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Eckmann C, Sunderkötter C, Becker K, Grabein B, Hagel S, Hanses F, Wichmann D, Thalhammer F. Left ventricular assist device-associated driveline infections as a specific form of complicated skin and soft tissue infection/acute bacterial skin and skin structure infection - issues and therapeutic options. Curr Opin Infect Dis 2024; 37:95-104. [PMID: 38085707 PMCID: PMC10911258 DOI: 10.1097/qco.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
PURPOSE OF REVIEW This review comments on the current guidelines for the treatment of wound infections under definition of acute bacterial skin and skin structure infections (ABSSSI). However, wound infections around a catheter, such as driveline infections of a left ventricular assist device (LVAD) are not specifically listed under this definition in any of the existing guidelines. RECENT FINDINGS Definitions and classification of LVAD infections may vary across countries, and the existing guidelines and recommendations may not be equally interpreted among physicians, making it unclear if these infections can be considered as ABSSSI. Consequently, the use of certain antibiotics that are approved for ABSSSI may be considered as 'off-label' for LVAD infections, leading to rejection of reimbursement applications in some countries, affecting treatment strategies, and hence, patients' outcomes. However, we believe driveline exit site infections related to LVAD can be included within the ABSSSI definition. SUMMARY We argue that driveline infections meet the criteria for ABSSSI which would enlarge the 'on-label' antibiotic armamentarium for treating these severe infections, thereby improving the patients' quality of life.
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Affiliation(s)
- Christian Eckmann
- Academic Hospital of Goettingen University, Department of General, Visceral and Thoracic Surgery, Klinikum Hannoversch-Muenden, Hannoversch-Muenden
| | - Cord Sunderkötter
- Martin-Luther-University Halle-Wittenberg, University and University Hospital of Halle, Department of Dermatology and Venerology, Halle
| | - Karsten Becker
- University Medicine Greifswald, Friedrich Loeffler-Institute of Medical Microbiology, Greifswald
| | - Béatrice Grabein
- LMU Hospital, Clinical Microbiology and Hospital Hygiene, Munich
| | - Stefan Hagel
- Jena University Hospital-Friedrich Schiller University Jena, Institute for Infectious Diseases and Infection Control, Jena
| | - Frank Hanses
- University Hospital Regensburg, Department of Infection Prevention and Infectious Diseases
- University Hospital Regensburg, Emergency Department, Regensburg
| | - Dominic Wichmann
- University Medical Center Hamburg-Eppendorf, Department of Intensive Care Medicine, Hamburg
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Cikirikcioglu M, Ponchant K, Murith N, Meyer P, Yilmaz N, Huber C. Treatment of HeartMate III-LVAD driveline infection by negative pressure wound therapy: Result of our case series. Int J Artif Organs 2021; 44:912-916. [PMID: 34558333 PMCID: PMC8559168 DOI: 10.1177/03913988211047250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Driveline infection is one of the most frequent complications following left ventricular assist device (LVAD) treatment and there is no consensus for its management. The standard approach to treat foreign-body infection is complete device ablation, which is not always feasible and therefore not an elected method for LVAD driveline infections. Here we share the results from a series of cases successfully treated for driveline infection by negative pressure wound therapy (NPWT) therapy. Between 2016 and 2020, five male patients were hospitalized in our unit with a driveline infection of HeartMate III-LVAD®. Ultrasonography and/or thoraco-abdominal CT confirmed the diagnosis, infection localization, and abscess formation. Following an antibiotic treatment, an urgent surgical abscess drainage and debridement of the infected tissues were performed. At the end of the procedure, NPWT was applied. NPWT re-dressing and debridement of wound was performed every 3-4 days. The wound was closed surgically after obtaining negative culture results and good healing. The patients were discharged in good condition, without signs of infection. Two patients underwent successful heart transplantation after 1 and 13 months. Other patients did not show any residual or recurrent infection during the follow-up within 25 months. Driveline infection following LVAD implantation is a significant complication and a challenging in terms of management for both; the surgical team and the patient. These results from our case series report a successful and less invasive approach by using NPWT for the treatment of LVAD driveline infections.
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Affiliation(s)
- Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery,
Department of Surgery, University Hospitals and Faculty of Medicine, Geneva,
Switzerland
- Mustafa Cikirikcioglu, Division of
Cardiovascular Surgery, Department of Surgery, University Hospital of Geneva,
Rue Gabrielle Perret-Gentil 4, Geneva 1211, Switzerland.
| | - Kevin Ponchant
- Division of Cardiovascular Surgery,
Department of Surgery, University Hospitals and Faculty of Medicine, Geneva,
Switzerland
| | - Nicolas Murith
- Division of Cardiovascular Surgery,
Department of Surgery, University Hospitals and Faculty of Medicine, Geneva,
Switzerland
| | - Philippe Meyer
- Division of Cardiology, Department of
Internal Medicine, University Hospitals and Faculty of Medicine, Geneva,
Switzerland
| | - Nurcan Yilmaz
- Division of Cardiovascular Surgery,
Department of Surgery, University Hospitals and Faculty of Medicine, Geneva,
Switzerland
| | - Christoph Huber
- Division of Cardiovascular Surgery,
Department of Surgery, University Hospitals and Faculty of Medicine, Geneva,
Switzerland
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3
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Qu Y, Peleg AY, McGiffin D. Ventricular Assist Device-Specific Infections. J Clin Med 2021; 10:453. [PMID: 33503891 DOI: 10.3390/jcm10030453] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 12/30/2022] Open
Abstract
Ventricular assist device (VAD)-specific infections, in particular, driveline infections, are a concerning complication of VAD implantation that often results in significant morbidity and even mortality. The presence of a percutaneous driveline at the skin exit-site and in the subcutaneous tunnel allows biofilm formation and migration by many bacterial and fungal pathogens. Biofilm formation is an important microbial strategy, providing a shield against antimicrobial treatment and human immune responses; biofilm migration facilitates the extension of infection to deeper tissues such as the pump pocket and the bloodstream. Despite the introduction of multiple preventative strategies, driveline infections still occur with a high prevalence of ~10-20% per year and their treatment outcomes are frequently unsatisfactory. Clinical diagnosis, prevention and management of driveline infections are being targeted to specific microbial pathogens grown as biofilms at the driveline exit-site or in the driveline tunnel. The purpose of this review is to improve the understanding of VAD-specific infections, from basic "bench" knowledge to clinical "bedside" experience, with a specific focus on the role of biofilms in driveline infections.
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Qu Y, McGiffin D, Kure C, McLean J, Duncan C, Peleg AY. In vitro Evaluation of Medihoney Antibacterial Wound Gel as an Anti-biofilm Agent Against Ventricular Assist Device Driveline Infections. Front Microbiol 2020; 11:605608. [PMID: 33329497 PMCID: PMC7719625 DOI: 10.3389/fmicb.2020.605608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Objectives: In adult ventricular assist device (VAD) programs in Australian hospitals, Medihoney Antibacterial Wound Gel (MAWG) is routinely used at the skin exit-site of VAD drivelines to prevent infections; however, its effectiveness remains unclear. Our aim was to assess antimicrobial activity of Medihoney wound gel, using in vitro models that mimic clinical biofilms grown at the driveline exit-site. Methods: Antimicrobial susceptibility testing of MAWG was performed for 24 clinical isolates grown under planktonic conditions, and four representative strains grown as biofilms. Different antimicrobial mechanisms of MAWG were assessed respectively for their relative contribution to its anti-biofilm activity. A colony biofilm assay and a drip-flow biofilm reactor assay mimicking the driveline exit-site environment were used to evaluate the activity of MAWG against biofilm growth at the driveline exit-site. Results: MAWG demonstrated species-specific activity against planktonic cultures [minimum inhibitory concentrations (MICs), 5-20% weight/volume (W/V) for Staphylococcus species, 20->40% (W/V) for Pseudomonas aeruginosa and Candida species]. Higher concentrations [MICs, 30->80% (W/V)] were able to inhibit biofilm growth, but failed to eradicate pre-established biofilms. The anti-biofilm properties of MAWG were multi-faceted, with the often-advertised "active" ingredient methylglyoxal (MGO) playing a less important role. The colony biofilm assay and the drip-flow biofilm reactor assay suggested that MAWG was unable to kill biofilms pre-established in a driveline exit-site environment, or effectively prevent planktonic cells from forming adherent monolayers and further developing mature biofilms. Conclusion: Our work suggests a suboptimal effectiveness of MAWG in preventing driveline infections due to biofilm development.
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Affiliation(s)
- Yue Qu
- Infection and Immunity Theme, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, VIC, Australia.,Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Christina Kure
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Janelle McLean
- Transplant Services, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Courtney Duncan
- Transplant Services, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Anton Y Peleg
- Infection and Immunity Theme, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, VIC, Australia.,Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
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5
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Qu Y, McGiffin D, Hayward C, McLean J, Duncan C, Robson D, Kure C, Shen R, Williams H, Mayo S, Thissen H, Marasco S, Zimmet A, Negri J, Jansz P, Dhital K, Kaye DM, Peleg AY. Characterization of infected, explanted ventricular assist device drivelines: The role of biofilms and microgaps in the driveline tunnel. J Heart Lung Transplant 2020; 39:1289-1299. [PMID: 32771438 DOI: 10.1016/j.healun.2020.07.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/28/2020] [Accepted: 07/17/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Driveline infections remain a major complication of ventricular assist device (VAD) implantation. This study aimed to characterize in vivo microbial biofilms associated with driveline infections and host tissue integration of implanted drivelines. METHODS A total of 9 infected and 13 uninfected drivelines were obtained from patients with VAD undergoing heart transplantation in Australia between 2016 and 2018. Each driveline was sectioned into 11 pieces of 1.5 cm in length, and each section was examined by scanning electron microscopy (SEM) and viable counts for microbial biofilms. Microorganisms were cultured and identified. Host tissue integration of clinical drivelines was assessed with micro-computed tomography (CT) and SEM. An in vitro interstitial biofilm assay was used to simulate biofilm migration in the driveline tunnel, and time-lapse microscopy was performed. RESULTS Of the 9 explanted, infected drivelines, all had organisms isolated from varying depths along the velour section of the drivelines, and all were consistent with the swab culture results of the clinically infected exit site. SEM and micro-CT suggested insufficient tissue integration throughout the driveline velour, with microgaps observed. Clinical biofilms presented as microcolonies within the driveline tunnel, with human tissue as the sub-stratum, and were resistant to anti-microbial treatment. Biofilm migration mediated by a dispersal-seeding mechanism was observed. CONCLUSIONS This study of explanted infected drivelines showed extensive anti-microbial-resistant biofilms along the velour, associated with microgaps between the driveline and the surrounding tissue. These data support the enhancement of tissue integration into the velour as a potential preventive strategy against driveline infections by preventing biofilm migration that may use microgaps as mediators.
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Affiliation(s)
- Yue Qu
- Infection and Immunity Theme, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Melbourne, Victoria, Australia; Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Christopher Hayward
- Department of Cardiology, St Vincent's Public Hospital, Sydney, Darlinghurst, New South Wales, Australia
| | - Janelle McLean
- Department of Cardiothoracic Surgery, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Courtney Duncan
- Department of Cardiothoracic Surgery, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Desiree Robson
- Department of Cardiology, St Vincent's Public Hospital, Sydney, Darlinghurst, New South Wales, Australia
| | - Christina Kure
- Department of Cardiothoracic Surgery, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Rong Shen
- Department of Cardiothoracic Surgery, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Helen Williams
- School of Applied Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Sherry Mayo
- CSIRO Manufacturing, Clayton, Victoria, Australia
| | | | - Silvana Marasco
- Department of Cardiothoracic Surgery, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Adam Zimmet
- Department of Cardiothoracic Surgery, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Justin Negri
- Department of Cardiothoracic Surgery, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Paul Jansz
- Department of Cardiothoracic Surgery, St Vincent's Public Hospital, Sydney, Darlinghurst, New South Wales, Australia
| | - Kumud Dhital
- Department of Cardiothoracic Surgery, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Anton Y Peleg
- Infection and Immunity Theme, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Melbourne, Victoria, Australia; Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia.
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Bolle ECL, Verderosa AD, Dhouib R, Parker TJ, Fraser JF, Dargaville TR, Totsika M. An in vitro Reconstructed Human Skin Equivalent Model to Study the Role of Skin Integration Around Percutaneous Devices Against Bacterial Infection. Front Microbiol 2020; 11:670. [PMID: 32477277 PMCID: PMC7240036 DOI: 10.3389/fmicb.2020.00670] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/24/2020] [Indexed: 01/19/2023] Open
Abstract
Percutaneous devices are a key technology in clinical practice, used to connect internal organs to external medical devices. Examples include prosthesis, catheters and electrical drivelines. Percutaneous devices breach the skin's natural barrier and create an entry point for pathogens, making device infections a widespread problem. Modification of the percutaneous implant surface to increase skin integration with the aim to reduce subsequent infection is attracting a great deal of attention. While novel surfaces have been tested in various in vitro models used to study skin integration around percutaneous devices, no skin model has been reported, for the study of bacterial infection around percutaneous devices. Here, we report the establishment of an in vitro human skin equivalent model for driveline infections caused by Staphylococcus aureus, the most common cause of driveline-related infections. Three types of mock drivelines manufactured using melt electrowriting (smooth or porous un-seeded and porous pre-seeded with human fibroblasts) were implanted in human skin constructs and challenged with S. aureus. Our results show a high and stable load of S. aureus in association with the skin surface and no signs of S. aureus-induced tissue damage. Furthermore, our results demonstrate that bacterial migration along the driveline surface occurs in micro-gaps caused by insufficient skin integration between the driveline and the surrounding skin consistent with clinical reports from explanted patient drivelines. Thus, the human skin-driveline infection model presented here provides a clinically-relevant and versatile experimental platform for testing novel device surfaces and infection therapeutics.
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Affiliation(s)
- Eleonore C. L. Bolle
- Tissue Repair and Translational Physiology Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
- The Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Infection and Immunity Research Program, Institute of Health and Biomedical Innovation, School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Anthony D. Verderosa
- Infection and Immunity Research Program, Institute of Health and Biomedical Innovation, School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Rabeb Dhouib
- Infection and Immunity Research Program, Institute of Health and Biomedical Innovation, School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Tony J. Parker
- Tissue Repair and Translational Physiology Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - John F. Fraser
- The Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Tim R. Dargaville
- Tissue Repair and Translational Physiology Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Makrina Totsika
- Infection and Immunity Research Program, Institute of Health and Biomedical Innovation, School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
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Hernandez GA, Breton JDN, Chaparro SV. Driveline Infection in Ventricular Assist Devices and Its Implication in the Present Era of Destination Therapy. Open J Cardiovasc Surg 2017; 9:1179065217714216. [PMID: 28680268 PMCID: PMC5489074 DOI: 10.1177/1179065217714216] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 05/16/2017] [Indexed: 12/28/2022] Open
Abstract
Advances in mechanical circulatory support devices provided the technology to develop long-term, implantable left ventricular assist devices as bridge to transplant, destination therapy, and in a lesser group of patients, as bridge to recovery. Despite the benefits from this innovative therapy, with their increased use, many complications have been encountered, one of the most common being infections. With the driveline acting as a portal to the exterior environment, an infection involving this structure is the most frequent one. Because patients with destination therapy are expected to receive circulatory support for a longer period of time, we will focus this review on the risk factors, prevention, and treatment options for driveline infections.
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Affiliation(s)
- Gabriel A Hernandez
- Cardiovascular Division, University of Miami Hospital and Jackson Memorial Hospital, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Jonatan D Nunez Breton
- Department of Internal Medicine, University of Miami Hospital and Jackson Memorial Hospital, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Sandra V Chaparro
- Cardiovascular Division, University of Miami Hospital and Jackson Memorial Hospital, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
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Nienaber JJC, Kusne S, Riaz T, Walker RC, Baddour LM, Wright AJ, Park SJ, Vikram HR, Keating MR, Arabia FA, Lahr BD, Sohail MR. Clinical manifestations and management of left ventricular assist device-associated infections. Clin Infect Dis 2013; 57:1438-48. [PMID: 23943820 DOI: 10.1093/cid/cit536] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Infection is a serious complication of left ventricular assist device (LVAD) therapy. Published data regarding LVAD-associated infections (LVADIs) are limited by single-center experiences and use of nonstandardized definitions. METHODS We retrospectively reviewed 247 patients who underwent continuous-flow LVAD implantation from January 2005 to December 2011 at Mayo Clinic campuses in Minnesota, Arizona, and Florida. LVADIs were defined using the International Society for Heart and Lung Transplantation criteria. RESULTS We identified 101 episodes of LVADI in 78 patients (32%) from this cohort. Mean age (± standard deviation [SD]) was 57±15 years. The majority (94%) underwent Heartmate II implantation, with 62% LVADs placed as destination therapy. The most common type of LVADIs were driveline infections (47%), followed by bloodstream infections (24% VAD related, and 22% non-VAD related). The most common causative pathogens included gram-positive cocci (45%), predominantly staphylococci, and nosocomial gram-negative bacilli (27%). Almost half (42%) of the patients were managed by chronic suppressive antimicrobial therapy. While 14% of the patients had intraoperative debridement, only 3 underwent complete LVAD removal. The average duration (±SD) of LVAD support was 1.5±1.0 years. At year 2 of follow-up, the cumulative incidence of all-cause mortality was estimated to be 43%. CONCLUSION Clinical manifestations of LVADI vary on the basis of the type of infection and the causative pathogen. Mortality remained high despite combined medical and surgical intervention and chronic suppressive antimicrobial therapy. Based on clinical experiences, a management algorithm for LVADI is proposed to assist in the decision-making process.
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