Use of a taurolidine containing antimicrobial wash to reduce cardiac implantable electronic device infection

AIMS

TauroPace (Tauropharm, Bavaria Germany), a taurolidine solution for combating cardiac implantable electronic device (CIED) infection, was compared with a historical control of 3% hydrogen peroxide (H2O2) in a prospective observational study.

METHODS AND RESULTS

The device pocket was irrigated, and all hardware accessible within (leads, suture sleeves, pulse generator) was wiped with H2O2, TauroPace, or taurolidine in a galenic formulation during any invasive CIED procedure at the study centre. Only CIED procedures covered by TauroPace or H2O2 from 1 January 2017 to 28 February 2022 were included for analysis. Patients who underwent >1 procedure were censored for the last treatment group and reassigned at the next procedure. The primary endpoint was major CIED infection within 3 months. The secondary endpoints were CIED infection beyond 3 months, adverse events potentially related to the antimicrobial solutions, CIED system, procedure, and death, till the end of follow-up. TauroPace covered 654 procedures on 631 patients, and H2O2 covered 551 procedures on 532 patients. The TauroPace group had more patient risk factors for infection than the H2O2 group (P = 0.0058) but similar device and procedure-specific risk factors (P = 0.17). Cardiac implantable electronic device infection occurred in 0/654 (0%) of the TauroPace group and 6/551 (1.1%) of the H2O2 group (P = 0.0075). Death occurred in 23/654 (3.5%) of the TauroPace group and 14/551 (2.5%) of the H2O2 group (P = 0.33). Non-infection related adverse events were rarer in the TauroPace (3.8%) than the H2O2 (6.0%) group (P = 0.0802).

CONCLUSION

TauroPace is safe but more effective than H2O2 in reducing CIED infection.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05576194.

The European TauroPace™ Registry

BACKGROUND

Cardiac implantable electronic device (CIED) placement comes with certain complications. CIED infection is a severe adverse event related to CIED placement. In randomised controlled trials, the preoperative intravenous administration of antibiotics and the adjunctive use of an antibiotic mesh envelope resulted in significant reduction in infections related to cardiac implantable electronic devices. The adjunctive use of taurolidine for this purpose is relatively novel and not considered in the guidelines. The required evidence may consist of a set of clinical studies.

METHODS

The European TauroPaceTM registry (ETPR) prospectively evaluates every consecutive invasive procedure involving any CIED with adjunct TauroPace™ use in the contributing centres. As the estimation of the infection rate needs to be defensible, only interventions registered prior to the procedure will be followed-up. The endpoint is a major cardiac implantable electronic device infection according to the novel CIED infection criteria (1). Secondary endpoints comprise all-cause mortality, complications, adverse events of all grades, and major CIED infections during all follow-up examinations. The follow-up times are three months, twelve months, and eventually 36 months, as acute, subacute, and long-term CIED infections are of interest.

RESULTS

As the rate of CIED infections is expected to be very low, this registry is a multicentre, international project that will run for several years. Several reports are planned. The analyses will be included in the case number calculations for future randomised controlled trials.

CONCLUSIONS

The ETPR will accumulate large case numbers to estimate small event rates more precisely; we intend to follow up on participants for years to reveal possible late effects.

Use of Taurolidine in a Patient With a Cardiac Implantable Electronic Device Protrusion

We report the successful salvage of cardiac implantable electronic device pulse generator protrusion sealed by the surrounding skin in a frail patient presenting 5 months after the last surgical revision. (Level of Difficulty: Advanced.).

Salvage of infected cardiac implantable electronic device with taurolidine—a case report

Background

Cardiac implantable electronic devices (CIEDs) are commonly used to treat cardiac arrhythmias and prevent sudden cardiac death. Complications of CIED therapy include component malfunction, lead dislodgement, skin erosion and infection. Infection can result in significant morbidity and even mortality. The recommended treatment of CIED skin erosion and infection is urgent complete device extraction. When this is infeasible due to patient or resource factors, an attempt could be made to salvage the exposed or infected CIED system by debridement of all the infected necrotic tissues and irrigation of the pocket and contaminated hardware with anti-septic/antibiotic solutions. Taurolidine, when dissolved in an aqueous solution, produces a broad spectrum of antimicrobial actions and may be used as a novel irrigation agent during CIED salvage.

Case presentation

This report describes the first use of a taurolidine-containing solution for pocket irrigation and in situ hardware sterilisation that resulted in the successful salvage of a CIED infected with multi-resistant Staphylococcus epidermidis.

Conclusions

A taurolidine-containing antimicrobial solution can be a safe and effective alternative to traditional antiseptic/antibiotic solutions for pocket irrigation and in situ hardware sterilisation during CIED salvage, and may produce better clinical outcomes by some unique mechanisms of action such as inhibition of biofilm formation and neutralisation of endotoxins, with little risk of inducing and encountering resistance.

Eradication of Ventricular Assist Device Driveline Infection in Paediatric Patients with Taurolidine

Ventricular assist devices (VADs) are used to provide mechanical circulatory support to patients with end-stage heart failure. The driveline connecting the external power source to the pump(s) of the intra-corporal VAD breaches the protective skin barrier and provides a track for microbes to invade the interior of the patient’s body. Driveline infection constitutes a major and potentially fatal vulnerability of VAD therapy. Driveline infection cannot traditionally be salvaged and requires the extraction of the entire VAD system. We report here the successful eradication of a VAD driveline infection with a taurolidine-containing antimicrobial solution used for preventing the infection of cardiac implantable electronic devices. If replicated in more cases, the novel treatment concept described here may provide a valuable alternative management strategy of salvage rather than explantation for VAD driveline infection.

Differences in coronary vasodilatory capacity and atherosclerosis in endurance athletes using coronary CTA and computational fluid dynamics (CFD): Comparison with a sedentary lifestyle

BACKGROUND

The aim was to assess the effect of endurance exercise on coronary vasodilatory capacity and atherosclerosis by coronary computed tomography angiography (CTA) and computational fluid dynamic (CFD) modelling.

METHODS

100 subjects (age 56.2y±11, 29 females) who underwent coronary CTA were included into this retrospectively matched cohort study. Endurance athletes (≥1 h per unit and ≥3 times per week training) were compared to controls with a sedentary lifestyle, and within subgroups with and without sublingual nitroglycerin preparation. CTA image analysis included coronary stenosis severity (CADRADS), total (segment involvement score = SIS) and mixed plaque burden (G-score), high-risk plaque criteria, the coronary artery calcium score (CACS) and CFD analysis including Fractional Flow Reserve (FFR_CT), myocardial mass (M), total vessel lumen volume (V) and volume-to-mass (V/M) ratio.

RESULTS

The prevalence of atherosclerosis by CTA was 65.4 % and >50 % coronary stenosis was found in 17.3 % of athletes. Coronary stenosis severity (CADRADS), total and mixed non-calcified plaque burden (SIS and G-score) were lower in athletes (p = 0.003 and p < 0.001) but not CACS (p = 0.055) and less high-risk plaques were found (p < 0.001). The G-score was correlated with distal FFR_CT (p = 0.025). V/M-ratio was different between athletes who received nitroglycerin compared with those who did not (V/M: 21.1 vs. 14.8; p < 0.001), but these differences were not observed in the control subjects.

CONCLUSION

Endurance training improves coronary vasodilatory capacity and reduces high-risk plaque and mixed non-calcifed plaque burden as assessed by coronary CTA angiography. Our study may advocate coronary CTA with FFR_CT for evaluation of coronary artery disease in endurance athletes.

Who does workforce planning well? Workforce review team rapid review summary

PURPOSE

This paper sets out to disseminate new knowledge about workforce planning, a crucial health sector issue. The Health Select Committee criticised NHS England's failure to develop and apply effective workforce planning. The Workforce Review Team (WRT) commissioned the Institute for Employment Research, Warwick University, to undertake a "rapid review" of global literature to identify good practice. A workforce planning overview, its theoretical principles, good practice exemplars are provided before discussing their application to healthcare.

DESIGN/METHODOLOGY/APPROACH

The literature review, undertaken September-November 2007, determined the current workforce planning evidence within and outside health service provision and any consensus on successful workforce planning.

FINDINGS

Much of the literature was descriptive and there was a lack of comparative or evaluative research-based evidence to inform U.K. healthcare workforce planning. Workforce planning practices were similar in other countries.

PRACTICAL IMPLICATIONS

There was no evidence to challenge current WRT approaches to NHS England workforce planning. There are a number of indications about how this might be extended and improved, given additional resources. The evidence-base for workforce planning would be strengthened by robust and authoritative studies.

ORIGINALITY/VALUE

Systematic workforce planning is a key healthcare quality management element. This review highlights useful information that can be turned into knowledge by informed application to the NHS. Best practice in other sectors and other countries appears to warrant exploration.