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Lumish HS, Cagliostro B, Braghieri L, Bohn B, Mondellini GM, Antler K, Feldman V, Kleet A, Murphy J, Tiburcio M, Fidlow K, Jennings D, Sayer GT, Takeda K, Naka Y, Demmer RT, Aaron JG, Uriel N, Colombo PC, Yuzefpolskaya M. Driveline Infection in Left Ventricular Assist Device Patients: Effect of Standardized Protocols, Pathogen Type, and Treatment Strategy. ASAIO J 2022; 68:1450-1458. [PMID: 35239537 PMCID: PMC9469917 DOI: 10.1097/mat.0000000000001690] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Driveline infection (DLI) is common after left ventricular assist device (LVAD). Limited data exist on DLI prevention and management. We investigated the impact of standardized driveline care initiatives, specific pathogens, and chronic antibiotic suppression (CAS) on DLI outcomes. 591 LVAD patients were retrospectively categorized based on driveline care initiatives implemented at our institution (2009-2019). Era (E)1: nonstandardized care; E2: standardized driveline care protocol; E3: addition of marking driveline exit site; E4: addition of "no shower" policy. 87(15%) patients developed DLI at a median (IQR) of 403(520) days. S. aureus and P. aeruginosa were the most common pathogens. 31 (36%) of DLI patients required incision and drainage (I&D) and 5 (5.7%) device exchange. P. aeruginosa significantly increased risk for initial I&D (HR 2.7, 95% CI, 1.1-6.3) and recurrent I&D or death (HR 4.2, 95% CI, 1.4-12.5). Initial I&D was associated with a significant increased risk of death (HR 2.92 (1.33-6.44); P = 0.008) when compared to patients who did not develop DLI. Implementation of standardized driveline care protocol (E2) was associated with increased 2-year freedom from DLI compared to nonstandardized care (HR 0.36, 95% CI, 0.2-0.6, P < 0.01). Additional preventive strategies (E3&E4) showed no further reduction in DLI rates. 57(65%) DLI patients received CAS, 44% of them required escalation to intravenous antibiotics and/or I&D. Presence of P. aeruginosa DLI markedly increased risk for I&D or death. Conditional survival of patients progressing to I&D is diminished. Standardized driveline care protocol was associated with a significant reduction in DLI, while additional preventive strategies require further testing.
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Affiliation(s)
- Heidi S. Lumish
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Barbara Cagliostro
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Bruno Bohn
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Giulio M. Mondellini
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Karen Antler
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Vivian Feldman
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Audrey Kleet
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jennifer Murphy
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Melie Tiburcio
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Kathryn Fidlow
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Douglas Jennings
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Gabriel T. Sayer
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York
| | - Ryan T. Demmer
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York
| | - Justin G. Aaron
- Department of Medicine Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Paolo C. Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Paolo C. Colombo and Melana Yuzefpolskaya contributed equally to this study
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Paolo C. Colombo and Melana Yuzefpolskaya contributed equally to this study
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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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Hernandez JM, Huff M, Nlandu Z, Vekariya B, Torres J. Mycobacterium abscessus Infection in Left Ventricular Assist Device (LVAD): A Case Series. Cureus 2021; 13:e15718. [PMID: 34290918 PMCID: PMC8288603 DOI: 10.7759/cureus.15718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/05/2022] Open
Abstract
The limited availability of donor organs worldwide, has provoked a surge in the need for implantable left ventricular assist devices (LVADs) mainly as a bridge to heart transplantation or destination therapy. The rate of complications from LVAD use is also increasing, impacting morbidity, mortality, and costs. LVAD infections due to nontuberculous mycobacteria (NTM) are exceedingly rare, yet very difficult to treat. Here we present three cases of Mycobacterium abscessus LVAD infections. To our knowledge, only two other cases have been documented.
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Affiliation(s)
- Jarelys M Hernandez
- Infectious Diseases, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Mallorie Huff
- Infectious Diseases, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Zola Nlandu
- Infectious Diseases, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Bhavesh Vekariya
- Infectious Diseases, Orlando Regional Medical Center, Orlando, USA
| | - Jeniffer Torres
- Infectious Diseases, University of South Florida Morsani College of Medicine, Tampa, USA
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Hamad Y, Blanco-Guzman MO, Olsen MA, Wang X, Vader J, Verma A, Dubberke ER. The role of chronic suppressive antibiotics therapy in superficial drive line infection relapse of left ventricular assist devices: A retrospective cohort from a tertiary care center. Transpl Infect Dis 2021; 23:e13686. [PMID: 34251073 DOI: 10.1111/tid.13686] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/11/2021] [Accepted: 06/17/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Drive line infections (DLIs) are common complications of left ventricular assist devices (LVADs). Data on use of suppression antibiotic therapy are limited. METHODS We performed a retrospective review of 451 patients who underwent LVAD placement from January 2009 to May 2015. First superficial DLIs were included for analysis. We examined factors associated with the use of chronic suppressive antibiotics (CSAs) therapy. Cox proportional hazards models were performed to identify factors associated with DLI relapse with the same organism as the initial DLI. RESULTS A total of 69 patients developed a superficial DLI within a median of 195 (interquartile range [IQR] 98-348) days of LVAD insertion. The median age was 57 years, 87% were males, and 74% were White. Gram positive bacteria caused 61% of infections, with Staphylococcus aureus being the most common (35%). Forty-three (62%) patients received suppressive antibiotic therapy. Relapse DLI occurred in 29 (42%) patients. Independent risk factors for relapse infection in multivariable analysis were sepsis (aHR 5.94 [CI 1.42-24.92]), and MRSA DLI (aHR 4.19 [CI 1.37-12.79]). There was no difference in the proportion of patients with relapse among those who were treated with antibiotic suppression therapy versus not (44% vs. 38%, p = 0.64), although relapse occurred at a later time in those who received suppression (185 vs. 69 days, p < 0.01). CONCLUSION CSA therapy was associated with delayed time to DLI relapse but no significant difference in the proportion of patients with relapse. A prospective study is needed to examine the effect of suppression on relapse rates.
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Affiliation(s)
- Yasir Hamad
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
| | | | - Margaret A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
| | - Xiaowen Wang
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Justin Vader
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Amanda Verma
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Erik R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
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