% of patients. In-hospital mortality was 8% and one-year mortality was 4%. Univariate analysis demonstrated that renal failure at admission (OR 6.2; 95% CI 1.3-30.3), septic shock (OR 8.9; 95% CI 1.7-47.9) and persistent infection during clinical course (OR 19.4; 95% CI 3-125.7) increase in-hospital mortality while device removal is a protective factor (OR 0.08; 95% CI 0.02-0.39). CONCLUSIONS RSIE have low in-hospital and one-year mortality. Coagulase-negative Staphylococci is responsible of almost half of the episodes and methicillin-resistant incidence is high. Device removal is mandatory since it decreases in-hospital mortality.
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Lee C, Pizarro-Berdichevsky J, Clifton MM, Vasavada SP. Sacral Neuromodulation Implant Infection: Risk Factors and Prevention. Curr Urol Rep 2017; 18:16. [PMID: 28224396 DOI: 10.1007/s11934-017-0663-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Device infection is one of the most common complications of sacral nerve stimulator placement and occurs in approximately 3-10% of cases. Infection is a serious complication, as it often requires complete explantation of the device. Not much is known regarding risk factors for and methods of preventing infection in sacral nerve stimulation. Multiple risk factors have been linked to device infection including prolonged percutaneous testing and choice of preoperative antibiotic. Methods of infection prevention have also been studied recently, including antibiotic-impregnated collage and type of skin preparation. This review will discuss the recent literature identifying risk factors and means of preventing infection in sacral nerve stimulation. Finally, we will outline a protocol we have enacted at our institution which has resulted in an incidence of infection of 1.6%.
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Affiliation(s)
- Calvin Lee
- Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Javier Pizarro-Berdichevsky
- Department of Urology, Cleveland Clinic Foundation, Q10-1, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
- Urogynecology Unit, Hospital Dr. Sotero del Rio, Santiago, Chile
- Division de Obstetricia y Ginecologia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Marisa M Clifton
- Department of Urology, Cleveland Clinic Foundation, Q10-1, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Sandip P Vasavada
- Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
- Department of Urology, Cleveland Clinic Foundation, Q10-1, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Palraj BR, Farid S, Sohail MR. Strategies to prevent infections associated with cardiovascular implantable electronic devices. Expert Rev Med Devices 2017; 14:371-381. [PMID: 28434261 DOI: 10.1080/17434440.2017.1322506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Infections involving cardiovascular implantable electronic devices (CIED) are associated with high morbidity and mortality and substantial financial cost. In the past two decades, the rate of CIED infections has increased disproportionate to the number of devices implanted, likely due to aging patient population with multiple comorbidities. Microbial contamination of the generator pocket and or leads by skin flora at the time of implantation is a major mechanism for early CIED infections. Due to resistance to host immune cells and antibiotics caused by biofilm formation, complete removal of the device generator and leads is required to achieve cure. Areas covered: In this manuscript, we review the published literature regarding epidemiology, risk factors, and pathogenesis of CIED infections with primary focus on the preventative strategies to reduce the incidence of device infections. Expert commentary: Strict adherence to infection control measures at the time of CIED implantation is critical in reducing the risk of device infection while adjunctive strategies such as use of antimicrobial envelopes might help in certain high-risk individuals. Technological advances in device manufacturing with availability of subcutaneous devices without transvenous leads and self-contained intracardiac devices without leads and generator show promise with lower risk of infection.
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Affiliation(s)
- Bharath Raj Palraj
- a Divisions of Infectious Diseases, Department of Medicine , Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - Saira Farid
- a Divisions of Infectious Diseases, Department of Medicine , Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - M Rizwan Sohail
- a Divisions of Infectious Diseases, Department of Medicine , Mayo Clinic College of Medicine and Science , Rochester , MN , USA.,b Department of Cardiovascular Diseases , Mayo Clinic College of Medicine and Science , Rochester , MN , USA
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Manolis AS, Melita H. Prevention of Cardiac Implantable Electronic Device Infections: Single Operator Technique with Use of Povidone-Iodine, Double Gloving, Meticulous Aseptic/Antiseptic Measures and Antibiotic Prophylaxis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:26-34. [PMID: 27996097 DOI: 10.1111/pace.12996] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/05/2016] [Accepted: 12/11/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cardiac implantable electronic device (CIED) implantation is complicated by infection still at a worrisome rate of 2-5%. Since early on during device implantation procedures, we have adopted an infection-preventive technique which has hitherto resulted in effective prevention of infections. Herein we present our results of applying this technique by a single operator in a prospective series of 762 consecutive patients undergoing device implantation. METHODS A meticulous search for and treatment of active, occult, or smoldering infection was undertaken preoperatively. An aseptic/antiseptic technique was used for implantation of each device. Skin preparation is thorough with initial cleansing performed with alcohol followed by povidone-iodine 10% solution, which is also used in the wound and inside the pocket. In addition, we routinely use double gloving, and IV antibiotic prophylaxis 1 hour before and for 48 hours afterwards followed by oral antibiotic for 2-3 days after discharge. The skin is closed with absorbable sutures. The study includes 382 patients having a new pacemaker (n = 333) or battery change, system upgrade or lead revision (n = 49), and 380 patients having a new implantable cardioverter-defibrillator (ICD) (n = 296) or device replacement/upgrade/lead revision (n = 84). RESULTS The pacemaker group, aged 70.2 ± 16.5 years, includes 18% VVI, 49% DDD, 29% VDD, and 4% cardiac resynchronization therapy (CRT) devices. The ICD group, aged 61.3 ± 13.0 years, with a mean ejection fraction of 36 ± 13%, includes 325 ICD and 55 CRT implants. Over 26.6 ± 33.4 months for the pacemaker group and 36.6 ± 38.3 months for the ICD group, infection occurred in one patient in each group (0.26%) having a device replacement. CONCLUSION A consistent and strict approach of aseptic/antiseptic technique with the use of double gloving and povidone-iodine solution within the pocket plus a 4-day regimen of antibiotic prophylaxis minimizes infections in CIED implants.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Helen Melita
- Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
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11
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LAKSHMANADOSS UMASHANKAR, NUANEZ BONITA, KUTINSKY ILANA, KHALID RIZWAN, HAINES DAVIDE, WONG WAISHUN. Incidence of Pocket Infection Postcardiac Device Implantation Using Antibiotic versus Saline Solution for Pocket Irrigation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:978-84. [DOI: 10.1111/pace.12920] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 07/11/2016] [Accepted: 07/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - BONITA NUANEZ
- Oakland University William Beaumont School of Medicine; Rochester Michigan
| | - ILANA KUTINSKY
- Department of Cardiology; Beaumont Health; Royal Oak Michigan
| | - RIZWAN KHALID
- Department of Cardiology; University of Rochester Medical Center; Rochester New York
| | - DAVID E HAINES
- Department of Cardiology; Beaumont Health; Royal Oak Michigan
| | - WAI SHUN WONG
- Department of Cardiology; Beaumont Health; Royal Oak Michigan
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12
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Tarakji KG, Ellis CR, Defaye P, Kennergren C. Cardiac Implantable Electronic Device Infection in Patients at Risk. Arrhythm Electrophysiol Rev 2016; 5:65-71. [PMID: 27403296 DOI: 10.15420/aer.2015.27.2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The incidence of infection following implantation of cardiac implantable electronic devices (CIEDs) is increasing at a faster rate than that of device implantation. Patients with a CIED infection usually require hospitalisation and complete device and lead removal. A significant proportion die from their infection. Transvenous lead extraction (TLE) is associated with rare but serious complications including major vascular injury or cardiac perforation. Operator experience and advances in lead extraction methods, including laser technology and rotational sheaths, have resulted in procedures having a low risk of complication and mortality. Strategies for preventing CIED infections include intravenous antibiotics and aseptic surgical techniques. An additional method to reduce CIED infection may be the use of antibacterial TYRX™ envelope. Data from non-randomised cohort studies have indicated that antibacterial envelope use can reduce the incidence of CIED infection by more than 80 % in high-risk patients and a randomised clinical trial is ongoing.
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Affiliation(s)
| | - Christopher R Ellis
- Vanderbilt Heart and Vascular Institute at Vanderbilt University, Nashville, Tennessee, US
| | - Pascal Defaye
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
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Korantzopoulos P, Sideris S, Dilaveris P, Gatzoulis K, Goudevenos JA. Infection control in implantation of cardiac implantable electronic devices: current evidence, controversial points, and unresolved issues. Europace 2016; 18:473-478. [DOI: 10.1093/europace/euv260] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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