Device‐related Infection Associated with Increased Mortality Risk In De Novo Transvenous Implantable Cardioverter‐Defibrillator Medicare Patients

Outcome and microbiological findings of patients with cardiac implantable electronic device infection

INTRODUCTION

Infections associated with cardiac implantable electronic devices (CIEDs) are a multifactorial disease that leads to increased morbidity and mortality.

OBJECTIVE

The aim was to analyze patient-, disease- and treatment-related characteristics including microbiological and bacterial spectrum according to survival status and to identify risk factors for 1- and 3-year mortality in patients with local and systemic CIED infection.

METHODS

In a retrospective cohort study, we analyzed data from patients with CIED-related local or systemic infection undergoing successful transvenous lead extraction (TLE). Survival status as well as incidence and cause of rehospitalization were recorded. Microbiology and antibiotics used as first-line therapy were compared according to mortality. Independent risk factors for 1- and 3-year mortality were determined.

RESULTS

Data from 243 Patients were analyzed. In-hospital mortality was 2.5%. Mortality rates at 30 days, 1- and 3 years were 4.1%, 18.1% and 30%, respectively. Seventy-four (30.5%) patients had systemic bacterial infection. Independent risk factors for 1-year mortality included age (OR 1.05 [1.01-1.10], p = 0.014), NT-proBNP at admission (OR 4.18 [1.81-9.65], p = 0.001), new onset or worsened tricuspid regurgitation after TLE (OR 6.04 [1.58-23.02], p = 0.009), and systemic infection (OR 2.76 [1.08-7.03], p = 0.034), whereas systemic infection was no longer an independent risk factor for 3-year mortality. Staphylococcus aureus was found in 18.1% of patients who survived and in 25% of those who died, p = 0.092. There was a high proportion of methicillin-resistant strains among coagulase-negative staphylococci (16.5%) compared to Staphylococcus aureus (1.2%).

CONCLUSIONS

Staphylococci are the most common causative germs of CIED-infection with coagulase-negative staphylococci showing higher resistance rates to antibiotics. The independent risk factors for increased long-term mortality could contribute to individual risk stratification and well-founded treatment decisions in clinical routine. Especially the role of tricuspid regurgitation as a complication after TLE should be investigated in future studies.

Temporal Trends of Device-Related Infection in De Novo Transvenous Implantable Cardioverter-Defibrillator Medicare Patients with Underlying Kidney Disease

BACKGROUND

Kidney disease is a risk factor for device infection in transvenous implantable cardioverter-defibrillator (TV-ICD) implants, with mechanisms that include immunodeficiency and a portal of entry for bacteria that can seed indwelling devices.

OBJECTIVE

To examine the impact of both kidney disease and dialysis-dependence on the incidence of device-related infection after de novo TV-ICD implantation and how the incidence changes over time in.

METHODS

Medicare 100% administrative and claims data were used to identify patients who underwent de novo TV-ICD implantation between 7/1/2016 and 12/31/2018. Baseline characteristics included underlying kidney disease (none; non-dialysis; and dialysis), plus device infection during follow-up. Patients were followed for TV-ICD infection up to 78 weeks after implantation. Piecewise Poisson regression was used to predict the incidence of and hazard ratios for infection over time.

RESULTS

Overall, 809/42,200 (1.9%) patients had at least one device infection during a mean follow-up of 66 weeks: 484/31,217 (1.6%) none; 202/9,151 (2.2%) non-dialysis; and 123/1,832 (6.7%) dialysis (p<0.001 via log-rank test). The incidence of infection increased during the first 8-12 weeks and declined thereafter. Hazard ratios increased over time (dialysis week 12=4.9/1,000 PYs and week 52=9.8; non-dialysis week 12=1.4 and week 52=2.5; all p<0.05), as did the difference in the cumulative incidence compared with none (dialysis week 12=Δ11.8 and week 78=Δ53.5; non-dialysis week 12= Δ1.4 and week 78=Δ7.0.

CONCLUSION

The incidence of infection after de novo TV-ICD implantation is higher when patients have kidney disease and is substantially higher when patients are dialysis-dependent.