• Heart Devices: 'Less is More' in Preventing Infection

    Simple procedures cut odds of post-op infection, study finds

    Patients who received implantable cardiac electronic devices (CIEDs), such as pacemakers, were associated with reduced odds of infection following simple infection prevention procedures such as skin cleaning and pre-procedure antibiotic prophylaxis, researchers found.

    Chlorhexidine skin cleaning (adjusted OR 0.41, 95% CI 0.22-0.76) and pre-procedure antimicrobial prophylaxis with a β-lactam versus vancomycin (aOR 0.6, 95% CI 0.37-0.96) were both associated with lower odds of infection among this population, reported Westyn Branch-Elliman, MD, of Boston VA Healthcare System in West Roxbury, Massachusetts, and colleagues.

    However, neither antibiotic irrigation of the pocket intra-procedure nor prolonged postprocedural antibiotics for over 24 hours were linked to a significant reduction in the risk of infection, the authors wrote in Infection Control and Hospital Epidemiology.

    They noted that while the patient population who uses CIEDs has gotten older and sicker, incidence of infections of CIEDs has also more than doubled over the last 10 years. However, little is known about the most clinically effective methods of preventing these infections, the authors argued, with preventative measures mostly taken from cardiac surgery versus the field of electrophysiology.

    While pre-incisional antimicrobial prophylaxis is supported by high quality evidence, there is limited data on other measures, such as combination prophylactic regimens and methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization, topical application of antimicrobials, or bundled approaches, they said.

    Researchers examined a sampling of procedures from the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP) database from 2008 to 2015. The primary outcome was a 6 month incidence of infections of CIEDs.

    There were 2,059 patients -- 99 with an infection of CIEDs, and 1,960 without this type of infection. Overall, patients were a median age of about 72, nearly all were men and over 85% were white. Over half used tobacco, 47% had diabetes, and about a third had chronic kidney disease. Among 2,098 examined procedures, a little under 40% of patients were prescribed anticoagulants, and about 14% had complications.

    Of the 101 definite, probable, and possible infection of CIEDs, 44% had no specific pathogen identified, though the most common pathogen from those with positive test results was gram-positive bacteria, especially Staphylococcus spp.

    A review of procedures found that pre-procedure antibiotics were administered in nearly all procedures, and almost 80% of patients received antimicrobials after skin closure, while about 47% received antibiotics for over 24 hours following the procedure. There was about an even split between ß-lactam antibiotics and vancomycin (46% vs 44%, respectively). Chlorhexidine skin cleaning occurred in about 29% of procedures, the authors said.

    Factors linked to increased odds of infection included:

    • Wound complications: aOR 8.74 (95% CI, 3.16–24.40)
    • Pre-procedure MRSA status: aOR 6.56 (95% CI, 1.55–27.77)
    • Revision procedures: aOR 2.4 (95% CI, 1.12–2.18)
    • INR >1.5 prior to the procedure: aOR 1.56 (95% CI, 1.12–2.18)

     

    Study limitations included that it may not be representative of all infections of CIED procedures, and results may not be generalizable to non-VA populations. The authors also noted that due to relying on only data available in VA records, there may have been adverse events outside the VA system that were not captured.

    "Straightforward and easy-to-implement interventions should form the basis of standardized protocols and bundles improve infection prevention in the electrophysiology laboratory," the authors wrote. "Although a variety of activities are commonly used in clinical practice, our findings highlight the principle that 'less is more.'"

     

    The study was supported by the American Heart Association's Institute for Precision Cardiovascular Medicine Award.

    Branch-Elliman disclosed support from the Veterans Integrated Service Network (VISN)-1 Career Development Award and DLA Piper. Asundi disclosed support from Gilead Sciences. Co-authors disclosed support from Abbott Laboratories.

    Source:

    Infection Control & Hospital Epidemiology

    Source Reference: Asundi A, et al "Real-world effectiveness of infection prevention interventions for reducing procedure-related cardiac device infections: Insights from the veterans affairs clinical assessment reporting and tracking program" Infect Control Hosp Epidemiol 2019; DOI: 10.1017/S0899823X19001272.

     

    Read the original article on Medpage Today: Heart Devices: 'Less is More' in Preventing Infection

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