In the Journals

Time-consuming CIED infection interventions create gap in care

Many commonly used interventions to reduce cardiac implantable electronic device infections, or CIEDs, are ineffective, and the simplest strategies often have the greatest potential for improving CIED infection outcomes, according to results from a large, multicenter cohort study published in Infection Control & Hospital Epidemiology.

“Many of the most effective infection prevention interventions — such as screening for MRSA and decolonization — take several days’ advance notice in order to be effective,” Westyn Branch-Elliman, MD, MMSc, investigator at Veterans Affairs Boston Center for Healthcare Organization and Implementation Research, told Infectious Disease News. “In many cases, urgent and emergent cases go immediately to the operating room or procedural suite, and so it is not feasible to administer some of the lengthy prevention protocols prior to their surgical procedure.”

Branch-Elliman further explained that this creates a large gap in care.

“The patients least likely to benefit from the available infection prevention interventions — in other words, stable, elective cases — are the most likely to receive them,” she said.

Researchers analyzed a sample of procedures that were entered into the VA Clinical Assessment Reporting and Tracking-Electrophysiology database between 2008 and 2015. The primary outcome was 6-month incidence of CIED infection following the procedures, according to the study.

From 2,098 total procedures at 39 different VA medical centers, Branch-Elliman and colleagues identified 101 procedure-related CIED infections, they wrote. The patient cohort was 97.9% male, with a median age of 71.7 years.

According to the researchers, factors associated with increased odds of CIED infections included wound complications (adjusted OR = 8.74; 95% CI, 3.16-24.4); procedural factors, like a generator that needed to be replaced (aOR = 2.4; 95% CI, 1.59-3.63); an elevated international normalized ratio above 1.5 (aOR = 1.56; 95% CI, 1.12-2.18); and MRSA colonization (aOR = 9.56; 95% CI, 1.55-27.77).

Of the interventions evaluated in the study, skin cleaning with chlorhexidine vs. other topical agents (aOR = 0.41; 95% CI, 0.22-0.76) and antimicrobial prophylaxis with a beta-lactam antibiotic vs. vancomycin (aOR = 0.6; 95% CI, 0.37-0.96) were associated with reduced odds of infection, according to the study. Strategies that were ineffective included the use of mesh pockets and the continuation of antimicrobial prophylaxis after skin closure.

“First, it is really important that we advance infection prevention by identifying strategies that can be applied quickly and at the point of care to reduce the risk of surgical site infections and optimize postoperative outcomes,” Branch-Elliman said. “Some examples include decolonization with intranasal iodine and combination prophylaxis regimens. Second, when designing infection prevention protocols, we need to pay very close attention to how patients flow through the health care system, so that we can improve the implementation and application [of] evidence-based interventions in all clinical settings, and not just in those where implementation is convenient.” – by Joe Gramigna

Disclosures: Branch-Elliman reports providing consulting services to DLA Piper. Please see the study for all other authors’ relevant financial disclosures.

Many commonly used interventions to reduce cardiac implantable electronic device infections, or CIEDs, are ineffective, and the simplest strategies often have the greatest potential for improving CIED infection outcomes, according to results from a large, multicenter cohort study published in Infection Control & Hospital Epidemiology.

“Many of the most effective infection prevention interventions — such as screening for MRSA and decolonization — take several days’ advance notice in order to be effective,” Westyn Branch-Elliman, MD, MMSc, investigator at Veterans Affairs Boston Center for Healthcare Organization and Implementation Research, told Infectious Disease News. “In many cases, urgent and emergent cases go immediately to the operating room or procedural suite, and so it is not feasible to administer some of the lengthy prevention protocols prior to their surgical procedure.”

Branch-Elliman further explained that this creates a large gap in care.

“The patients least likely to benefit from the available infection prevention interventions — in other words, stable, elective cases — are the most likely to receive them,” she said.

Researchers analyzed a sample of procedures that were entered into the VA Clinical Assessment Reporting and Tracking-Electrophysiology database between 2008 and 2015. The primary outcome was 6-month incidence of CIED infection following the procedures, according to the study.

From 2,098 total procedures at 39 different VA medical centers, Branch-Elliman and colleagues identified 101 procedure-related CIED infections, they wrote. The patient cohort was 97.9% male, with a median age of 71.7 years.

According to the researchers, factors associated with increased odds of CIED infections included wound complications (adjusted OR = 8.74; 95% CI, 3.16-24.4); procedural factors, like a generator that needed to be replaced (aOR = 2.4; 95% CI, 1.59-3.63); an elevated international normalized ratio above 1.5 (aOR = 1.56; 95% CI, 1.12-2.18); and MRSA colonization (aOR = 9.56; 95% CI, 1.55-27.77).

Of the interventions evaluated in the study, skin cleaning with chlorhexidine vs. other topical agents (aOR = 0.41; 95% CI, 0.22-0.76) and antimicrobial prophylaxis with a beta-lactam antibiotic vs. vancomycin (aOR = 0.6; 95% CI, 0.37-0.96) were associated with reduced odds of infection, according to the study. Strategies that were ineffective included the use of mesh pockets and the continuation of antimicrobial prophylaxis after skin closure.

“First, it is really important that we advance infection prevention by identifying strategies that can be applied quickly and at the point of care to reduce the risk of surgical site infections and optimize postoperative outcomes,” Branch-Elliman said. “Some examples include decolonization with intranasal iodine and combination prophylaxis regimens. Second, when designing infection prevention protocols, we need to pay very close attention to how patients flow through the health care system, so that we can improve the implementation and application [of] evidence-based interventions in all clinical settings, and not just in those where implementation is convenient.” – by Joe Gramigna

Disclosures: Branch-Elliman reports providing consulting services to DLA Piper. Please see the study for all other authors’ relevant financial disclosures.