Preventing CIED infections - Venice Arrhythmias · Cardiologia 2 Aritmologia . Preventing CIED infections E.Soldati Disclosures None Division of Cardiovascular Diseases - University

Preventing CIED infections

E.Soldati University Hospital of Pisa Cardiologia 2 Aritmologia


E.Soldati

Disclosures

None

Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)

• Infection ≈ 1 % – 2-7% infection rate for replacement/upgrades1

– ≤ 0.5% infection rate for new implants1

• Malfunction ≈ 2.5 % – 1.65-20% annual ICD lead failure based on age2,3

CIEDs Complications


CIED Infections


1.1 LOCAL INFECTION


1.1 LOCAL INFECTION


Rising Rates of Cardiac Rhythm Management Device Infections in the United States: 1996 through 2006

A Voigt et al, PACE 2010; 33:414–419

…possible causes for this on-going epidemic include sicker patients and more complex procedures…

CIED implanted

Infections


Why?

•  Patients with more co-morbidities • �Sicker Patients�

•  Larger Devices • More ICDs

•  Longer implant time • Less experienced implanters • More complex devices

•  �Cathlab sterile technique� Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)

CIED infection is a serious complication

associated with sustantial morbidity, mortality and costs.

CIED infection increases the risk of in-hospital death by more than 2

fold

Baddour LM et al, Circulation 2010; 121:458-477 Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)



• Before the implant

• During the implant

• After the implant



• Before the implant

• Avoid temporary pacing • Wait if fever or BS abnormal • Avoid Bridging • Scrub the patient • AB prophylaxis • Choose the right hardware • Operators, staff and OR asepsys

Odds ratio for developing CIED Infection

Klug D et al. Circulation 2007;116(12):1349-1355. - Lekkerkerker JC et al. Heart 2009;95(9):715-720. Margey R et al. Europace 2010;12(1):64-70. - Sohail MR et al. Clin Infect Dis. 2007;45(2):166-173. Bloom H et al. Pacing Clinical Electrophysiology 2006;29(2):142-145.


CIEDs Infections RISK FACTORS


Klug Circ 2007; 116 Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)


Haeparin Bridging

Darouiche et al NEJM 2010

Which Antiseptic?

chlorhexidine–alcohol surgical prevent an estimated 40% of all

surgical-site infections


PACE 2012;00:1–13

For patients undergoing a CIED implant, perioperative systemic antibiotic (PSA) plus antiseptics delivered 1 hour

before the procedure significantly reduced the incidence of postoperative infection

META-ANALYSIS 15 studies (3.970 partecipants)


AHA/HRS 2010 Recommendations for Antimicrobial Prophylaxis at the time of CIED placement

Class I Prophylaxis with an antibiotic that has in vitro activity against staphylococci should be administered. - If cefazolin is selected for use, then it should be administered intravenously within 1 hour before incision; - if vancomycin is given, then it should be adminstered intravenously within 2 hours before incision. (Level of Evidence: A)

Baddour LM et al. Circulation 2010;121(3):458-477.

Which Antibiotic?


Sohail et al JACC 2007 189 positive CIED coltures

Bongiorni et al. Europace 2012

854 positive CIED coltures

69

13,86,1 5 5,1

10

10

20

3040

50

60

70

80

CoNS

Stf2Aureus

Gram2Negative

Corynebacterium

Other

Fungi


•  642 patients enrolled at 10 U.S. centers with 1.9 +/- 2.4 months FU. •  > 99% of all CIEDs successfully implanted (35% PM, 29% ICD, 36% CRT-D). •  Near half (49%) of the patients had at least 3 risk factors for CIEDs infections

1. Bloom H et al. PACE 2011;34(2):133-142 2. Krahn et al. Circ EP 2011;4(2):136-142 3. Gould et al. JAMA. 2006 295(16),1907-1911


Less hardware Single lead VDD AAI when WCL is acceptable Single chamber ICD for primary prevention

Implant time The shorter the better

Prevention of Complications


Operating Room and Staff Surgical Technique

PREVENTION OF INFECTION



• During the implant

• Check time • Replacements • Prevent bleeding • Operators, staff and OR asepsys

Romeyer-Bouchard C, et al. European Heart Journal 2010; 31: 203–210


Danish Pacemaker Registry

Johansen J B et al. Eur Heart J 2011;32:991-8

n= 44631

n= 8380




• After the implant

• Avoid reintervention • Reduce replacements • AB prophylaxis

Klug Circ 2007; 116 Division of Cardiovascular Diseases - University Hospital of Pisa (Italy)

Treatment of Complications


Conservative approach Reintervention if stricly necessary Use OR

Haematoma/Revision

Cardiac Devices Infection (CDI)



CIED Infections

Suspect!!!!......

• Physical examination • Blood samples • Blood coltures; Duke criteria • Vegetations • PET, Labeled WBC • ICE

1.1 LOCAL INFECTION


CIED Infections

…. and extract!!!!!!


Preventing CIED infections - Venice Arrhythmias · Cardiologia 2 Aritmologia . Preventing CIED infections E.Soldati Disclosures None Division of Cardiovascular Diseases - University

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