Cardiac implantable electronic device infections (CIEDIs) present substantial challenges for infectious diseases specialists, encompassing diagnosis, management, and complex decision making involving patients, families, and multidisciplinary teams. This review, guided by a common clinical case presentation encountered in daily practice, navigates through the diagnostic process, management strategies in unique scenarios, long-term follow-up, and critical discussions required for CIEDIs.
Urinary tract infections (UTIs) are responsible for more than one third of nosocomial infections; urinary catheter use is often to blame. In 2009, the Department of Health and Human Services set a goal of reducing catheter-associated UTI (CAUTI) rates by 25% by 2013. At that time, the …
Cardiovascular implantable electronic device (CIED) infection may present as pocket infection or as infective endocarditis (CIED-IE) with vegetation on device leads or heart valves. As aspirin has both anti-inflammatory properties and interferes with platelet aggregation, we hypothesized that ongoing anti-platelet therapy with aspirin may impact clinical and echocardiographic manifestations of CIED infection. We retrospectively reviewed 415 cases of CIED infection admitted to Mayo Clinic Rochester from 1991 to 2008. Information regarding aspirin use was available in 392 (94.5%) cases and 178 (45%) had received aspirin therapy prior to clinical onset of CIED infection. Although there were no significant differences in pathogen distribution between patients who had received prior aspirin therapy as compared with those who did not, patients on aspirin therapy were less likely to report chills (25% vs. 35%, P = 0.04), sweats (9% vs.18%, P = 0.01), or have peripheral leukocytosis on admission (33% vs. 46%, P = 0.005). Overall, 82 (21%) of 392 patients met the clinical criteria for CIED-IE. Patients on prior aspirin therapy were significantly less likely to have vegetations on CIED leads or heart valves than those who had not received it (15% vs. 26%, P = 0.01). However, despite the lower frequency of CIED-IE in the aspirin group, there was no significant difference (P = 0.97) in the overall survival between the two groups. Aspirin therapy prior to onset of CIED infection was associated with a lower likelihood of vegetation formation on CIED leads or heart valves and associated systemic manifestations of infection.
Bloodstream infection (BSI) is a major cause of morbidity and mortality. This retrospective cohort study examined the discriminative ability of Systemic Inflammatory Response Syndrome (SIRS), quick Sepsis-Related Organ Failure Assessment (qSOFA), and a simplified quick form of the Pitt Bacteremia Score (qPitt) to predict mortality in patients with gram-negative (BSI). Hospitalized adults with BSI due to aerobic gram-negative bacilli at Palmetto Health hospitals in Columbia, South Carolina from January 1, 2010 to December 31, 2013 were identified. Multivariate Cox proportional hazards regression was used to determine variables associated with 14-day mortality. Area under receiver operating characteristic curve (AUROC) was used to examine model discrimination. Among 832 patients with gram-negative BSI, median age was 65 years, 449 (54%) were women and 444 (53%) had a urinary source of infection. After adjustments for age and Charleston comorbidity score, all five components of qPitt were independently associated with mortality: temperature <36 degrees C (hazard ratio [HR] 3.02, 95% confidence interval [CI] 1.95–4.62, P < 0.001), systolic blood pressure <90 mmHg or vasopressor use (HR 2.40, 95% CI 1.37–4.13, P = 0.002), respiratory rate ≥25/minute or mechanical ventilation (HR 3.01, 95% CI 1.81–5.14, P < 0.001), cardiac arrest (HR 5.35, 95% CI 2.81–9.43, P < 0.001), and altered mental status (HR 3.99, 95% CI 2.44–6.80, P < 0.001). Among this cohort, 324 (39%), 450 (54%), and 771 (93%) patients had qPitt ≥2, qSOFA ≥2, and SIRS ≥2, respectively. qPitt had higher discrimination to predict mortality (AUROC 0.85) than both qSOFA (AUROC 0.77, P < 0.001) and SIRS (AUROC 0.63, P < 0.001). In patients with qPitt ≥2, mortality declined from 49% with inappropriate empirical antimicrobial therapy to 24% with appropriate therapy (P < 0.001). There was no significant difference in mortality between inappropriate and appropriate therapy in patents with qPitt <2 (5% vs. 3%, P = 0.36). qPitt had high discrimination in identifying patients with life-threatening infections and performed better than other scores to predict mortality. In addition, appropriate empirical antimicrobial therapy improved survival in patients with a qPitt ≥2. P. B. Bookstaver, Rock Pointe: Content Developer, Consulting fee
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