preventing cied infections - venice arrhythmias · cardiologia 2 aritmologia . preventing cied...
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Preventing CIED infections
E.Soldati
Disclosures
None
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
• Infection ≈ 1 % – 2-7% infection rate for replacement/upgrades1
– ≤ 0.5% infection rate for new implants1
• Malfunction ≈ 2.5 % – 1.65-20% annual ICD lead failure based on age2,3
CIEDs Complications
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Rising Rates of Cardiac Rhythm Management Device Infections in the United States: 1996 through 2006
A Voigt et al, PACE 2010; 33:414–419
…possible causes for this on-going epidemic include sicker patients and more complex procedures…
CIED implanted
Infections
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Why?
• Patients with more co-morbidities • �Sicker Patients�
• Larger Devices • More ICDs
• Longer implant time • Less experienced implanters • More complex devices
• �Cathlab sterile technique� Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
CIED infection is a serious complication
associated with sustantial morbidity, mortality and costs.
CIED infection increases the risk of in-hospital death by more than 2
fold
Baddour LM et al, Circulation 2010; 121:458-477 Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Preventing CIED infections
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
• Before the implant
• During the implant
• After the implant
Preventing CIED infections
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
• Before the implant
• Avoid temporary pacing • Wait if fever or BS abnormal • Avoid Bridging • Scrub the patient • AB prophylaxis • Choose the right hardware • Operators, staff and OR asepsys
Odds ratio for developing CIED Infection
Klug D et al. Circulation 2007;116(12):1349-1355. - Lekkerkerker JC et al. Heart 2009;95(9):715-720. Margey R et al. Europace 2010;12(1):64-70. - Sohail MR et al. Clin Infect Dis. 2007;45(2):166-173. Bloom H et al. Pacing Clinical Electrophysiology 2006;29(2):142-145.
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
CIEDs Infections RISK FACTORS
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Darouiche et al NEJM 2010
Which Antiseptic?
chlorhexidine–alcohol surgical prevent an estimated 40% of all
surgical-site infections
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
PACE 2012;00:1–13
For patients undergoing a CIED implant, perioperative systemic antibiotic (PSA) plus antiseptics delivered 1 hour
before the procedure significantly reduced the incidence of postoperative infection
META-ANALYSIS 15 studies (3.970 partecipants)
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
AHA/HRS 2010 Recommendations for Antimicrobial Prophylaxis at the time of CIED placement
Class I Prophylaxis with an antibiotic that has in vitro activity against staphylococci should be administered. - If cefazolin is selected for use, then it should be administered intravenously within 1 hour before incision; - if vancomycin is given, then it should be adminstered intravenously within 2 hours before incision. (Level of Evidence: A)
Baddour LM et al. Circulation 2010;121(3):458-477.
Which Antibiotic?
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Sohail et al JACC 2007 189 positive CIED coltures
Bongiorni et al. Europace 2012
854 positive CIED coltures
69
13,86,1 5 5,1
10
10
20
3040
50
60
70
80
CoNS
Stf2Aureus
Gram2Negative
Corynebacterium
Other
Fungi
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
• 642 patients enrolled at 10 U.S. centers with 1.9 +/- 2.4 months FU. • > 99% of all CIEDs successfully implanted (35% PM, 29% ICD, 36% CRT-D). • Near half (49%) of the patients had at least 3 risk factors for CIEDs infections
1. Bloom H et al. PACE 2011;34(2):133-142 2. Krahn et al. Circ EP 2011;4(2):136-142 3. Gould et al. JAMA. 2006 295(16),1907-1911
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Less hardware Single lead VDD AAI when WCL is acceptable Single chamber ICD for primary prevention
Implant time The shorter the better
Prevention of Complications
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Preventing CIED infections
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
• During the implant
• Check time • Replacements • Prevent bleeding • Operators, staff and OR asepsys
Romeyer-Bouchard C, et al. European Heart Journal 2010; 31: 203–210
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Danish Pacemaker Registry
Johansen J B et al. Eur Heart J 2011;32:991-8
n= 44631
n= 8380
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Preventing CIED infections
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
• After the implant
• Avoid reintervention • Reduce replacements • AB prophylaxis
Treatment of Complications
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Conservative approach Reintervention if stricly necessary Use OR
Haematoma/Revision
Cardiac Devices Infection (CDI)
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
CIED Infections
Suspect!!!!......
• Physical examination • Blood samples • Blood coltures; Duke criteria • Vegetations • PET, Labeled WBC • ICE
1.1 LOCAL INFECTION
Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)
CIED Infections
…. and extract!!!!!!