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      Outcomes of Infected Cardiovascular Implantable Devices in Dialysis Patients

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          Abstract

          Background/Aims: Dialysis patients are at a higher risk for cardiovascular implantable electronic device (CIED) infection-related hospitalizations. We compared the outcomes and cost for dialysis and non-dialysis patients hospitalized with CIED infections. Methods: We conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) discharge records from 2005 to 2010. Patients with CIED infections were identified using ICD-9 codes for device-related infections or device procedure along with bacteremia, endocarditis or systemic infection. Dialysis patients were identified using ICD-9 codes. Multivariable logistic and linear regressions were performed to examine in-hospital mortality, length of stay and cost. Results: Of the 87,798 estimated hospitalizations with CIED infections, 6,665 (7.6%) were dialysis patients. CIED-infection-related hospitalization has increased over time among dialysis patients. In-hospital mortality was higher among dialysis patients (13.6% vs. 5.9%, p < 0.001). In the multivariable model, dialysis patients had higher odds of in-hospital mortality (odds ratio 1.98; 95% CI: 1.6, 2.4) compared to the non-dialysis group. Dialysis patients had a longer median length of stay (12 days vs. 7 days, p < 0.001) and majority required extended care facility upon discharge (51.2% vs. 35.0%, p < 0.001) compared to the non-dialysis group. Dialysis status was associated with 50.3% increased cost of hospitalization (p < 0.001). Conclusion: CIED-infection related hospitalization is increasing among patients undergoing dialysis and is associated with higher in-hospital mortality, longer hospital stay and higher costs of hospitalization. Future studies should examine the reasons for such a high risk and find means to improve outcomes in dialysis population.

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          Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association.

          Larry M Baddour, Andrew E Epstein, Christopher C Erickson … (2010)
          Despite improvements in cardiovascular implantable electronic device (CIED) design, application of timely infection control practices, and administration of antibiotic prophylaxis at the time of device placement, CIED infections continue to occur and can be life-threatening. This has prompted the study of all aspects of CIED infections. Recognizing the recent advances in our understanding of the epidemiology, risk factors, microbiology, management, and prevention of CIED infections, the American Heart Association commissioned this scientific statement to educate clinicians about CIED infections, provide explicit recommendations for the care of patients with suspected or established CIED infections, and highlight areas of needed research.
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            16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008.

            Behzad B Pavri, Edmund Lau, Tony Ho … (2011)
            We analyzed the infection burden associated with the implantation of cardiac implantable electrophysiological devices (CIEDs) in the United States for the years 1993 to 2008. Recent data suggest that the rate of infection following CIED implantation may be increasing. The Nationwide Inpatient Sample (NIS) discharge records were queried between 1993 and 2008 using the 9th Revision of the International Classification of Diseases (ICD-9-CM). CIED infection was defined as either: 1) ICD-9 code for device-related infection (996.61) and any CIED procedure or removal code; or 2) CIED procedure code along with systemic infection. Patient health profile was evaluated by coding for renal failure, heart failure, respiratory failure, and diabetes mellitus. The infection burden and patient health profile were calculated for each year, and linear regression was used to test for changes over time. During the study period (1993 to 2008), the incidence of CIED infection was 1.61%. The annual rate of infections remained constant until 2004, when a marked increase was observed, which coincided with an increase in the incidence of major comorbidities. This was associated with a marked increase in mortality and in-hospital financial charges. The infection burden associated with CIED implantation is increasing over time and is associated with prolonged hospital stays and high financial costs. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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              Associations between hemodialysis access type and clinical outcomes: a systematic review.

              Emily J Oliver, Giovanni Strippoli, Neesh I Pannu … (2013)
              Clinical practice guidelines recommend an arteriovenous fistula as the preferred vascular access for hemodialysis, but quantitative associations between vascular access type and various clinical outcomes remain controversial. We performed a systematic review of cohort studies to evaluate the associations between type of vascular access (arteriovenous fistula, arteriovenous graft, and central venous catheter) and risk for death, infection, and major cardiovascular events. We searched MEDLINE, EMBASE, and article reference lists and extracted data describing study design, participants, vascular access type, clinical outcomes, and risk for bias. We identified 3965 citations, of which 67 (62 cohort studies comprising 586,337 participants) met our inclusion criteria. In a random effects meta-analysis, compared with persons with fistulas, those individuals using catheters had higher risks for all-cause mortality (risk ratio=1.53, 95% CI=1.41-1.67), fatal infections (2.12, 1.79-2.52), and cardiovascular events (1.38, 1.24-1.54). Similarly, compared with persons with grafts, those individuals using catheters had higher risks for mortality (1.38, 1.25-1.52), fatal infections (1.49, 1.15-1.93), and cardiovascular events (1.26, 1.11-1.43). Compared with persons with fistulas, those individuals with grafts had increased all-cause mortality (1.18, 1.09-1.27) and fatal infection (1.36, 1.17-1.58), but we did not detect a difference in the risk for cardiovascular events (1.07, 0.95-1.21). The risk for bias, especially selection bias, was high. In conclusion, persons using catheters for hemodialysis seem to have the highest risks for death, infections, and cardiovascular events compared with other vascular access types, and patients with usable fistulas have the lowest risk.
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                Author and article information

                Journal
                Journal ID (publisher-id): AJN
                Journal ID (nlm-ta): Am J Nephrol
                Journal ID (doi): 10.1159/issn.0250-8095
                Title: American Journal of Nephrology
                Publisher: S. Karger AG
                ISSN (Print): 0250-8095
                ISSN (Electronic): 1421-9670
                Publication date Subscription-year: 2014
                Publication date (Print): October 2014
                Publication date (Electronic): 15 October 2014
                Volume: 40
                Issue: 3
                Pages: 280-287
                Affiliations
                aDepartment of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, bDepartment of Nephrology and Hypertension, University of Michigan, Ann Arbor, Mich., cDepartment of Quantitative Health Sciences, Cleveland Clinic, dDepartment of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, and eCleveland Clinic Lerner College of Medicine of CWRU, Cleveland Clinic, Cleveland, Ohio, USA
                Author notes
                *Sankar D. Navaneethan, MD, MPH, Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, 9500 Euclid Avenue - Q7, Cleveland Clinic, Cleveland, Ohio 44195 (USA), E-Mail navanes@ccf.org
                Article
                Publisher ID: 366453 Pmcid ID: PMC4216629 Other ID: Am J Nephrol 2014;40:280-287
                DOI: 10.1159/000366453
                PMC ID: PMC4216629
                PubMed ID: 25323128
                SO-VID: 3b127c06-56a3-4177-96bd-60e21fb0e0be
                Copyright © © 2014 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 24 February 2014
                Date accepted : 31 July 2014
                Page count
                Figures: 2, Tables: 3, Pages: 8
                Categories
                Subject: Original Report: Patient-Oriented, Translational Research

                ScienceOpen disciplines: Cardiovascular Medicine,Nephrology
                Keywords: Dialysis,Infection,Mortality,Hospitalization
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine, Nephrology
                Keywords: Dialysis, Infection, Mortality, Hospitalization

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