Device Infection Research Articles

Chronic kidney disease and transvenous cardiac implantable electronic device infection-is there an impact on healthcare utilization, costs, disease progression, and mortality?

Cardiac implantable electronic device (CIED) infections are a burden to hospitals and costly for healthcare systems. Chronic kidney disease (CKD) increases the risk of CIED infections, but its differential impact on healthcare utilization, costs, and outcomes is not known. This retrospective analysis used de-identified Medicare Fee-for-Service claims to identify patients implanted with a CIED from July 2016 to December 2020. Outcomes were defined as hospital days and costs within 12 months post-implant, post-infection CKD progression, and mortality. Generalized linear models were used to calculate results by CKD and infection status while controlling for other comorbidities, with differences between cohorts representing the incremental effect associated with CKD. A total of 584 543 patients had a CIED implant, of which 26% had CKD and 1.4% had a device infection. The average total days in hospital for infected patients was 23.5 days with CKD vs. 14.5 days (P < 0.001) without. The average cost of infection was $121 756 with CKD vs. $55 366 without (P < 0.001), leading to an incremental cost associated with CKD of $66 390. Infected patients with CKD were more likely to have septicaemia or severe sepsis than those without CKD (11.0 vs. 4.6%, P < 0.001). After infection, CKD patients were more likely to experience CKD progression (hazard ratio 1.26, P < 0.001) and mortality (hazard ratio 1.89, P < 0.001). Cardiac implantable electronic device infection in patients with CKD was associated with more healthcare utilization, higher cost, greater disease progression, and greater mortality compared to patients without CKD.

Outcomes of complete removal versus conservative therapy in cardiac implantable electronic device infections – A systematic review and Meta-analysis

BackgroundComplete removal of cardiac implantable electronic devices (CIEDs) is recommended in patients with CIED infections, including both systemic and localized pocket infection. The aim of the study was to provide an up-to-date and comprehensive assessment of evidence relating to the effect of complete CIED extraction in patients with a CIED infection. MethodsWe performed a systematic review and meta-analysis of studies reporting short- and mid-term outcomes in patients who had a device infection or infective endocarditis (IE) and underwent complete removal of the cardiac device (generator and leads) compared to those who received conservative therapy (no removal, partial removal, local antibiotic infiltration or isolated antibiotic therapy). The primary outcome was reinfection/relapse. Secondary outcomes were short-term (30-day/in-hospital) and mid-term (mean follow-up: 43.0 months) mortality. Random effects model was performed. ResultsThirty-two studies met the criteria for inclusion in the final analysis. Patients with complete CIED extraction (n = 905) exhibited a lower rate of relapse/re-infection compared to patients (n = 195) with a conservative treatment approach (n = 195, OR 0.02, 95%CI 0.01–0.06, p < 0.0001, mean-follow-up: 16.1 months). Additionally, these patients displayed a lower short- (OR 0.40, 95%CI 0.23–0.69, p = 0.01) and mid-term (OR 0.52, 95%CI 0.34–0.78, p = 0.002) mortality. ConclusionsThe analysis indicates that patients with a CIED infection who undergo complete CIED extraction exhibit a lower rate of relapse/re-infection. Additionally, a lower short- and mid-term mortality is observed, although it is acknowledged that this outcome may be influenced by treatment allocation bias.

Welcoming Discourse on the Approach for Gram-Negative Bacteremia and Candidemia in Cardiovascular Implantable Electronic Device Infections.

Welcoming Discourse on the Approach for Gram-Negative Bacteremia and Candidemia in Cardiovascular Implantable Electronic Device Infections.

Evaluating the Approach for Gram-Negative Bacteremia and Fungemia in Cardiovascular Implantable Electronic Device Infections from a Recent IDSA Guideline on Advanced Nuclear Imaging in Cardiovascular Infections.

Evaluating the Approach for Gram-Negative Bacteremia and Fungemia in Cardiovascular Implantable Electronic Device Infections from a Recent IDSA Guideline on Advanced Nuclear Imaging in Cardiovascular Infections.

Circular economy for medical devices: Barriers, opportunities and best practices from a design perspective

In an era of electronics-driven healthcare, the disposability of many medical devices raises environmental concerns. Transitioning these devices towards a circular economy, involving practices like reuse, remanufacturing, and recycling, holds promise. Our paper explores this transition through desk research, literature review, and expert interviews, examining the current state of circular design in electronic medical devices. We unveil barriers, opportunities, and design recommendations for circularization. First, we highlight the circularity potential of medical devices currently on the market, implementing e.g. refuse, reuse, recycle, etc. Second, we present barriers for circular medical device design, (e.g. (perceived) safety and infection risks, (perceived) regulatory difficulties, financial constraints, and difficulties in collection and separation) and opportunities to overcome these barriers. Finally, we present 29 design-specific recommendations for creating circular medical devices. Our insights into circular healthcare practices urge design engineers to integrate sustainable principles into medical device development without compromising safety, quality, or functionality.

A Case-Based Review of LVAD Infection by MABC

Abstract We present a review of literature and report a case of left ventricular assist device (LVAD) infection and postsurgical wound infection with Mycobacterium abscessus complex (MABC) following exposure to sewage and tap water, respectively. The initial infectious process involved the driveline and the deep pocket and progressed to involve LVAD. Prior to availability of culture results, the patient was started on linezolid followed by surgical debridement of driveline site and change of exit site. The debrided tissue grew a smooth and a rough colony variant of MABC. After 2 weeks of imipenem intravenous (IV), tigecycline IV, azithromycin oral (PO), and tedizolid PO, the patient presented to us with worsening of wound status. Antimicrobial therapy was changed to amikacin IV, imipenem IV, and cefoxitin IV along with bedside debridement, removal of 3 sutures, and placement of wound vacuum device. Amikacin IV, imipenem IV, and cefoxitin IV were then replaced with Recarbio (imipenem/cilastatin/relebactam) IV plus amoxicillin PO with significant improvement. The patient underwent LVAD removal and heart transplantation after 5 weeks and was discharged 15 days later. Following showering at home, the patient developed signs of extensive infection involving the surgical wound (chest and abdominal walls). Tigecycline IV and azithromycin IV were started. Imipenem/cilastatin/ relebactam IV plus amoxicillin PO were replaced by bedaquiline PO because of the continued financial burden to the patient. The patent was discharged on bedaquiline PO and azithromycin PO to complete 18 months of antimicrobial therapy at which time he was enjoying a very active lifestyle as he did prior to the diagnosis of advanced heart failure. He continues to do well 2 years 9 months after heart transplantation and more than a year after stopping all antimycobacterial therapy.

Infection of Transcatheter Valvular Devices.

This review explores the epidemiology, clinical traits, and diagnosis of Transcatheter Aortic Valve Replacement-Associated Infective Endocarditis (TAVR-IE) and mitral transcatheter edge-to-edge repair infective endocarditis (TEER-IE), focusing on a multimodal imaging approach. It addresses the rising prevalence of TAVR and TEER, emphasizing the need to understand long-term complications and clinical consequences, which poses significant challenges despite advancements in valve technology. Studies report a variable incidence of TAVR-IE and TEER-IE influenced by diverse patient risk profiles and procedural factors. Younger age, male gender, and certain comorbidities emerge as patient-related risk factors. Procedure-related factors include intervention location, valve type, and technical aspects. Microbiologically, Staphylococcus aureus, Viridans Group Streptococcus, and Enterococcus are frequently encountered pathogens. TAVR-IE and TEER-IE diagnosis involves a multimodal imaging approach due to limitations in echocardiography. Blood cultures and imaging aid identification, with Fluorescence in situ hybridization is showing promise. Treatment encompasses medical management with antibiotics and, when necessary, surgical intervention. The management approach requires a multidisciplinary "Endocarditis Team." This review underscores the need for continued research to refine risk prediction, enhance diagnostic accuracy, and optimize management strategies for TAVR-IE, considering the evolving landscape of transcatheter interventions.

Efficacy of a gentamycin-collagen sponge to prevent infection in implantable cardioverter defibrillator patients undergoing revision surgery - results of a monocentric ICD registry observational study

Abstract Introduction Despite the obvious benefits, the use of implantable cardioverter defibrillators (ICDs) is associated with serious complications, including infections. In particular, device replacement or revision procedures are associated with an increased risk of infection. Aim of the study was to compare the cardiac device infection rate with and without the use of the gentamycin-collagen sponge (GCS) in patients undergoing device replacement or revision procedures of implanted ICDs. Methods A total of 491 consecutive ICD patients from a prospective single-centre ICD-registry who underwent elective device replacement, system upgrade or lead revision between 2017 and 6/2023 were analyzed. From September 2020 onwards, a GCS was inserted into the device pocket (GCS group, n = 256). These patients were compared to the patients implanted/ revised between 2017 and 8/2020 (control group, n = 235). Results The baseline characteristics and the PADIT score were similar in both groups (Table 1). The GCS was well tolerated and there were no complications associated with the GCS. The mean follow-time was 15 + 10 months in the GCS group and 30 + 11 months in the control group. The Kaplan-Meier estimated infection rate after one year was 1.0% in the GCS group and 3.5% in the control group (p = 0.03, Figure 1). Time from revision to infection was 144 + 134 days in the GCS group vs. 362 + 297 days in the control group. Conclusion Adjunctive use of a GCS was associated with a lower incidence of device infections than standard-of-care infection-prevention strategies alone.

Risk factors for asymptomatic bacterial colonization of cardiac implantable electronic devices

Abstract Introduction With broadening indications and a progressively ageing demographic, incidence of cardiac electronic implantable device (CIED) implantation increased. Despite device infection being rare, it persists as a serious complication concomitant with a high mortality rate. While extensive research on cardiac device infection (CDI) has been conducted, the incidence and clinical significance of asymptomatic bacterial CIED colonisation has not been investigated so far. Purpose Our study aims to elucidate potential risk factors for and investigate the clinical significance of asymptomatic bacterial CIED colonisation. Methods and Results In this prospective single centre study, 345 patients with no clinical signs of CIED infection underwent a generator exchange. In total, 78 pacemakers (PM), 97 implantable cardiac defibrillators (ICD), 67 cardiac resynchronisation therapy devices (CRT), 1 baroreceptor stimulator, as well as 102 implantable loop recorders were sonicated to determine the presence of adherent microorganisms (biofilms). Intraoperative swabs were collected in 329 patients. For statistical analysis, detection of ≥1 colony forming units (CFU) during sonication was considered a significant level of bacterial colonisation. The ≥50 CFU threshold was established in order to examine risk factors relevant for higher levels of bacterial colonization. 88 CIED (25.5%) showed bacterial colonisation ≥1 CFU while 44 CIED (12.8%) were colonised with ≥50 CFU. Multivariate analysis revealed male gender as independent risk factor for both ≥1 CFU (p&amp;lt;0.001; OR 7.73, CI 2.84-21.04) and ≥50 CFU (p&amp;lt;0.001; OR 12.14, CI 2.79-52.78). and immunosuppressive medication (p=0.018; OR 3.31; CI 1.23-8.92) as independent risk factor identified for ≥50 CFU colonisation. For both cutoffs, Cutibacterium acnes emerged as the most frequently detected bacterium during sonication, followed by coagulase negative Staphylococci (CoNS) with Staphylococcus epidermidis being the most common within this CoNS group. During the follow-up (384.5 +/- 480.6 days), 287 patients showed absence of CDI (53 patients lost to follow-up). Of the five patients with CDI, one exhibited concordant results between sonication, swab, and blood culture for Cutibacterium acnes, one presented with partially concordant results, whereas the other three showed varying degrees of disconcordance between index event microbiological results and subsequent CDI pathogens. Conclusion Remarkably, 27.2% of CIEDs with leads (PM, ICD, CRT) exhibited bacterial colonisation. Out of the 5 CDIs identified, 4 were associated with positive sonication results. In addition, our study identifies male gender and immunosuppressive medication as significant risk factors for asymptomatic bacterial CIED colonisation. Thus, in patients with these given risk factors, CIED sonication should be considered for risk stratification with regard to a subsequent CIED infection and possible targeted antimicrobial therapy.Flow Chart

Optimal timing of of cardiac implantable electronic device reoperation

Abstract Background Early re-intervention may increase the risk of infection of cardiac implantable electronic devices (CIED). Some operators therefore delay lead repositioning in case of dislocation by weeks, however there is no evidence to support this practice. The aim of our study was to evaluate the impact of the timing of re-operation on infection risk. Methods Data from consecutive patients (n=249) receiving lead/generator repositioning in one Hungarian and one German tertiary centre between January 1995 and August 2022 were retrospectively analysed. Relative risk of CIED infection in the first year was compared among patients undergoing early (≤1 week) vs. delayed (from 1 week to 1 year) re-operation. Results Out of 249 patients (mean age 70 ± 13 years, 54% male) requiring CIED re-intervention (30% single-chamber, 48% dual-chamber, and 22% CRT devices), 55 patients underwent right atrial (22%), 145 patients underwent right ventricular (59%), 20 patients underwent coronary sinus (8%), and 28 patients underwent multiple lead (11%) repositioning. Eighty-five patients (34%) went through an early (median 2, interquartile range (IQ): 1-4.5) and 164 (66%) patients had a delayed lead/pocket revision (median 53, IQ 36-209 days). A total of 9 (3,6%) wound/device infections were identified during the first year of follow-up, 1 (1,2%) vs. 8 (4,9%) in the in the early vs delayed groups. The risk of infection was numerically lower in the early vs. the delayed intervention groups yielding no statistically significant difference (OR=0.232; 95% CI 0.029-1.888; p=0.172). After adjustment for typical risk factors for CIED infection (i.e., number of implanted leads, diabetes, heart failure, fever prior to implant, therapy with corticosteroids, anticoagulation or antiplatelet therapy, temporary pacemaker) this difference remained non-significant (adjusted OR=0.266, 95% CI 0.032-2.246, p=0.224). System explantation/extraction was necessary in 7 cases (2,8 %), all being revised in the delayed group (OR early vs. delayed 0.128, 95% CI 0.01-2.273, p=0.161). Conclusion In this bicentric study, delayed re-intervention did not reduce the risk of CIED infection compared to patients undergoing an early (&amp;lt;1 week) re-operation.

Incidence of infections related to cardiac implantable electronic devices in Germany

Abstract Background Worldwide, the risk of cardiovascular implantable electronic device (CIED) infection is increasing. Publications of contemporary big data regarding CIED infections for Germany are lacking. This investigation is providing rates of CIED, hospital admission for CIED infection and related mortality in Germany. Methods Data from the biggest healthcare insurance fund was screened for CIED procedures, including placement, revision with aim to up- or downgrade, generator substitution, early revision and partial or complete extraction using specific procedure codes for reimbursement in Germany during 2015. Among the total population of beneficiaries with CIED placement in that year international Classification of Diseases, 10th revision German modification codes were used to identify CIED infections and lead related endocarditis. Results In 2015 altogether 60,296 patients (57.3% male) underwent a CIED procedure. 1129 (1.9%) patients underwent at least one procedure related to CIED infection and 466 (0.77%) participants underwent at least one procedure for treatment of a lead related endocarditis. CIED infection was associated with a mortality rate of 8.4%. Lead related endocarditis was associated with a mortality rate of 15.4% in 2015. Patients presenting with CIED infection and lead related endocarditis were younger (69.5 and 67.3 vs 73.5 years) and more often male (69.4 and 70.2 vs 57.3%) 2.22 procedures in case of hospital admission with CIED infection and 1.93 procedures in case of lead related endocarditis were conducted in 2015. Conclusions Our observational study shows that the rate of CIED infection is greater than has been reported by large randomised trials. Mortality rates for CIED infection and lead related endocarditis are in line with published rates. Younger age and male gender are host related risk factors for an increased risk for CIED infection and lead related endocarditis.

Impact of taurolidine use during cardiac electronic implantable device implantation in heart failure patients

Abstract Background Cardiac Implantable Electronic Device (CIED) infections represent a critical health threat with potentially fatal consequences. The TauroPace™ is an innovative solution that contains taurolidine specifically formulated to eradicate environmental microbial contamination on the surface of CIEDs. To date, scarce data are available in literature about Taurolidine’s effect on preventing CIED infections. Aims To investigate the ability of the TauroPace™ to reduce major CIED infections through 12 months follow-up in fragile patients such as heart failure (HF) patients. Methods This prospective cohort study included patients with HF and an ejection fraction ≤ 35%, who were referred for de novo implantation, upgrading or battery replacement of Implantable Cardioverter Defibrillator (ICD) or Cardiac Resynchronization Therapy with defibrillator (CRT-D), to the EP labs of two tertiary care hospitals. Patients with previous CIED infections were excluded. During the procedures, the catheters were submerged in the TauroPace™ solution and the pocket was irrigated with taurolidine. Starting from the main risk factors for the development of CIED-related infections as identified in the literature (including individuals with heart failure, diabetes, chronic kidney disease, and those undergoing defibrillators implantation, especially upgrades or revisions procedure), we conducted a meta-analysis and meta-regression to evaluate the relationship between the treatment effect's magnitude and various predictors. To estimate the incidence of CIED infections in high-risk subgroups, we utilized the percentage of patients with diabetes, chronic renal failure, or those undergoing replacement, upgrade, or revision procedures, along with other risk factors for CIED infections, as continuous variables and we were able to modify our comparison parameters based on the real percentage of risk factors that we obtained. Results The study included 69 consecutive patients (53 male [76.8 %], 34 ischemic [49,3 %], median [IQR] age 68 [59-73] years, 19 diabetic [27.5 %] and 34 [49.2 %] with chronic renal failure), of whom 39 (56.5 %) received ICD and 30 (43.5 %) CRT-D, with 28 (40.6 %) replacement procedures, 2 (2.9 %) upgrades, and 39 (57%) de novo implantations. During the one-year follow-up period, 1 [1.45 (Standard Error, SE 0.014) %] patient undergoing a CRT replacement developed an infection. The available data from the literature estimate an incidence rate of 6% (SE 0.0106) when considering a selected patient population with a very high risk of infection similar to our population. This is significantly higher than our cohort (z-score -2.5447, p value = 0.011). Conclusions Taurolidine has yielded promising results, demonstrating a low incidence rate of infections within our cohort of high-risk patients, which is below that reported in the literature. Further data will be necessary to validate and confirm these initial findings.

Investigating long-term outcomes and predictors of primary outcomes in patients treated for cardiac implantable electronic device infections

Abstract Background The estimated current infection rate after cardiac implantable electronic devices (CIED) implantation ranges between 1% and 2%, with variations in the literature from 0.13% to 12.6% (2). The rise in CIED implantation rates over the years has led to an escalation in the frequency of device-related infections. This trend is compounded by the elongation of patient comorbidities and life expectancy (3). Purpose The study aimed to investigate the primary outcome rates (including death, myocardial infarction (MI), cerebrovascular accidents (CVA), and reinfection) and identify predictors of primary outcomes in patients receiving treatment for CIED infection. Methods A retrospective analysis was conducted at a single-center. The study encompassed 2322 patients who sought treatment at the arrhythmia clinic of our Institute between March 2011 and July 2020 and underwent CIED implantation. After excluding 20 patients with active infections and 3 patients postoperative cardiac arrest, 36 patients were diagnosed with CIED infection (1.55% incidence). Diagnosis was based on the Novel 2019 International CIED Infection Criteria. Patients were categorized into groups based on the occurrence of all-cause death, MI, CVA, and reinfection during the follow-up period. Results The median follow-up period post admission with CIED infection was 42.5 (7-141) months. Table 1 presents patient characteristics, procedure details, and management-related parameters in the groups stratified by the primary endpoint. Notably, 58.3% of the patients had previously undergone a replacement procedure. Among patients with CIED infection, reinfection was observed in 20.0% of those who had a de novo procedure and 38.1% of those who underwent a secondary procedure (p: 0.25). Cox regression analysis revealed that pre-procedure C-reactive protein (CRP) levels and CHA2DS2-VASc score were independent predictors of the primary outcome (OR: 1.03 (1.00-1.06); P: 0.035, OR: 1.34(1.03-1.88); P: 0.030, respectively) (Table 2). Conclusion Long-term outcomes in patients with CIED infection appear to be correlated with pre-procedure CRP levels, indicating the severity of infection, and the CHA2DS2-VASc score, providing valuable insights into patient comorbidities. These factors seem to outweigh the impact of the specific procedure and antibiotic regimens administered. Management should not only focus on the history of CIED infection during follow-up but also prioritize the management of existing comorbidities to improve outcomes. Given the study's limitations such as the small sample size and retrospective nature, further investigations are warranted to confirm these findings.Table 1Table 2

Transfemoral leadless pacemaker implantation after tricuspid valve surgery and intervention

Abstract Background and Purpose Pacemaker (PM) implantation after surgical or transcatheter tricuspid valve (TV) repair or replacement may be challenging. Transcatheter leadless pacemaker (LPM) implantation has become a routine procedure and is frequently adopted in patients without the need for an atrial lead, in cases with cardiac implantable device infection or in patients with marked comorbidities. The use of LPM in patients with previous TV repair or replacement has only been described in singular cases in literature. We present our single center experience of LPM implantation after TV repair. Methods Patients with a history of TV repair or replacement who underwent LPM in our institution between 01/2020 and 11/2023 were retrospectively analyzed. All patients underwent routine clinical follow-up investigations including LPM interrogation and transthoracic echocardiography to assess for TV status. For LPM implantation right anterior oblique (RAO) and left anterior oblique (LAO) caudal fluoroscopy projections were utilized to enable LPM device passage across the TV. Results The study population consisted of 10 patients (9 females, mean age 74.0±10.0 years). Two patients had a history of surgical TV annuloplasty repair and two patients a history of surgical valve replacement, four patients of transcatheter TV repair (one through the mitral clip), one patient of transcatheter valve-in-ring bio prosthesis implantation prosthesis after previous surgical ring deployment and one patient transcatheter TV replacement (Figure1). All patients suffered from permanent atrial fibrillation previous to implantation procedures. Three patients were on chronic hemodialysis therapy before LPM implantation. LPM systems were successfully implanted in all cases with a mean procedure time of 43.5±26.5 minutes and a mean fluoroscopy time of 5.9±5.5 minutes and a radiation dose of 1148,7±1424,9 cGy·cm2. For fluoroscopically guided TV crossing a mean LAO angle of 43.6±14.1° (range 22 to 53°) and caudal angle of 8.5±6.9° (range 0 to 20°) was utilized (Figure 2). The LPM device was positioned in the first positioning attempt in a right ventricular high septal localization in 8 cases. Mean pacing threshold was 0.36±0.07 V at 0.25 ms, with a mean sensing amplitude of 10.5±2.9 mV and a mean of 853±324 Ohms pacing impedance. No periprocedural complications occurred. Mean duration of follow-up was 8.1±9.2 months. There were no newly developed TV regurgitations noted. Pacing thresholds (0.37±0.1 V/0.25 ms), sensing amplitude (11.8±4.5 mV) as well as pacing impedances (865±365 Ohms) remained stable until the last follow-up investigation. Conclusion LPM implantation was feasible in patients with a history of TV repair or replacement. LPM implantation was safe and effective in various modalities of TV repair. LPM may be an alternative to conventional pacemaker implantations as well as surgical lead placement in selected patients.Figure 1.Figure 2.

Phage Therapy for Cardiac Implantable Electronic Devices and Vascular Grafts: A Targeted Literature Review.

Infections of cardiac implantable electronic devices (CIEDs) and vascular grafts are some of the most dreaded complications of these otherwise life-saving devices. Many of these infections are not responsive to conventional treatment, such as systemic antibiotics and surgical irrigation and debridement. Therefore, innovative strategies to prevent and manage these conditions are warranted. Among these, there is an increasing interest in phages as a therapeutical option. In this review, we aim to collect the available evidence for the clinical application of phage therapy for CIED and vascular graft infections through literature research. We found 17 studies for a total of 34 patients. Most of the indications were left ventricular assist device (LVAD) (n = 20) and vascular graft infections (n = 7). The bacteria most often encountered were Staphylococcus aureus (n = 18) and Pseudomonas aeruginosa (n = 16). Clinical improvements were observed in 21/34 (61.8%) patients, with microbiological eradication in 18/21 (85.7%) of them. In eight cases, an adverse event related to phage therapy was reported. Phage therapy is a promising option for difficult-to-treat CIED and vascular graft infections by means of an individualized approach. Clinical trials and expanded access programs for compassionate use are needed to further unveil the role of phage therapy in clinical application.

WEARABLE CARDIOVERTER–DEFIBRILLATORS IN CLINICAL PRACTICE IMPLEMENTATION OF THE ANMCO POSITION PAPER FOR APPROPRIATE USE OF THE WEARABLE CARDIOVERTER DEFIBRILLATOR

Abstract Introduction Wearable cardioverter–defibrillators (WCD) have emerged as a valuable tool in the management of patients at risk for life–threatening arrhythmias. These devices offer a non–invasive and temporary solution, providing continuous monitoring and the potential for prompt defibrillation when needed. In this study, we explore the indications for WCD and evaluate arrhythmic events through comprehensive monitoring. Methods From November 2022 to December 2023, we conducted an outpatient follow–up of 18 patients receiving WCD. Regular check–ups and comprehensive echocardiography were performed to optimize therapy based on specific indications for each patient. Results The average age of the patients was 59.3±17.4 years, with 79% being male. Among the cohort, 58% had hypertension, and a similar percentage comprised smokers and individuals with dyslipidemia, while 32% were diabetic. The indications for receiving WCD were: de novo diagnosis of dilated cardiomyopathy with reduced ejection fraction in 9 (50%) patients, recent acute coronary syndrome and ejection fraction &amp;lt; 35% in 5 (28%), cardiac electronic device infections in 3 (17%) patients and myocarditis with electrical instability in 1 (5%) patient. Patients were in optimal medical therapy (OMT) tailored to their specific comorbidities, with 84% on renin–angiotensin–aldosterone system inhibitors, 95% on beta–blockers, 53% on mineralocorticoid receptor antagonists, 53% on sodium–glucose cotransporter–2 inhibitors, and 37% on antiarrhythmics. The average follow–up was 64±45 days according to specific etiology, with a daily wearing time of 22.9±1.1 hours. No device interventions were recorded. At the end of the follow–up period, 6 (33%) patients still required implantable cardioverter–defibrillator (ICD). Among these, 4 patients (22%) underwent to ICD implantation, 3 for secondary prevention, and 1 for primary prevention, while notably, 2 (11%) patients, declined the procedure. Conclusions The use of wearable cardioverter–defibrillators in the outpatient setting for patients at risk of life–threatening arrhythmias allowed to optimize therapy and restrict the indications for ICD, in our cohort up to 67%, with a good safety profile due to the low incidence of device interventions.

USE OF LIFE–VEST AND COMPLEX RE–IMPLANTATION OF CRT–D IN PATIENT WITH POCKET INFECTION BY MULTIRESISTENT S. AUREUS AND PERSISTENCE OF LEFT SUPERIOR VENA CAVA

Abstract Patient with primary hypokinetic dilated cardiomyopathy, previously underwent coronary angioplasty with stent implantation on MO branch and subsequent implantation of CRT–D in right subclavian region for persistence of left superior vena cava and complicated left sided implantation; hypertensive, dyslipidaemic, diabetic. Repeated subsequent surgery for shock channel malfunction with re–implantation of right ventricular lead. He came to our observation for infection of the CRT–D pocket by multiresistant Staphylococcus Aureus treated by intravenous antibiotic therapy and explantation of the infected device. We therefore proceeded to discharge the patient with Life–Vest as a bridging strategy until re–implantation and continued with long–acting antibiotic therapy administered every fortnight. After about 8 weeks, once the presence of infectious/inflammatory processes has been ruled out, CRT–D reimplantation is performed, after prophylaxis with Vancomycin, in the right subclavian region under sterile conditions and in the absence of complications. The management of cardiac device infections represents a challenge for the cardiologist especially in the complex patient with a history of re–interventions in which multi–resistant pathogens are often found. This clinical case demonstrates how collegial patient assessment and long–term protection strategies, such as the use of a Life–Vest, can achieve the diagnostic–therapeutic goal.

Differences in clinical outcomes of bloodstream infections caused by Klebsiella aerogenes, Klebsiella pneumoniae and Enterobacter cloacae: a multicentre cohort study

BackgroundKlebsiella aerogenes has been reclassified from Enterobacter to Klebsiella genus due to its phenotypic and genotypic similarities with Klebsiella pneumoniae. It is unclear if clinical outcomes are also more similar. This study aims to assess clinical outcomes of bloodstreams infections (BSI) caused by K. aerogenes, K. pneumoniae and Enterobacter cloacae, through secondary data analysis, nested in PRO-BAC cohort study.MethodsHospitalized patients between October 2016 and March 2017 with monomicrobial BSI due to K. aerogenes, K. pneumoniae or E. cloacae were included. Primary outcome was a composite clinical outcome including all-cause mortality or recurrence until 30 days follow-up. Secondary outcomes were fever ≥ 72 h, persistent bacteraemia, and secondary device infection. Multilevel mixed-effect Poisson regression was used to estimate the association between microorganisms and outcome.ResultsOverall, 29 K. aerogenes, 77 E. cloacae and 337 K. pneumoniae BSI episodes were included. Mortality or recurrence was less frequent in K. aerogenes (6.9%) than in E. cloacae (20.8%) or K. pneumoniae (19.0%), but statistical difference was not observed (rate ratio (RR) 0.35, 95% CI 0.08 to 1.55; RR 0.42, 95% CI 0.10 to 1.71, respectively). Fever ≥ 72 h and device infection were more common in K. aerogenes group. In the multivariate analysis, adjusted for confounders (age, sex, BSI source, hospital ward, Charlson score and active antibiotic therapy), the estimates and direction of effect were similar to crude results.ConclusionsResults suggest that BSI caused by K. aerogenes may have a better prognosis than E. cloacae or K. pneumoniae BSI.

Prevention and Risk Assessment of Cardiac Device Infections in Clinical Practice.

The implantation of cardiac electronic devices (CIEDs), including pacemakers and defibrillators, has become increasingly prevalent in recent years and has been accompanied by a significant rise in cardiac device infections (CDIs), which pose a substantial clinical and economic burden. CDIs are associated with hospitalizations and prolonged antibiotic therapy and often necessitate device removal, leading to increased morbidity, mortality, and healthcare costs worldwide. Approximately 1-2% of CIED implants are associated with infections, making this a critical issue to address. In this contemporary review, we discuss the burden of CDIs with their risk factors, healthcare costs, prevention strategies, and clinical management.

P48. Escalating Surgical Treatment for Left Ventricular Assist Device Infections is associated with Decreased Expected Mortality: A Clinical Risk Prediction Score

P48. Escalating Surgical Treatment for Left Ventricular Assist Device Infections is associated with Decreased Expected Mortality: A Clinical Risk Prediction Score