Review article

Infections of intracardiac devices☆

Infections in cardiac implantable electronic devices (CIEDs) constitute a serious complication. We sought to identify contamination of gloves before handling the device in primary and replacement CIED procedures.

Two groups of 30 patients underwent primary CIED implantation or replacement. Before the device entered the surgical field, surgeon and assistant imprinted their outer gloves on aerobe and anaerobe agar plates, and a wound swab was performed. Samples were cultured, and the presence of bacteria was identified, counted as the number of colony forming units, and characterized to the level of genus and species.

Samples from 40 (67%) procedures revealed bacteria on surgeons' or assistants' gloves. Contamination occurred in 80% of replacements and 67% of primary implantations (risk difference, 13%; 95% confidence interval [CI], −8.8 to 35.5). Contamination of surgeons' and assistants' gloves occurred in 55% and 44% of procedures, respectively. Coagulase-negative Staphylococcus (CNS) occurred in 52%, and Propionibacterium spp (PS) occurred in 84% of positive cases. For every 15 minutes of procedure time, colony levels increased by 7.4% (95% CI, 1.4%-13.4%).

Contamination of gloves is common during CIED procedures before handling the device. Therefore, devices are often handled with contaminated gloves. The most prevalent bacteria were PS and CNS, which are associated with clinical CIED infections. Changing outer gloves before handling the device might improve sterile state and lower infection risk.

La cirrosis hepática condiciona un empeoramiento del pronóstico en pacientes con endocarditis infecciosa (EI) y la indicación quirúrgica en este tipo de pacientes es controvertida. Nuestro objetivo fue el análisis de la morbimortalidad en este grupo de pacientes.

Se han revisado los casos de EI diagnosticados en nuestro hospital desde el 1 de enero de 1985 hasta el 15 de junio del 2015. Se ha realizado un estudio descriptivo de todos los casos, así como un análisis del subgrupo de pacientes que además presentaba algún grado de cirrosis hepática.

Se registraron 996 episodios de EI durante el periodo de estudio, de los cuales 54 episodios (5,42%) se diagnosticaron en pacientes con hepatopatía. Veintinueve pacientes (44,4%) se encontraban en estadio A de Child-Pugh, 19 pacientes (35,2%) en estadio B y 11 pacientes (20,37%) en estadio C. La mortalidad global de los pacientes cirróticos fue del 37%. La mortalidad en estos pacientes intervenidos quirúrgicamente aumentó de manera significativa del 20% en estadio A al 83% en estadio C de Child-Pugh, con una incidencia de complicaciones mayores del 77,1%.

La cirrosis hepática empeora claramente el pronóstico de la EI, aumentando la mortalidad global del 19,2% al 37%. Además se asocia a una tasa de complicaciones mayores muy elevada. Aunque los pacientes en estadio A intervenidos quirúrgicamente presentaron una mortalidad inferior a quienes siguieron tratamiento médico exclusivamente, la elevada mortalidad en estadios más avanzados obliga a establecer la indicación quirúrgica de manera individualizada y procurar un cuidadoso manejo perioperatorio en estos pacientes.

Liver cirrhosis worsens the prognosis of patients with infective endocarditis (IE), and the indication of surgery in this group of patients remains controversial. The aim of this study was to analyse the mortality of patients with liver cirrhosis and IE.

The study included all the patients diagnosed with IE in our Hospital, from 1 January 1985 to 15 June 2015. A descriptive analysis was performed on the whole cohort of patients, as well as on the subgroup that also had liver cirrhosis.

A total of 996 patients were diagnosed with IE, 54 (5.42%) of whom also had liver cirrhosis. Of these, 29 (44.4%) patients were in stage A on the Child-Pugh scale, 19 (35.2%) patients were in stage B, and (20.37%) 11 patients were in stage C. The incidence of major complications in cirrhotic patients was 77.1%. The overall mortality was 37%. Postoperative mortality significantly increased from 20% in stage A, to 83% in stage C of Child-Pugh scale.

Hepatic cirrhosis worsens the prognosis of IE, increasing postoperative mortality from 19.2% to 37%. Moreover, it is associated with a very high rate of major complications (77.1%). The mortality of stage A cirrhotic patients assigned to surgery was lower than the mortality of patients assigned to medical treatment. The high mortality rate in advanced stages of cirrhosis suggests that a more individualized surgical indication needs to be established, as well as a more careful post-operative management.

The use of cardiac implantable electronic device (CIED; pacemakers, implantable cardioverter-defibrillators [ICD], cardiac re-synchronized therapy [CRT]) implantation, one essential treatment for cardiac arrhythmias, is increasing. Infectious complications related to implants are the main reason for device removal and patient morbidity. We sought to identify the incidence of infectious complications among patients with cardiac device implantation and analyze the risk factors for infectious complications.

A retrospective analysis was conducted of 1307 patients (61.5±14.2 years-old, 49.6% male) with cardiac device implantation from January 1990 to April 2013. We analyzed the incidence of infectious complications during the follow-up period. To investigate risk factors associated with infectious complications, we conducted a 1:2 matched case-control study of patients with infectious complications and controls without infectious complications who had the same implantation period and physician.

Among 1307 patients, 12 had a confirmed device-related infection: 7 with a pocket infection and 5 with infective endocarditis. Over a total of 9091.9 device-years, the incidence of infectious complications was 1.3/1000 device-years, based on the 12 patients with an infection. ICD (5.1/1000 device-year) had a higher incidence of infectious complications than other cardiac devices, and no infectious complications were observed among patients with CRT implantation. Mean duration from the time of implantation to infection was 2.02±1.65 years. In a multivariate analysis, the number of prior procedures including wound revision or scar revision was an independent risk factor for infectious complications (OR=10.88, 95% CI 1.11->999, p=0.040).

Infection was a rare complication of cardiac device implantation, but repeated procedures were associated with infectious complications.

The aim of this study was to determine the hospitalization rates and outcomes of endocarditis among older adults.

Endocarditis is the most serious cardiovascular infection and is especially common among older adults. Little is known about recent trends for endocarditis hospitalizations and outcomes.

Using Medicare inpatient Standard Analytic Files, we identified all fee-for-service beneficiaries age ≥65 years with a principal or secondary diagnosis of endocarditis from 1999 to 2010. We used Medicare Denominator Files to report hospitalizations per 100,000 person-years. Rates of 30-day and 1-year mortality were calculated using Vital Status Files. We used mixed-effects models to calculate adjusted rates of hospitalization and mortality and to compare the results before and after 2007, when the American Heart Association revised their recommendations for endocarditis prophylaxis.

Overall, 262,658 beneficiaries were hospitalized with endocarditis. The adjusted hospitalization rate increased from 1999 to 2005, reaching 83.5 per 100,000 person-years in 2005, and declined during 2006 to 2007. After 2007, the decline continued, reaching 70.6 per 100,000 person-years in 2010. Adjusted 30-day and 1-year mortality rates ranged from 14.2% to 16.5% and from 32.6% to 36.2%, respectively. There were no consistent changes in adjusted rates of 30-day and 1-year mortality after 2007. Trends in rates of hospitalization and outcomes were consistent across demographic subgroups. Adjusted rates of hospitalization and mortality declined consistently in the subgroup with a principal diagnosis of endocarditis.

Our study highlights the high burden of endocarditis among older adults. We did not observe an increase in adjusted rates of hospitalization or mortality associated with endocarditis after publication of the 2007 guidelines.