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Kerai A, Doshi S, Laleker A, Majumdar A. Fungal Foe and Mechanical Hearts: A Retrospective Case Series on Candida auris Bloodstream Infection With Left Ventricular Assist Devices. Open Forum Infect Dis 2024; 11:ofae286. [PMID: 38868314 PMCID: PMC11167671 DOI: 10.1093/ofid/ofae286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/16/2024] [Indexed: 06/14/2024] Open
Abstract
No guidelines currently exist for the management of Candida auris bloodstream infection in patients with left ventricular assist devices (LVADs). We aim to share our management experience through this retrospective case series outlining 15 episodes of C auris candidemia identified in 7 patients over 18 months. The initial source of candidemia was central venous catheter in 5 patients, driveline exit site infection in 1 patient, and possible pump infection in 1 patient. All patients were initially treated with micafungin. Despite susceptibility to micafungin, 4 patients experienced recurrent C auris candidemia. All patients died within 1 year of their first episode of C auris candidemia. Source control is challenging in patients with LVADs, and strict infection prevention measures should be practiced. More studies are needed to evaluate the role of newer antifungal agents, use of combination antifungal regimens, and impact on morbidity in patients with LVADs.
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Affiliation(s)
- Ajay Kerai
- Department of Internal Medicine and Department of Infectious Disease, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Saumil Doshi
- Department of Internal Medicine and Department of Infectious Disease, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Ashley Laleker
- Department of Internal Medicine and Department of Infectious Disease, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Anjali Majumdar
- Division of Allergy and Infectious Disease, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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2
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Luong ML, Nakamachi Y, Silveira FP, Morrissey CO, Danziger-Isakov L, Verschuuren EAM, Wolfe CR, Hadjiliadis D, Chambers DC, Patel JK, Dellgren G, So M, Verleden GM, Blumberg EA, Vos R, Perch M, Holm AM, Mueller NJ, Chaparro C, Husain S. Management of infectious disease syndromes in thoracic organ transplants and mechanical circulatory device recipients: a Delphi panel. Transpl Infect Dis 2024; 26:e14251. [PMID: 38351512 DOI: 10.1111/tid.14251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/23/2023] [Accepted: 01/25/2024] [Indexed: 06/19/2024]
Abstract
PURPOSE Antimicrobial misuse contributes to antimicrobial resistance in thoracic transplant (TTx) and mechanical circulatory support (MCS) recipients. This study uses a modified Delphi method to define the expected appropriate antimicrobial prescribing for the common clinical scenarios encountered in TTx and MCS recipients. METHODS An online questionnaire on managing 10 common infectious disease syndromes was submitted to a multidisciplinary Delphi panel of 25 experts from various disciplines. Consensus was predefined as 80% agreement for each question. Questions where consensus was not achieved were discussed during live virtual live sessions adapted by an independent process expert. RESULTS An online survey of 62 questions related to 10 infectious disease syndromes was submitted to the Delphi panel. In the first round of the online questionnaire, consensus on antimicrobial management was reached by 6.5% (4/62). In Round 2 online live discussion, the remaining 58 questions were discussed among the Delphi Panel members using a virtual meeting platform. Consensus was reached among 62% (36/58) of questions. Agreement was not reached regarding the antimicrobial management of the following six clinical syndromes: (1) Burkholderia cepacia pneumonia (duration of therapy); (2) Mycobacterium abscessus (intra-operative antimicrobials); (3) invasive aspergillosis (treatment of culture-negative but positive BAL galactomannan) (duration of therapy); (4) respiratory syncytial virus (duration of antiviral therapy); (5) left ventricular assist device deep infection (initial empirical antimicrobial coverage) and (6) CMV (duration of secondary prophylaxis). CONCLUSION This Delphi panel developed consensus-based recommendations for 10 infectious clinical syndromes seen in TTx and MCS recipients.
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Affiliation(s)
- Me-Linh Luong
- Department of Medicine, Division of Infectious Diseases, CHUM, Montreal, Quebec, Canada
| | | | - Fernanda P Silveira
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh and UPMC, Pittsburgh, Pennsylvania, USA
| | - Catherine O Morrissey
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Erik A M Verschuuren
- Department of Pulmonary diseases and tuberculosis, University Medical Center Groningen, Groningen, The Netherlands
| | - Cameron R Wolfe
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Denis Hadjiliadis
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel C Chambers
- Queensland Lung Transplant Program, The Prince Charles Hospital, Brisbane, Australia
| | - Jignesh K Patel
- Department of Medicine, Division of Cardiology, Cedars Sinai Heart Institute, Los Angeles, California, USA
| | - Goran Dellgren
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Miranda So
- University Health Network, Toronto, Ontario, Canada
| | - Geert M Verleden
- Department of Medicine, Division of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Emily A Blumberg
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robin Vos
- Department of Medicine, Division of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Michael Perch
- Department of Cardiology, Section for Lung transplantation, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Are M Holm
- Department of Medicine, Division of Respirology, Oslo University Hospital, Oslo, Norway
| | - Nicholas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Cecilia Chaparro
- Department of Medicine, Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Department of Medicine, Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
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3
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Meinert ÉFRC, Kremer J, Tochtermann U, Sommer W, Warnecke G, Karck M, Meyer AL. Pericardial Closure With Expanded Polytetrafluoroethylene Patch in Left Ventricular Assist Device Surgery. ASAIO J 2024; 70:371-376. [PMID: 38153977 DOI: 10.1097/mat.0000000000002126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Abstract
To reduce adhesions after left ventricular assist device (LVAD) implantation, pericardial closure using an expanded polytetrafluoroethylene (ePTFE) patch has been suggested. However, as foreign material, ePTFE patches could increase the risk of infectious complications. In this single-center retrospective study, we investigated outcomes of pericardial closure using an ePTFE patch in LVAD implantation. We included all patients who underwent LVAD implantation at our center between 2011 and 2020 (n = 166). Primary endpoint was development of mediastinitis at any point of time between LVAD implantation and heart transplantation (HTx) or death. Secondary endpoint was overall survival. Preoperative and postoperative clinical data were collected to ensure comparability between the groups. We included 166 patients with LVAD. A total of 116 patients (70%) underwent pericardial closure using an ePTFE patch. There were significant differences between the groups in treatment setting, previous cardiac surgery, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level, development of driveline infection, and HTx. Patients with an ePTFE patch developed mediastinitis more frequently (16%) than patients without ePTFE patch (4%) ( p = 0.039). A significant difference in overall survival between the groups could not be confirmed ( p = 0.29). The use of PTFE patches for pericardial closure in LVAD implantation was associated with a higher incidence of mediastinitis, but not with a difference in overall survival.
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Affiliation(s)
- Étienne F R C Meinert
- From the Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
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4
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Mornese Pinna S, Corcione S, Cavallone E, Shbaklo N, Vita D, De Benedetto I, Montrucchio G, Pasero D, Trompeo AC, Costamagna A, Brazzi L, Rinaldi M, Boffini M, De Rosa FG. Epidemiology and Risk Factors for Nosocomial Infections in Left Ventricular Assist Device Recipients. Life (Basel) 2024; 14:270. [PMID: 38398779 PMCID: PMC10890466 DOI: 10.3390/life14020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Left ventricular assist devices (LVADs) have been increasingly used as a valid option to improve the prognosis and reduce the symptoms of end-stage heart failure. However, long-term complications, mostly infections and coagulation disorders, are frequent. We described the epidemiology and risk factors for nosocomial infections (NIs) in a cohort of adult patients who underwent continuous-flow LVAD implant between January 2010 and December 2017 in Turin, Italy. Secondary outcomes were the prevalence of multidrug-resistant (MDR) bacteria and mortality. Results: Overall, 64 LVADs were implanted. A total of 32 (50%) patients experienced at least one episode of NI, with a total of 46 infectious events. VAD-related infections occurred in 22 patients (68.8%). Non VAD-related NIs occurred in 12 patients (37.5%), mainly low respiratory tract infections. Length of intensive care unit admission was a risk factor for NI (OR 1.224, 95%CI; 1.049, 1.429). Gram-negative bacilli were responsible for 58.8% of VAD-related infections and 79.5% of non-VAD related infections. In sixteen patients (50%), at least one episode of infection was related to an MDR strain. INTERMACS class and length of MV were independent risk factors for NIs by MDR strains (respectively, OR 2.12, 95%CI: 1.08, 6.80; p = 0.02 and OR 1.46, 95%CI: 1.07, 5.52, p = 0.047). In-hospital mortality was 6.3%. No differences in mortality were observed between infected and non-infected patients (p = 0.61) even when caused by MDR strains (p = 0.143). Conclusion: the rate of nosocomial infections in LVAD patients is associated with the length of ICU admission, and the etiology of nosocomial infection after LVAD implant is mainly due to GNB, including a high rate of MDR strains, especially KPC-KP and MDR PA.
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Affiliation(s)
- Simone Mornese Pinna
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10124 Turin, Italy (N.S.); (I.D.B.); (F.G.D.R.)
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10124 Turin, Italy (N.S.); (I.D.B.); (F.G.D.R.)
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - Elena Cavallone
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy;
| | - Nour Shbaklo
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10124 Turin, Italy (N.S.); (I.D.B.); (F.G.D.R.)
| | - Davide Vita
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10124 Turin, Italy (N.S.); (I.D.B.); (F.G.D.R.)
| | - Ilaria De Benedetto
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10124 Turin, Italy (N.S.); (I.D.B.); (F.G.D.R.)
| | - Giorgia Montrucchio
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (A.C.); (L.B.)
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza University Hospital, 10126 Turin, Italy;
| | - Daniela Pasero
- Department of Emergency, Anaesthesia and Intensive Care Unit, AOU Sassari, 07100 Sassari, Italy;
| | - Anna Chiara Trompeo
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza University Hospital, 10126 Turin, Italy;
| | - Andrea Costamagna
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (A.C.); (L.B.)
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza University Hospital, 10126 Turin, Italy;
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (A.C.); (L.B.)
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza University Hospital, 10126 Turin, Italy;
| | - Mauro Rinaldi
- Department of Surgical Sciences, Cardiac Surgery Division, University of Turin, 10124 Turin, Italy (M.B.)
| | - Massimo Boffini
- Department of Surgical Sciences, Cardiac Surgery Division, University of Turin, 10124 Turin, Italy (M.B.)
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10124 Turin, Italy (N.S.); (I.D.B.); (F.G.D.R.)
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5
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Lacy MG, Filippov E, Nematollahi S. Controlling infections in hospitalized pretransplant candidates. Curr Opin Organ Transplant 2024; 29:56-63. [PMID: 37991047 DOI: 10.1097/mot.0000000000001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
PURPOSE OF REVIEW Infections in hospitalized patients awaiting solid organ transplantation can pose complicated diagnostic and therapeutic challenges. Goals of management include stabilizing the patient, treating or controlling infections, and decreasing the risk of reactivation of infection after transplant. RECENT FINDINGS Groups such as The Organ Procurement and Transplantation Network, American Society of Transplantation Infectious Diseases Community of Practice and the European Society of Clinical Microbiology and Infectious Diseases have updated their guidelines on screening and treatment of infection in transplant candidates. There are also recent developments in therapeutic options for tuberculosis, COVID-19, Clostridioides difficile colitis, bloodstream infections, and other common infections. SUMMARY Ideally, antimicrobial therapy should be complete prior to transplantation. In situations in which completion of therapy prior to transplant is not feasible, therapy may need to be prolonged or modified. In most situations, infections can be managed similarly to the general population, although some infections, particularly fungal and mycobacterial, require a different management approach. We review disease- and organ-specific management.
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Affiliation(s)
- Marian G Lacy
- Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Evgenii Filippov
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Saman Nematollahi
- Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona
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6
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Lissandrin R, Sangani A, Pesare R, Minucci R, Pisani GP, Gazzoli F, Pelenghi S, Bruno R, Seminari E. Ultrasound for management of left ventricular assist device driveline infections: A single-center experience. Transpl Infect Dis 2024; 26:e14178. [PMID: 37870489 DOI: 10.1111/tid.14178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/24/2023]
Affiliation(s)
| | - Aurelia Sangani
- Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Internal Medicine and Treatment, University di Pavia, Pavia, Italy
| | - Rebecca Pesare
- Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Internal Medicine and Treatment, University di Pavia, Pavia, Italy
| | - Rita Minucci
- Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Internal Medicine and Treatment, University di Pavia, Pavia, Italy
| | - Giulia Pinuccia Pisani
- Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Cardiac Surgery Depertment, ASST Lecco, "A. Manzoni" Hospital, Lecco, Italy
| | - Fabrizio Gazzoli
- Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefano Pelenghi
- Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raffaele Bruno
- Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Medical, Surgical, Diagnostic and Pediatric Science, University of Pavia, Pavia, Italy
| | - Elena Seminari
- Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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7
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Fuller R, Jacobs SE. Candida Infectious Endocarditis and Implantable Cardiac Device Infections. Mycopathologia 2023; 188:893-905. [PMID: 37277679 DOI: 10.1007/s11046-023-00745-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
Intravascular diseases due to Candida species, including endocarditis and cardiac device-associated infections, are rare yet devastating manifestations of invasive candidiasis affecting an already vulnerable population. Despite their significant associated morbidity and mortality, limited prospective data exist to inform the optimal diagnostic and therapeutic approaches to these entities. Herein, we review the existing literature pertaining to the epidemiology, diagnosis, and management of infectious endocarditis, rhythm management device infections, and circulatory support device infections caused by Candida species and suggest areas for future research.
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Affiliation(s)
- Risa Fuller
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Samantha E Jacobs
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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8
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Inglis SS, Suh GA, Razonable RR, Schettle SD, Spencer PJ, Villavicencio MA, Rosenbaum AN. Infections in Patients With Left Ventricular Assist Devices: Current State and Future Perspectives. ASAIO J 2023; 69:633-641. [PMID: 37145863 DOI: 10.1097/mat.0000000000001956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
Mechanical circulatory support is increasingly being used as bridge-to-transplant and destination therapy in patients with advanced heart failure. Technologic improvements have led to increased patient survival and quality of life, but infection remains one of the leading adverse events following ventricular assist device (VAD) implantation. Infections can be classified as VAD-specific, VAD-related, and non-VAD infections. Risk of VAD-specific infections, such as driveline, pump pocket, and pump infections, remains for the duration of implantation. While adverse events are typically most common early (within 90 days of implantation), device-specific infection (primarily driveline) is a notable exception. No diminishment over time is seen, with event rates of 0.16 events per patient-year in both the early and late periods postimplantation. Management of VAD-specific infections requires aggressive treatment and chronic suppressive antimicrobial therapy is indicated when there is concern for seeding of the device. While surgical intervention/hardware removal is often necessary in prosthesis-related infections, this is not so easily accomplished with VADs. This review outlines the current state of infections in patients supported with VAD therapy and discusses future directions, including possibilities with fully implantable devices and novel approaches to treatment.
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Affiliation(s)
- Sara S Inglis
- From the Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota
| | - Gina A Suh
- Department of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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9
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Kitaura S, Jindai K, Okamoto K. Japan perspective on antimicrobial stewardship and solid organ transplantation. Transpl Infect Dis 2022; 24:e13939. [DOI: 10.1111/tid.13939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/22/2022] [Accepted: 07/17/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Satoshi Kitaura
- Department of Infectious Diseases The University of Tokyo Hospital Tokyo Japan
- The National Institute of Infectious Diseases Tokyo Japan
| | - Kazuaki Jindai
- Department of Virology Tohoku University Graduate School of Medicine Sendai Japan
- Department of Healthcare Epidemiology Kyoto University Kyoto Japan
| | - Koh Okamoto
- Department of Infectious Diseases The University of Tokyo Hospital Tokyo Japan
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10
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Singh M, Krishnan M, Ruiz ME, Sheikh FH. Nontuberculous Mycobacterial Infections Associated With Left Ventricular Assist Devices in 3 Patients. Tex Heart Inst J 2022; 49:483734. [PMID: 35838643 DOI: 10.14503/thij-20-7498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Durable left ventricular assist devices (LVADs) provide circulatory support in patients with end-stage heart failure; however, complications include infection of the driveline exit site. Nontuberculous mycobacterial infections are rare in patients with LVADs, but they should be considered in those who have undergone device exchanges and have bacterial infections with driveline exit-site discharge but no fever or leukocytosis. We reviewed the charts of patients who had an LVAD implanted at our institution from January 2009 through December 2019, to identify those with a device-related nontuberculous mycobacterial infection. Collected data included patient demographics, premorbid conditions, infection type, previous device complications, treatment, and outcomes. We identified infections in 3 patients (mean age, 41 yr): Mycobacterium abscessus in 2 and M. chimaera in 1. All had a HeartMate II device and had undergone device exchanges for pump thrombosis or for driveline fault or infections. All presented with driveline exit-site discharge without fever or leukocytosis. The mean time between initial device implantation and diagnosis of a nontuberculous mycobacterial infection was 55 months. All 3 patients were treated with antibiotics and underwent localized surgical débridement; one underwent an additional device exchange. The M. abscessus infections disseminated, and both patients died; the patient with M. chimaera infection continued to take suppressive antibiotics. Nontuberculous mycobacterial infections are associated with high morbidity and mortality rates, warranting prompt diagnosis and treatment.
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Affiliation(s)
- Manavotam Singh
- Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Mrinalini Krishnan
- Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Maria Elena Ruiz
- Section of Infectious Diseases, Department of Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Farooq H Sheikh
- Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
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11
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Julia BV, Yochiro N, Matthias L. Infections in LVAD patients. J Card Surg 2022; 37:2307-2308. [PMID: 35589559 DOI: 10.1111/jocs.16591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/23/2022] [Indexed: 01/05/2023]
Abstract
Infections in LVAD patients continue to be a major cause of morbidity and mortality. One needs to separate between early infections which are mostly driven by the general state of the patient before implant, and infections during long term support, mostly related to drive line issues. A diligent risk stratification before implant and close follow up after implant will help to reduce the incidence of infection.
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Affiliation(s)
- Bini Viotti Julia
- Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA.,Division of Infectious Diseases, University of Miami School of Medicine, Miami, Florida, USA
| | - Natori Yochiro
- Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA.,Division of Infectious Diseases, University of Miami School of Medicine, Miami, Florida, USA
| | - Loebe Matthias
- Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
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12
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Bini Viotti J, Natori Y, Loebe M. Infections in LVAD patients. J Card Surg 2022; 37:2090-2091. [PMID: 35490345 DOI: 10.1111/jocs.16576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 01/05/2023]
Abstract
Infections in left ventricular assist device (LVAD) patients remain common. Differentiating into device related and non-device related infection is crucial. The incidence of non-device related infections seems to be more determined by the overall condition of the LVAD recipient. Device related infections can be treated by innovative surgical approaches or by transplant. Infection increases the risk of mortaility while on LVAD.
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Affiliation(s)
- Julia Bini Viotti
- Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA.,Division of Infectious Diseases, University of Miami School of Medicine, Miami, Florida, USA
| | - Yochiro Natori
- Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA.,Division of Infectious Diseases, University of Miami School of Medicine, Miami, Florida, USA
| | - Matthias Loebe
- Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
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13
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Verkaik NJ, Yalcin YC, Bax HI, Constantinescu AA, Brugts JJ, Manintveld OC, Birim O, Croughs PD, Bogers AJJC, Caliskan K. Single-Center Experience With Protocolized Treatment of Left Ventricular Assist Device Infections. Front Med (Lausanne) 2022; 9:835765. [PMID: 35685416 PMCID: PMC9171101 DOI: 10.3389/fmed.2022.835765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/22/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Because of the current lack of evidence-based antimicrobial treatment guidelines, Left Ventricular Assist Device (LVAD) infections are often treated according to local insights. Here, we propose a flowchart for protocolized treatment, in order to improve outcome. Methods The flowchart was composed based on literature, consensus and expert opinion statements. It includes choice, dosage and duration of antibiotics, and indications for suppressive therapy, with particular focus on Staphylococcus aureus (SA) (Figure 1). The preliminary treatment results of 28 patients (2 from start cephalexin suppressive therapy) after implementation in July 2018 are described. Results Cumulative incidence for first episode of infection in a 3-year time period was 27% (26 of 96 patients with an LVAD). Twenty-one of 23 (91%) first episodes of driveline infection (10 superficial and 13 deep; nine of 13 caused by SA) were successfully treated with antibiotics according to flowchart with complete resolution of clinical signs and symptoms. For two patients with deep driveline infections, surgery was needed in addition. There were no relapses of deep driveline infections, and only 2 SA deep driveline re-infections after 6 months. Nine patients received cephalexin of whom four patients (44%) developed a breakthrough infection with cephalexin-resistant gram-negative bacteria. Conclusions The first results of this protocolized treatment approach of LVAD infections are promising. Yet, initiation of cephalexin suppressive therapy should be carefully considered given the occurrence of infections with resistant micro-organisms. The long-term outcome of this approach needs to be established in a larger number of patients, preferably in a multi-center setting.
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Affiliation(s)
- Nelianne J Verkaik
- Department of Medical Microbiology and Infectious Diseases, Rotterdam, Netherlands
| | - Yunus C Yalcin
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Rotterdam, Netherlands.,Department of Cardio-Thoracic Surgery, Rotterdam, Netherlands
| | - Hannelore I Bax
- Department of Medical Microbiology and Infectious Diseases, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Alina A Constantinescu
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Rotterdam, Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Rotterdam, Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Rotterdam, Netherlands
| | - Ozcan Birim
- Department of Cardio-Thoracic Surgery, Rotterdam, Netherlands
| | - Peter D Croughs
- Department of Cardio-Thoracic Surgery, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardio-Thoracic Surgery, Rotterdam, Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Unit of Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Rotterdam, Netherlands
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14
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So M, Tsai H, Swaminathan N, Bartash R. Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e72. [PMID: 36483373 PMCID: PMC9726551 DOI: 10.1017/ash.2022.53] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 06/17/2023]
Abstract
Antimicrobial therapies are essential tools for transplant recipients who are at high risk for infectious complications. However, judicious use of antimicrobials is critical to preventing the development of antimicrobial resistance. Treatment of multidrug-resistant organisms is challenging and potentially leads to therapies with higher toxicities, intravenous access, and intensive drug monitoring for interactions. Antimicrobial stewardship programs are crucial in the prevention of antimicrobial resistance, though balancing these strategies with the need for early and frequent antibiotic therapy in these immunocompromised patients can be challenging. In this review, we summarize 5 frequently encountered transplant infectious disease stewardship challenges, and we suggest strategies to improve practices for each clinical syndrome. These 5 challenging areas are: asymptomatic bacteriuria in kidney transplant recipients, febrile neutropenia in hematopoietic stem cell transplantation, antifungal prophylaxis in liver and lung transplantation, treatment of left-ventricular assist device infections, and Clostridioides difficile infection in solid-organ and hematopoietic stem-cell transplant recipients. Common themes contributing to these challenges include limited data specific to transplant patients, shortcomings in diagnostic testing, and uncertainties in pharmacotherapy.
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Affiliation(s)
- Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Helen Tsai
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Neeraja Swaminathan
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
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15
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Fuller R, Taimur S, Baneman E. Mechanical Circulatory Support Infections in Heart Transplant Candidates. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00772-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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16
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Castrodeza J, Ortiz-Bautista C, Fernández-Avilés F. Continuous-flow left ventricular assist device: Current knowledge, complications, and future directions. Cardiol J 2021; 29:293-304. [PMID: 34967940 PMCID: PMC9007493 DOI: 10.5603/cj.a2021.0172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/25/2022] Open
Abstract
Long-term continuous-flow left ventricular assist devices have become a real alternative to heart transplantation in patients with advanced heart failure, achieving a promising 2-year event-free survival rate with new-generation devices. Currently, this technology has spread throughout the world, and any cardiologist or cardiac surgeon should be familiar with its fundamentals and its possible complications as well as the advances made in recent years. The aim of this review is to describe current knowledge, management of complications, and future directions of this novel heart-failure therapy.
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Affiliation(s)
- Javier Castrodeza
- Cardiology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain.
- CIBER de Enfermedades Cardiovasculares (CIBER - CV), Spain.
| | - Carlos Ortiz-Bautista
- Cardiology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
- CIBER de Enfermedades Cardiovasculares (CIBER - CV), Spain
| | - Francisco Fernández-Avilés
- Cardiology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
- CIBER de Enfermedades Cardiovasculares (CIBER - CV), Spain
- Universidad Complutense, Madrid, Spain
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17
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Iwata N, Shibata SC, Yoshioka D, Uchiyama A, Toda K, Sawa Y, Fujino Y. Impact of Ventricular Assist Device-Specific Infections on Post-Heart Transplant Infections: A Retrospective Single-Center Study. Transplant Proc 2021; 53:3030-3035. [PMID: 34732298 DOI: 10.1016/j.transproceed.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/31/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with a ventricular assist device (VAD) who are awaiting heart transplant (HTx) are susceptible to infections. Such infections, especially at the site of the VAD, may increase the risk of severe post-transplant infections and mortality. Information on the characteristics of VAD-specific infections and outcomes in HTx recipients after prolonged periods of LVAD therapy is scarce. PURPOSE We aimed to assess the impact of active VAD-specific infections on the incidence of early post-transplant infections and patient survival. METHODS We conducted a retrospective review of adult HTx cases at our center between April 2011 and October 2020. Informed consent was waived due to study design. A total of 86 patients were included in this study, among whom 94.2% (n = 81) were bridged with a VAD, and the median VAD support period was 1089 days. RESULTS Patients with active VAD-specific infections were significantly more likely to develop severe acute mediastinitis [odds ratio (OR) 14.8, 95% confidence interval (CI) 4.83-45.4, P < .01]. Active VAD infections were significantly related to increased length of intensive care unit stay (22.1 days vs 13.0 days, P = .016) and longer mechanical ventilation periods (324.7 hours vs 113.2 hours, P = .03). The 30-day survival rates for patients with and without post-transplant infections were 100% and 97.1%, respectively. CONCLUSION Compared to other risk factors, the presence of active VAD-specific infections increases the risk of early post-heart transplant infections and morbidity, without affecting mortality.
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Affiliation(s)
- Naomi Iwata
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Sho C Shibata
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akihiko Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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18
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Cardenas-Alvarez JL, Suarez J, Motoa G, Anjan S, Natori Y, Loebe M, Breda JR, Thakkar-Rivera N, Phancao A, Ghodsizad A, Bauerlein JE, Munagala MR, Simkins J. Cefazolin plus ertapenem and heart transplantation as salvage therapy for refractory LVAD infection due to methicillin-susceptible Staphylococcus aureus: A case series. J Card Surg 2021; 36:4786-4788. [PMID: 34599521 DOI: 10.1111/jocs.16040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/07/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022]
Abstract
The use of left ventricular assist devices (LVADs) is increasingly more common as the availability of donor organs in relation to failing hearts is outstandingly limited. Infections are the most common complications in LVAD recipients, particularly those caused by Staphylococcus spp. Refractory LVAD-related infections are not uncommon as achieving adequate source control is often not feasible before heart transplantation. Evidence suggest that cefazolin plus ertapenem is effective in refractory methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, but this approach has not been described in LVAD recipients. In this article, we report two cases of refractory MSSA bacteremia in LVAD recipients that were successfully treated with salvage therapy with cefazolin plus ertapenem and subsequent heart transplantation. This treatment strategy should be considered in patients with refractory LVAD-associated infection due to MSSA that are not responding to standard treatment.
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Affiliation(s)
- Jorge L Cardenas-Alvarez
- Department of Medicine, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Jose Suarez
- Division of Infectious Diseases, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Gabriel Motoa
- Department of Medicine, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Shweta Anjan
- Division of Infectious Diseases, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Yoichiro Natori
- Division of Infectious Diseases, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Matthias Loebe
- Department of Surgery, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Joao R Breda
- Department of Surgery, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Nina Thakkar-Rivera
- Division of Cardiology, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Anita Phancao
- Division of Cardiology, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Ali Ghodsizad
- Department of Surgery, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Joseph E Bauerlein
- Division of Cardiology, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Mrudula R Munagala
- Division of Cardiology, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Jacques Simkins
- Division of Infectious Diseases, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
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19
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Krzelj K, Petricevic M, Gasparovic H, Biocina B, McGiffin D. Ventricular Assist Device Driveline Infections: A Systematic Review. Thorac Cardiovasc Surg 2021; 70:493-504. [PMID: 34521143 DOI: 10.1055/s-0041-1731823] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Infection is the most common complication in patients undergoing ventricular assist device (VAD) implantation. Driveline exit site (DLES) infection is the most frequent VAD infection and is a significant cause of adverse events in VAD patients, contributing to morbidity, even mortality, and repetitive hospital readmissions. There are many risk factors for driveline infection (DLI) including younger age, smaller constitution of patients, obesity, exposed velour at the DLES, longer duration of device support, lower cardiac index, higher heart failure score, DLES trauma, and comorbidities such as diabetes mellitus, chronic kidney disease, and depression. The incidence of DLI depends also on the device type. Numerous measures to prevent DLI currently exist. Some of them are proven, whereas the others remain controversial. Current recommendations on DLES care and DLI management are predominantly based on expert consensus and clinical experience of the certain centers. However, careful and uniform DLES care including obligatory driveline immobilization, previously prepared sterile dressing change kits, and continuous patient education are probably crucial for prevention of DLI. Diagnosis and treatment of DLI are often challenging because of certain immunological alterations in VAD patients and microbial biofilm formation on the driveline surface areas. Although there are many conservative and surgical methods described in the DLI treatment, the only possible permanent solution for DLI resolution in VAD patients is heart transplantation. This systematic review brings a comprehensive synthesis of recent data on the prevention, diagnostic workup, and conservative and surgical management of DLI in VAD patients.
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Affiliation(s)
- Kristina Krzelj
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mate Petricevic
- Division of Health Studies, Department of Cardiac Surgery, University of Split, University Hospital Center Zagreb, Zagreb, Croatia
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - David McGiffin
- Department of Cardiothoracic Surgery and Transplantation, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Clayton, Victoria, Australia
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20
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Systems of conductive skin for power transfer in clinical applications. EUROPEAN BIOPHYSICS JOURNAL: EBJ 2021; 51:171-184. [PMID: 34477935 PMCID: PMC8964546 DOI: 10.1007/s00249-021-01568-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/29/2021] [Accepted: 08/12/2021] [Indexed: 11/03/2022]
Abstract
The primary aim of this article is to review the clinical challenges related to the supply of power in implanted left ventricular assist devices (LVADs) by means of transcutaneous drivelines. In effect of that, we present the preventive measures and post-operative protocols that are regularly employed to address the leading problem of driveline infections. Due to the lack of reliable wireless solutions for power transfer in LVADs, the development of new driveline configurations remains at the forefront of different strategies that aim to power LVADs in a less destructive manner. To this end, skin damage and breach formation around transcutaneous LVAD drivelines represent key challenges before improving the current standard of care. For this reason, we assess recent strategies on the surface functionalization of LVAD drivelines, which aim to limit the incidence of driveline infection by directing the responses of the skin tissue. Moreover, we propose a class of power transfer systems that could leverage the ability of skin tissue to effectively heal short diameter wounds. In this direction, we employed a novel method to generate thin conductive wires of controllable surface topography with the potential to minimize skin disruption and eliminate the problem of driveline infections. Our initial results suggest the viability of the small diameter wires for the investigation of new power transfer systems for LVADs. Overall, this review uniquely compiles a diverse number of topics with the aim to instigate new research ventures on the design of power transfer systems for IMDs, and specifically LVADs.
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21
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Ryu H, Narayanan N, Bhatt PJ. Prevention of infection and optimizing vaccination in the solid organ transplant candidate and recipient. Curr Opin Organ Transplant 2021; 26:445-455. [PMID: 34227584 DOI: 10.1097/mot.0000000000000902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Infections can result in serious complications in solid organ transplant (SOT) patients. The need to remain up to date on recommendations on screening, vaccinations, and chemoprophylaxis is paramount in the management of SOT patients. The goal of this review is to provide an overview of current recommendations for the prevention of infections and optimization of vaccinations from the pretransplant through posttransplant periods. RECENT FINDINGS There is an emphasis on thorough pretransplant evaluation to guide clinicians and pretransplant testing based on epidemiological and endemic risk factors. Additionally, recent studies on vaccine safety and efficacy of newer vaccine formulations in SOT recipients are addressed. SUMMARY This review provides insight on updated recommendations for pretransplant screening, new data on vaccine optimization in SOT recipients and posttransplant prophylaxis. Further research is needed in order to improve preventive measures including screening tests, vaccines, and chemoprophylaxis.
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Affiliation(s)
- HaYoung Ryu
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick
| | - Navaneeth Narayanan
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, Piscataway
- Division of Allergy/Immunology and Infectious Diseases, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Pinki J Bhatt
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, Piscataway
- Division of Allergy/Immunology and Infectious Diseases, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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22
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Bhagra SK, Pettit S, Parameshwar J. Implantable left ventricular assist device: indications, eligibility and current outcomes. Heart 2021; 108:233-241. [PMID: 34099466 DOI: 10.1136/heartjnl-2020-317886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Sai Kiran Bhagra
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Stephen Pettit
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Jayan Parameshwar
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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23
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Abstract
PURPOSE OF REVIEW The use of durable ventricular assist devices (VAD) to manage end-stage heart failure is increasing, but infection remains a leading cause of morbidity and mortality among patients with VAD. In this review, we synthesize recent data pertaining to the epidemiology, diagnosis, management, and prevention of VAD infections, discuss transplant considerations in patients with VAD infections, and highlight remaining knowledge gaps. We also present a conceptual framework for treating clinicians to approach these infections that draws on the same principles that guide the treatment of analogous infections that occur in patients without VAD. RECENT FINDINGS Despite advances in device design, surgical techniques, and preventative interventions, more than a third of VAD recipients still experience infection as an adverse outcome. Positron emission tomography has emerged as a promising modality for identifying and characterizing VAD infections. High-quality data to support many of the routine therapeutic strategies currently used for VAD infections-including suppressive antibiotic therapy, surgical debridement/device exchange, and novel antimicrobials for emerging multidrug-resistant organisms-remain limited. Although pre-transplant VAD infection may impact some early transplant outcomes, transplantation remains a viable option for patients with most types of VAD infection. Standardized definitions of VAD infection applied to large registry datasets have yielded key insights into the epidemiology of infectious complications among VAD recipients, but more prospective studies are needed to evaluate the effectiveness of existing and novel diagnostic and therapeutic strategies.
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Affiliation(s)
- Varun K Phadke
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.
| | - Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
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24
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Ki KK, Millar JE, Langguth D, Passmore MR, McDonald CI, Shekar K, Shankar-Hari M, Cho HJ, Suen JY, Fraser JF. Current Understanding of Leukocyte Phenotypic and Functional Modulation During Extracorporeal Membrane Oxygenation: A Narrative Review. Front Immunol 2021; 11:600684. [PMID: 33488595 PMCID: PMC7821656 DOI: 10.3389/fimmu.2020.600684] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022] Open
Abstract
A plethora of leukocyte modulations have been reported in critically ill patients. Critical illnesses such as acute respiratory distress syndrome and cardiogenic shock, which potentially require extracorporeal membrane oxygenation (ECMO) support, are associated with changes in leukocyte numbers, phenotype, and functions. The changes observed in these illnesses could be compounded by exposure of blood to the non-endothelialized surfaces and non-physiological conditions of ECMO. This can result in further leukocyte activation, increased platelet-leukocyte interplay, pro-inflammatory and pro-coagulant state, alongside features of immunosuppression. However, the effects of ECMO on leukocytes, in particular their phenotypic and functional signatures, remain largely overlooked, including whether these changes have attributable mortality and morbidity. The aim of our narrative review is to highlight the importance of studying leukocyte signatures to better understand the development of complications associated with ECMO. Increased knowledge and appreciation of their probable role in ECMO-related adverse events may assist in guiding the design and establishment of targeted preventative actions.
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Affiliation(s)
- Katrina K Ki
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jonathan E Millar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Daman Langguth
- Clinical Immunology and Allergy, and Sullivan Nicolaides Pathology, Wesley Hospital, Brisbane, QLD, Australia
| | - Margaret R Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Charles I McDonald
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Kiran Shekar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Manu Shankar-Hari
- Department of Intensive Care Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom.,School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Hwa Jin Cho
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Paediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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25
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Brazeau NF, Levinson KJ, Schranz A, Moser KA, Hollis I, Iyer P, Chien C, Bowen A, van Duin D, Lachiewicz A, Andermann T, Jones M, Miller M, Juliano JJ, Bartelt LA. Loss of daptomycin susceptibility in clinical Staphylococcus epidermidis infection coincided with variants in WalK. EVOLUTION MEDICINE AND PUBLIC HEALTH 2020; 2020:219-224. [PMID: 33214904 PMCID: PMC7658547 DOI: 10.1093/emph/eoaa031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/07/2020] [Indexed: 01/25/2023]
Abstract
Daptomycin (DAP) is key in treating multidrug-resistant Staphylococcus infections. Diminished susceptibility to DAP is emerging among Staphylococcus epidermidis strains although mechanisms for non-susceptibility (NS) remain poorly understood. We report a case of persistent S. epidermidis bacteremia in which loss of DAP susceptibility arose during prolonged treatment. Whole genome sequencing identified two mutations, Q371del and P415L, in a single-affected gene, WalK, that coincided with the emergence of DAP-NS. Protein modeling of the mutations predicted a disruption of WalK protein configuration. The emergence of mutations in a single-gene during DAP exposure raises concerns in an era of increasingly treatment-resistant infections. Lay summary: Daptomycin is an important antibiotic for fighting Staphylococcus infections. We identified variants in the WalK gene that were coincident with resistance in a clinical Staphylococcus epidermidis infection. Clinicians, hospital epidemiologists, and microbiology laboratories need to be aware of the potential for the evolution of drug resistance during prolonged daptomycin therapy.
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Affiliation(s)
- Nicholas F Brazeau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Kara J Levinson
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Asher Schranz
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Kara A Moser
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Ian Hollis
- University of North Carolina Health, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599 USA
| | - Prashanth Iyer
- University of North Carolina Health, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599 USA
| | - Christopher Chien
- Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Amanda Bowen
- Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - David van Duin
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Anne Lachiewicz
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Tessa Andermann
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Melissa Jones
- Clinical Microbiology Laboratory, University of North Carolina Health Care, Chapel Hill, NC 27599, USA
| | - Melissa Miller
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Jonathan J Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Luther A Bartelt
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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26
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Radcliffe C, Doilicho N, Niu YS, Grant M. Efficacy and safety of chronic antimicrobial suppression therapy for left ventricular assist device driveline infections: A single-center descriptive experience. Transpl Infect Dis 2020; 22:e13379. [PMID: 32574417 DOI: 10.1111/tid.13379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/24/2020] [Accepted: 06/12/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Driveline infection (DLI) is the most common left ventricular assist device (LVAD) infectious complication. Short-term antimicrobial therapy and local debridement are the cornerstones of management for these infections, but the use of chronic antimicrobial suppression (CAS) therapy is not well characterized. METHODS To better characterize the efficacy of CAS therapy, we performed a retrospective review of all patients (N = 219) receiving care at our tertiary transplant center with continuous-flow LVADs placed between August 2007 and July 2019. RESULTS A total of 24 patients were identified as having received CAS therapy as treatment for DLIs. The mean age was 56 years, 50% were female, and chronic kidney disease affected 63% of patients. Staphylococcus aureus accounted for half of all initial DLIs, and the mean length of CAS therapy was 486 days (range 48-2287 days). All patients received per os regimens as suppression therapy. Adverse events impacted 5 of 24 patients (0.43 events per 1000 days). Overall, the use of CAS therapy led to successful outcomes in 50% of patients and 29% experienced treatment failures. The remaining patients experienced stable symptoms. Relapses were the most common cause of treatment failure, and three patients experienced reinfections while on CAS therapy. CONCLUSIONS Our study suggests that CAS therapy for DLIs can be well tolerated, and future studies are needed to determine which patients merit suppression.
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Affiliation(s)
| | | | - Yu Si Niu
- Yale School of Medicine, New Haven, CT, USA
| | - Matthew Grant
- Yale School of Medicine, New Haven, CT, USA.,Department of Internal Medicine, Section of Infectious Diseases, Yale New Haven Hospital, New Haven, CT, USA
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27
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Radcliffe C, Grant M. Over 870 days of successful antibiotic suppression therapy for VRE-infected left ventricular assist device. J Card Surg 2020; 35:1746-1748. [PMID: 32557822 DOI: 10.1111/jocs.14690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Left ventricular assist devices (LVADs) are used in patients with advanced heart failure. Infections are common complications following device placement; however, the efficacy of chronic antimicrobial suppression therapy for deep-seated infections is not well characterized. We report the case of a 49-year-old male with a HeartMate II LVAD who presented with a methicillin-sensitive Staphylococcus aureus pump pocket infection that was subsequently treated with antibiotics and HeartMate III pump exchange. A vancomycin-resistant Enterococcus faecium (VRE) pump pocket infection then developed and responded to surgical drainage followed by long-term suppression with daptomycin then linezolid for over 870 days. A second pump exchange was not required. To our knowledge, this represents the longest reported use of daptomycin (341 days) without symptomatic adverse events. Managing infections caused by multidrug-resistant pathogens presents a clinical challenge. This case demonstrates the potential for antimicrobial suppression therapy to allow for successful retention of a VRE-infected LVAD.
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Affiliation(s)
| | - Matthew Grant
- Yale School of Medicine, New Haven, Connecticut.,Department of Internal Medicine, Section of Infectious Diseases, Yale New Haven Hospital, New Haven, Connecticut
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28
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Cutaneous Fungal Infections in Left Ventricular Assist Device Recipients. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00396-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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29
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Expanding Use of New Technology Creates New Challenges in Preventing and Managing Infections: a Review of Diagnostic and Management Considerations for Infections Among Patients with Long-Term Invasive Devices for Advanced Heart Failure. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00724-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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30
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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] [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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31
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Zinoviev R, Lippincott CK, Keller SC, Gilotra NA. In Full Flow: Left Ventricular Assist Device Infections in the Modern Era. Open Forum Infect Dis 2020; 7:ofaa124. [PMID: 32405511 PMCID: PMC7209633 DOI: 10.1093/ofid/ofaa124] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/14/2020] [Indexed: 12/20/2022] Open
Abstract
With the rising prevalence of heart disease in the United States, there is increasing reliance on durable mechanical circulatory support (MCS) to treat patients with end-stage heart failure. Left ventricular assist devices (LVADs), the most common form of durable MCS, are implanted mechanical pumps that connect to an external power source through a transcutaneous driveline. First-generation LVADs were bulky, pulsatile pumps that were frequently complicated by infection. Second-generation LVADs have an improved design, though infection remains a common and serious complication due to the inherent nature of implanted MCS. Infections can affect any component of the LVAD, with driveline infections being the most common. LVAD infections carry significant morbidity and mortality for LVAD patients. Therefore, it is paramount for the multidisciplinary team of clinicians caring for these patients to be familiar with this complication. We review the epidemiology, prevention, diagnosis, treatment, and outcomes of LVAD infections.
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Affiliation(s)
- Radoslav Zinoviev
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Christopher K Lippincott
- Department of Medicine - Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sara C Keller
- Department of Medicine - Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Department of Medicine - Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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32
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Radcliffe C, Doilicho N, Grant M. Nontuberculous mycobacterial infections in left ventricular assist device patients. J Card Surg 2020; 35:1138-1141. [PMID: 32253770 DOI: 10.1111/jocs.14530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Left ventricular assist devices (LVADs) are integral for the management of medically refractory heart failure, and LVAD infections are common following device placement. Most infections are caused by Staphylococcal spp. and Gram-negative enteric bacteria but nontuberculous mycobacterial (NTM) infections have been reported. We present the second-ever reported case of a driveline infection caused by Mycobacterium fortuitum in a 75-year-old male with a continuous-flow LVAD. After receiving meropenem, azithromycin, and ciprofloxacin, he underwent device exchange and ultimately died after failing to recover neurologically. Management of NTM infections presents a clinical challenge due to the propensity for rapidly growing mycobacterial species to form biofilms and the possibility of negative cultures delaying diagnosis. To address the literature gap surrounding NTM infections in LVAD patients, we performed a systematic review and present all previously reported cases.
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Affiliation(s)
| | | | - Matthew Grant
- Yale School of Medicine, New Haven, Connecticut.,Department of Internal Medicine, Section of Infectious Diseases, Yale New Haven Hospital, New Haven, Connecticut
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33
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Haidar G, Green M. Intra-abdominal infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13595. [PMID: 31102546 DOI: 10.1111/ctr.13595] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/11/2019] [Indexed: 02/06/2023]
Abstract
This new guideline from the AST IDCOP reviews intra-abdominal infections (IAIs), which cause substantial morbidity and mortality among abdominal SOT recipients. Each transplant type carries unique risks for IAI, though peritonitis occurs in all abdominal transplant recipients. Biliary infections, bilomas, and intra-abdominal and intrahepatic abscesses are common after liver transplantation and are associated with the type of biliary anastomosis, the presence of vascular thrombosis or ischemia, and biliary leaks or strictures. IAIs after kidney transplantation include renal and perinephric abscesses and graft-site candidiasis, which is uncommon but may require allograft nephrectomy. Among pancreas transplant recipients, duodenal anastomotic leaks can have catastrophic consequences, and polymicrobial abscesses can lead to graft loss and death. Intestinal transplant recipients are at the highest risk for sepsis, infection due to multidrug-resistant organisms, and death from IAI, as the transplanted intestine is a contaminated, highly immunological, pathogen-rich organ. Source control and antibiotics are the cornerstone of the management of IAIs. Empiric antimicrobial regimens should be tailored to local susceptibility patterns and pathogens with which the patient is known to be colonized, with subsequent optimization once the results of cultures are reported.
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Affiliation(s)
- Ghady Haidar
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Green
- Departments of Pediatrics, Surgery & Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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