DeSimone, Daniel C.

AbstractBackgroundAscertaining involvement of left ventricular assist device (LVAD) in a patient presenting with bloodstream infection (BSI) can be challenging, frequently leading to use of chronic antimicrobial suppressive (CAS) therapy. We aimed to assess the efficacy of CAS therapy to prevent relapse of BSI from LVAD and non-LVAD sources.MethodsWe retrospectively screened adults receiving LVAD support from 2010 through 2018, to identify cases of BSI. Bloodstream infection events were classified into LVAD-related, LVAD-associated, and non-LVAD BSIs.ResultsA total of 121 episodes of BSI were identified in 80 patients. Of these, 35 cases in the LVAD-related, 14 in the LVAD-associated, and 46 in the non-LVAD BSI groups completed the recommended initial course of therapy and were evaluated for CAS therapy. Chronic antimicrobial suppressive therapy was prescribed in most of the LVAD-related BSI cases (32 of 35, 91.4%) and 12 (37.5%) experienced relapse. Chronic antimicrobial suppressive therapy was not prescribed in a majority of non-LVAD BSI cases (33, 58.9%), and most (31, 93.9%) did not experience relapse. Chronic antimicrobial suppressive therapy was prescribed in 9 of 14 (64.2%) cases of LVAD-associated BSI and none experienced relapse. Of the 5 cases in this group that were managed without CAS, 2 had relapse.ConclusionsPatients presenting with LVAD-related BSI are at high risk of relapse. Consequently, CAS therapy may be a reasonable approach in the management of these cases. In contrast, routine use of CAS therapy may be unnecessary for non-LVAD BSIs.

Background: Left atrial appendage occlusion with the Watchman device is an alternative strategy for stroke risk reduction in patients with non-valvular atrial fibrillation. There are rare case reports of Watchman associated infection. Currently, there is no formal study that evaluated the incidence and outcomes of Watchman-related infections. Methods: All patients who underwent Watchman implantation over a 14 year study period (July 2004 through December 2018) comprised our cohort. Baseline characteristics, procedural data, and post-implantation events were identified. Primary study outcomes included Watchman related infection, other cardiovascular device related infection, bacteremia, and mortality. Results: A total of 181 patients with an average age of 75, and a median CHA2DS2-VASc Score of 4 (interquartile range 2) and a median HAS-BLED Score of 3 (interquartile range 1), were included for analysis. A total of 534.7 patient years of follow up was accrued with an average of 2.9 years per patient. The most common indications for implantation included gastrointestinal bleeding (56 patients; 30.9%) and intracerebral bleeding (51 patients; 28.2%). During follow up, 38 patients (21%) died. Six developed evidence of bacteremia. Only one developed an implantable cardioverter defibrillator (ICD) infection that required complete system extraction. None of the cohort developed Watchman-related device infection during the study period. Conclusion: In a single center study spanning a 14 year period, we report no Watchman-related devices infections. This is despite the presence of patients with bacteremia, as well as an ICD infection requiring extraction. These data suggest that Watchman devices are extremely unlikely to become infected.

Background: The improved life expectancy observed in patients living with Human Immunodeficiency Virus (HIV) infection has made age-related cardiovascular complications, including arrhythmias, a growing health concern. We describe the temporal trends in frequency of various arrhythmias and assess impact of arrhythmias on hospitalized HIV patients using the Nationwide Inpatient Sample (NIS) Methods and Results: Data on HIV-related hospitalizations from 2005 to 2014 were obtained from the NIS using International Classification of Diseases, 9th Revision (ICD-9) codes. Data was further subclassified into hospitalizations with associated arrhythmias and those without arrhythmia. Baseline demographics and comorbidities were determined. Outcomes including in-hospital mortality, cost of care, and length of stay were extracted. SAS 9.4 (SAS Institute Inc., Cary, North Carolina) was utilized for analysis. A multivariable analysis was performed to identify predictors of arrhythmias among hospitalized HIV patients. Among 2,370,751 HIV-related hospitalizations identified, the overall frequency of any arrhythmia was 3.01%. Atrial fibrillation (AF) was the most frequent arrhythmia (2110 per 100,000). The overall frequency of arrhythmias has increased over time by 108%, primarily due to a 132% increase in AF. Arrhythmias are more frequent among older males, lowest income quartile and non-elective admissions. Patients with arrhythmias had a higher in-hospital mortality rate (9.6%). In-hospital mortality among patients with arrhythmias has decreased over time by 43.8%. The cost of care and length of stay associated with arrhythmia-related hospitalizations were mostly unchanged. Conclusions: Arrhythmias are associated with significant morbidity and mortality in hospitalized HIV patients. AF is the most frequent arrhythmia in hospitalized HIV patients.

Abstract Background Current guidelines from the American Heart Association (AHA) recommend repeating transesophageal echocardiography (TEE) in three to five days if there is high suspicion of IE despite an initial TEE that was negative. This recommendation, however, is based on limited published data. Objectives This investigation attempts to identify specific factors that prompted repeat TEE and evaluate the yield of IE‐related findings demonstrated by repeat TEE as compared to initial or prior TEE. Methods A retrospective cohort who had at least one repeat TEE during an index hospitalization or initial course of antimicrobial therapy for IE between January 2014 and September 2018. We assessed the impact of repeat TEE on IE diagnosis and patient management and included a comparative analysis of patients with initial TEE only. Results Overall, 59 (44.7%) of 132 IE patients underwent repeat TEE. In a comparative analysis that involved patients who had undergone an initial TEE only versus those who had repeat TEE, male gender ( P = .029) and presence of a prosthetic valve or annuloplasty ring ( P = .017) were significantly associated with repeat TEE. Importantly, 8 (17.4%) of repeat TEE were critical for IE diagnosis, 8 (17.4%) impacted antimicrobial management, and 11 (23.9%) supported cardiovascular surgical intervention. Conclusions From a population‐based cohort of incident IE cases, repeat TEE was more frequently (44.7%) done in patients with suspect or proven IE and associated complications than anticipated. Repeat TEE remains pivotal in a contemporary practice that involves critical aspects of IE diagnosis and management.

Abstract Objective To investigate the influence of acetylsalicylic acid (ASA) use on risk and outcome of community-acquired Staphylococcus aureus bacteremia (CA-SAB). Method We used population-based medical databases to identify all patients diagnosed in northern Denmark with first-time CA-SAB and matched population controls from 2000–2011. Categories for ASA users included current users (new or long-term users), former users, and nonusers. The analyses were adjusted for comorbidities, comedication use, and socioeconomic indicators. Results We identified 2638 patients with first-time CA-SAB and 26 379 matched population controls. Compared with nonusers, the adjusted odds ratio (aOR) for CA-SAB was 1.00 (95% confidence interval [CI], 0.88–1.13) for current users, 1.00 (95% CI, 0.86–1.16) for former users, 2.04 (95% CI, 1.42–2.94) for new users, and 0.95 (95% CI, 0.84–1.09) for long-term users. Thirty-day cumulative mortality was 28.0% among current users compared with 21.6% among nonusers, yielding an adjusted hazard rate ratio (aHRR) of 1.02 (95% CI, 0.84–1.25). Compared with nonusers, the aHRR was 1.10 (95% CI, 0.87–1.40) for former users, 0.60 (95% CI, 0.29–1.21) for new users, and 1.06 (95% CI, 0.87–1.31) for long-term users. We observed no difference in the risk or outcome of CA-SAB with increasing ASA dose or by presence of diseases commonly treated with ASA. Conclusions Use of ASA did not seem to influence the risk or outcome of CA-SAB. The apparent increased risk among new users may relate to residual confounding from the circumstances underlying ASA treatment initiation. Our finding of no association remained robust with increasing ASA dose and across multiple patient subsets.

Abstract Background Sonicate fluid (SF), a solution derived from vortexing and sonication of explanted cardiovascular implantable electronic devices (CIEDs), is a higher-yield specimen compared with swabs or tissues for culture-based detection of microorganisms associated with CIED infection. Despite this, SF culture fails to identify a causative organism in ~50% of cases. We aimed to evaluate the diagnostic performance of 16S ribosomal RNA gene (rRNA) polymerase chain reaction (PCR)/sequencing of SF and compare it with that of SF culture. Methods We identified 322 SF specimens from extracted CIEDs and reviewed clinical data for each patient. Subjects were classified as having or not having CIED infection. Cases were subcategorized as culture negative if no significant growth was reported from SF cultures and as culture positive if an organism was detected above predefined thresholds. 16S rRNA PCR/sequencing was performed, with the organisms identified reported according to Clinical and Laboratory Standards Institute guidelines for sequence data interpretation. Results A total of 278 SF samples corresponded to infected cases, of which 160 were culture positive and 118 culture negative. The remaining 44 were from noninfected cases, of which 2 were culture positive. Compared with SF culture, the sensitivity of 16S rRNA PCR/sequencing was higher (64% vs 57.5%, P = .003). 16S rRNA PCR/sequencing detected a potential pathogen in 28 of 118 culture-negative cases, identifying staphylococci in the majority (18/28). Conclusions 16S rRNA PCR/sequencing has higher sensitivity to detect bacteria in SF from extracted CIEDs than does SF culture.