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Prolonged antimicrobial prophylaxis following cardiac device procedures increases preventable harm: insights from the VA CART program

Published online by Cambridge University Press:  18 September 2018

Archana Asundi ,
Maggie Stanislawski ,
Payal Mehta ,
Anna E. Barón ,
Howard Gold ,
Hillary Mull ,
P. Michael Ho ,
Kalpana Gupta  and
Westyn Branch-Elliman
Archana Asundi
Affiliation:
Division of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
Maggie Stanislawski
Affiliation:
Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington and Denver, Colorado Department of Epidemiology, University of Colorado School of Public Health, Aurora, Colorado
Payal Mehta
Affiliation:
Department of Medicine, Division of Infectious Diseases, Boston VA Healthcare System, West Roxbury, Massachusetts
Anna E. Barón
Affiliation:
Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington and Denver, Colorado Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
Howard Gold
Affiliation:
Department of Medicine, Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts Harvard Medical School, Boston, Massachusetts
Hillary Mull
Affiliation:
Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts Department of Surgery, Boston University School of Medicine, Boston, MA
P. Michael Ho
Affiliation:
Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington and Denver, Colorado Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
Kalpana Gupta
Affiliation:
Department of Medicine, Division of Infectious Diseases, Boston VA Healthcare System, West Roxbury, Massachusetts Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
Westyn Branch-Elliman
Affiliation:
Department of Medicine, Division of Infectious Diseases, Boston VA Healthcare System, West Roxbury, Massachusetts Harvard Medical School, Boston, Massachusetts Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
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Abstract

Background

The rate of cardiovascular implantable electronic device (CIED) infection is increasing coincident with an increase in the number of device procedures. Preprocedural antimicrobial prophylaxis reduces CIED infections; however, there is no evidence that prolonged postprocedural antimicrobials additionally reduce risk. Thus, we sought to quantify the harms associated with this approach.

Objective

To measure the association between Clostridium difficile infection (CDI), acute kidney injury (AKI) and receipt of prolonged postprocedural antimicrobials.

Methods

CIED procedures entered into the VA Clinical Assessment Reporting and Tracking Electrophysiology (CART-EP) database during fiscal years 2008–2016 were included. The primary outcome was 90-day incidence of CDI and the secondary outcome was the 7-day incidence of AKI. The primary exposure measure was duration of postprocedural antimicrobial therapy. Associations were measured using Cox-proportional hazards and binomial regression.

Results

Prolonged postprocedural antimicrobial therapy was identified following 3,331 of 6,497 CIED procedures (51.3%), and the median duration of prophylaxis was 5 days. Prolonged postprocedural antimicrobial use was associated with increased risk of CDI (hazard ratio [HR], 2.90; 95% confidence interval [CI], 1.54–5.46). Of the 27 patients who developed CDI, 11 subsequently died. Postprocedural antimicrobial use with ≥2 antimicrobials was associated with an increased risk of AKI (OR, 4.16; 95% CI, 2.50–6.90). The impact was particularly significant when one of the dual agents prescribed was vancomycin (adjusted OR, 8.41; 95% CI, 5.53–12.79).

Conclusions

Prolonged antimicrobial prophylaxis following CIED procedures increases preventable harm; this practice should be discouraged in procedural settings such as the cardiac electrophysiology laboratory.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 9 , September 2018 , pp. 1030 - 1036
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 

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Footnotes

Cite this article: Asundi A, et al. (2018). Prolonged antimicrobial prophylaxis following cardiac device procedures increases preventable harm: insights from the VA CART program. Infection Control & Hospital Epidemiology 2018, 39, 1030–1036. doi: 10.1017/ice.2018.170

a

Authors of equal contribution.

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