Karasik, Pamela

Background: The rate of cardiovascular implantable electronic device infection (CIEDI) has increased, despite the use of preoperative antibiotics at the time of device placement or revision. Cefazolin, a beta-lactam antibiotic, is used as standard preoperative prophylaxis in the bulk of patients. Vancomycin is used in the small minority of patients who have IgE-mediated allergies to beta-lactams or have a history of colonization/infection with MRSA. As compared to cefazolin, vancomycin is less effective against methicillin-susceptible Staphylococcus aureus, has no gram-negative coverage, and has nephrotoxicity risk. Methods: A retrospective cohort study was performed to assess whether vancomycin use increased the risk of CIEDI in comparison to the standard preoperative prophylaxis. The VA Informatics and Computing Infrastructure (VINCI) database, which includes all veterans who underwent CIED placement or revision between 2008 and 2015, was used. A logistic regression model was constructed to estimate the adjusted risk of CIEDI among patients who received vancomycin after adjusting for confounding factors. Results: Overall, 10,454 CIED procedures were included, and 98% of them were performed in men with a mean age of 71 ± 12 years. Vancomycin was given in 40.6% of these procedures. The rate of diabetes mellitus, heart failure, and advanced chronic kidney diseases were 20.5%, 13.5%, and 2.3%, respectively. The logistic regression analysis showed that vancomycin increased the risk of CIEDI three-fold (OR 2.99 [1.76-5.06], P-value <0.001) as compared to the standard preoperative prophylaxis, after controlling for other effects including MRSA colonization. Conclusions: Our study revealed that among patients who received vancomycin as preoperative for CIED placement or revision, there was a three-fold increase in the risk of subsequent CIEDI.

AbstractBackgroundCefazolin is used as standard preoperative prophylaxis for a variety of surgical procedures that involve the skin. In contrast, vancomycin is recommended for a minority of patients, specifically those with an IgE‐mediated allergy to beta‐lactams and considered in patients with known colonization with methicillin‐resistant Staphylococcus aureus or at high risk for such. Vancomycin, however, has been overprescribed, has nephrotoxicity risk, and may be less effective due to its inferior coverage of methicillin‐susceptible S. aureus and lack of Gram‐negative coverage. This study was performed to assess whether vancomycin use was associated with an increased incidence of cardiovascular implantable electronic device infection (CIEDI) as compared to that of cefazolin or other antistaphylococcal beta‐lactam antibiotics.MethodsThe VA Informatics and Computing Infrastructure database, which included all veterans who underwent CIED placement or revision between 2008 and 2015, was used. A logistic regression model was constructed to estimate the adjusted odds of CIEDI.ResultsOverall, 10,454 CIED procedures were included, and 98% of them were performed in men with a mean age of 71 ± 12 years. The logistic regression analysis showed that vancomycin use alone or in combination with other antibiotics was associated with an increased risk of CIEDI (odds ratio 2.99 [1.76–5.06], P‐value < 0.001), after controlling for other effects.ConclusionsOur study revealed that among patients who received surgical site infection prophylaxis for CIED placement or revision, there was: (1) an unanticipated high rate of vancomycin use, and (2) a threefold increase in the incidence of subsequent CIEDI among vancomycin recipient

AbstractBackgroundThe rate of cardiovascular implantable electronic device infection (CIEDI) has increased, despite the use of perioperative antibiotics at the time of device placement or revision. This is due, in part, to the presence of multiple comorbid conditions in an elderly population, in general, who require CIED. Statins may have an antibacterial effect, although there is currently no evidence that the likelihood of CIEDI has been impacted by statin use.MethodsA retrospective cohort study was performed to assess whether statins are associated with a reduced risk of CIEDI. The VA Informatics and Computing Infrastructure (VINCI) database, which includes all veterans who underwent CIED placement between 2008 and 2015, was used. A logistic regression model was constructed to estimate the adjusted risk of CIEDI among patients who were receiving statins after adjusting for confounding factors.ResultsOverall, 18,970 CIED procedures were included, and 98% of them were performed in men with a mean age of 71 ± 11 years. The rate of diabetes mellitus, heart failure, advanced chronic kidney diseases, CIEDI, positive methicillin‐resistant Staphylococcus aureus nasal colonization, and statin use were 23%, 15.7%, 3.3%, 1.14%, 12.6%, and 56%, respectively. The logistic regression analysis showed that statins were significantly associated with a reduced risk of CIEDI; after controlling for other effects, the reduction was 66% (odds ratio 0.34 [0.2–0.59], P‐value < 0.001). The effect of statins was confirmed by propensity score analysis.ConclusionsOur study showed that among patients receiving statins who had undergone CIED placement, there was a 66% reduction in subsequent CIEDI.