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Maclean E, Mahtani K, Honarbakhsh S, Butcher C, Ahluwalia N, Dennis AS, Creta A, Finlay M, Elliott M, Mehta V, Wijesuriya N, Shaikh O, Zaw Y, Ogbedeh C, Gautam V, Lambiase PD, Schilling RJ, Earley MJ, Moore P, Muthumala A, Sporton SC, Hunter RJ, Rinaldi CA, Behar J, Martin C, Monkhouse C, Chow A. The BLISTER Score: A Novel, Externally Validated Tool for Predicting Cardiac Implantable Electronic Device Infections, and Its Cost-Utility Implications for Antimicrobial Envelope Use. Circ Arrhythm Electrophysiol 2024; 17:e012446. [PMID: 38258308 PMCID: PMC10949977 DOI: 10.1161/circep.123.012446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/18/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Antimicrobial envelopes reduce the incidence of cardiac implantable electronic device infections, but their cost restricts routine use in the United Kingdom. Risk scoring could help to identify which patients would most benefit from this technology. METHODS A novel risk score (BLISTER [Blood results, Long procedure time, Immunosuppressed, Sixty years old (or younger), Type of procedure, Early re-intervention, Repeat procedure]) was derived from multivariate analysis of factors associated with cardiac implantable electronic device infection. Diagnostic utility was assessed against the existing PADIT score (Prior procedure, Age, Depressed renal function, Immunocompromised, Type of procedure) in both standard and high-risk external validation cohorts, and cost-utility models examined different BLISTER and PADIT score thresholds for TYRX (Medtronic; Minneapolis, MN) antimicrobial envelope allocation. RESULTS In a derivation cohort (n=7383), cardiac implantable electronic device infection occurred in 59 individuals within 12 months of a procedure (event rate, 0.8%). In addition to the PADIT score constituents, lead extraction (hazard ratio, 3.3 [95% CI, 1.9-6.1]; P<0.0001), C-reactive protein >50 mg/L (hazard ratio, 3.0 [95% CI, 1.4-6.4]; P=0.005), reintervention within 2 years (hazard ratio, 10.1 [95% CI, 5.6-17.9]; P<0.0001), and top-quartile procedure duration (hazard ratio, 2.6 [95% CI, 1.6-4.1]; P=0.001) were independent predictors of infection. The BLISTER score demonstrated superior discriminative performance versus PADIT in the standard risk (n=2854, event rate: 0.8%, area under the curve, 0.82 versus 0.71; P=0.001) and high-risk validation cohorts (n=1961, event rate: 2.0%, area under the curve, 0.77 versus 0.69; P=0.001), and in all patients (n=12 198, event rate: 1%, area under the curve, 0.8 versus 0.75, P=0.002). In decision-analytic modeling, the optimum scenario assigned antimicrobial envelopes to patients with BLISTER scores ≥6 (10.8%), delivering a significant reduction in infections (relative risk reduction, 30%; P=0.036) within the National Institute for Health and Care Excellence cost-utility thresholds (incremental cost-effectiveness ratio, £18 446). CONCLUSIONS The BLISTER score (https://qxmd.com/calculate/calculator_876/the-blister-score-for-cied-infection) was a valid predictor of cardiac implantable electronic device infection, and could facilitate cost-effective antimicrobial envelope allocation to high-risk patients.
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Affiliation(s)
- Edd Maclean
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Karishma Mahtani
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Shohreh Honarbakhsh
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Charles Butcher
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Nikhil Ahluwalia
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Adam S.C. Dennis
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Antonio Creta
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Malcolm Finlay
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Mark Elliott
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Vishal Mehta
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Nadeev Wijesuriya
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Omar Shaikh
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Yom Zaw
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Chizute Ogbedeh
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Vasu Gautam
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Pier D. Lambiase
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Richard J. Schilling
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Mark J. Earley
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Philip Moore
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Amal Muthumala
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Simon C.E. Sporton
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Ross J. Hunter
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Christopher A. Rinaldi
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Jonathan Behar
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Claire Martin
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Christopher Monkhouse
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Anthony Chow
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
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de Heide J, van der Graaf M, Holl MJ, Hoogendijk MG, Bhagwandien RE, Wijchers SA, Theuns DAMJ, Szili-Torok T, Zijlstra F, Lenzen MJ, Yap SC. Device infection in patients undergoing pacemaker or defibrillator surgery: risk stratification using the PADIT score. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01759-1. [PMID: 38286881 DOI: 10.1007/s10840-024-01759-1] [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: 10/28/2023] [Accepted: 01/21/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND The use of an antibacterial envelope is cost-effective for patients at high risk of developing cardiac implantable electronic device (CIED) infection. The identification of these high-risk patients may be facilitated using a clinical risk score. The aim of the current study is to evaluate the PADIT score for identifying high-risk patients in patients undergoing a CIED procedure in a tertiary academic center. METHODS This was a retrospective single-center study of consecutive patients undergoing a CIED procedure between January 2016 and November 2021. Patients who received an antibacterial envelope were excluded from this study. The primary endpoint was hospitalization for a CIED infection in the first year after the procedure. RESULTS A total of 2333 CIED procedures were performed in the study period (mean age 61.6 ± 16.3 years, male sex 64.5%, previous CIED infection 1.7%, immunocompromised 5.4%). The median PADIT score was 4 (interquartile range, 2-6). CIED infection occurred in 10 patients (0.43%). The PADIT score had good discrimination in predicting major CIED infection (C-statistic 0.70; 95% confidence interval [CI] 0.54 to 0.86, P = 0.03). Using an optimal PADIT score cut-off value of 7, the risk of CIED infection was higher in the patients with a PADIT score of ≥ 7 in comparison to those with a lower PADIT score (1.23% vs. 0.26%, P = 0.02; odds ratio 4.8, 95% CI 1.4 to 16.6, P = 0.01). CONCLUSIONS The PADIT score is a clinically useful score for identifying patients at high risk of developing CIED infection. The use of an antibacterial envelope in these high-risk patients may be cost-effective.
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Affiliation(s)
- John de Heide
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Marisa van der Graaf
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Marijn J Holl
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Mark G Hoogendijk
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Rohit E Bhagwandien
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Sip A Wijchers
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Dominic A M J Theuns
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Mattie J Lenzen
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
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