Becker's Clinical Quality & Infection Control

67 Executive Briefing The Persistence of CIED Infections: A Progress Report on Improving Outcomes and Lowering Costs T he past several years have seen a significant decrease in healthcare-associated infections, in particular cen- tral line-associated bloodstream infections and certain surgical site infections. There is, however, one major exception to this successful trend. Infections associated with cardiac im- plantable electronic devices have not only persisted, but have actually been increasing. Consider this fact alone: CIED implants increased by 96 percent over a 15-year period, and the incidence of CIED-re- lated infection increased by more than double that rate (210 percent), according to a study in the Journal of the American College of Cardiology. Such infections may not only have po- tentially serious — even fatal — consequences for patients, but they may also result in higher healthcare costs for hospitals. As noted by Ibrahim Hanna, MD, director of cardiac electro- physiology at Baptist Health Centers in Birmingham, Ala., "The rates [of CIED-related] infections have been steadily increasing. We're seeing not only more infections, but also more serious infections, despite the best efforts of physicians." Risk factors behind the rising incidence Which risk factors may be contributing to this dramatic increase in CIED infections? Several have been identified, in particular older implant patients burdened with more comor- bidities. Because patients are living longer, they are more likely to need a CIED. In turn, implants may also need to be revised, replaced or upgraded at a later time. Other factors may include longer procedures, as well as the presence of organisms increasingly resistant to antibiotics. Certain organisms, coagulase-negative Staphylococcus and S. aureus (S. epidermidis, MSSA, MRSA) for instance, which are known to be responsible for approximately 70 percent of CIED infections, are increasingly resistant to the antibiotic methicillin. As noted by Dr. Hanna, this increase in antibiotic resistance has made infections more difficult to prevent and more difficult to treat. Risk factor importance assessed by odds ratio Odds ratios quantify a patient's risk of infection based on their particular medical characteristics and history, the medications they take and medical procedures they have undergone. Renal failure, to cite one example, has an odds ratio of 11.97; a patient with renal failure is approximately 12 times more likely to get a CIED infection than a patient who does not have renal failure. Other significant risk factors for CIED infection include early re-intervention (odds ratio 15.4), use of corticosteroids (13.9), diabetes (3.5) and device replacement or revision (3.67). In relation to device replacement, Christopher Ellis, MD, direc- tor of cardiac electrophysiology at Vanderbilt University Med- ical Center in Nashville, Tenn., shares that "patients in the last five to 10 years are living longer, and I'm doing more and more device change-outs [replacements], and those specifically have much higher infection rates than a new implant." Two clinical studies published in the journals Circulation and Heart Rhythm had similar findings. Worsened patient outcomes and increased treatment costs Regardless of risk factor, the increase in infection rates has a significant impact not just on treatment outcomes, but also on healthcare costs. Statistics reveal that preventing CIED infections can, in fact, be the difference between life and death. In a study published in the Archives of Internal Medicine, patients with CIED infection experience relatively higher admission mortality rates, as well as lower survival rates beyond three years, even after success- ful treatment of the infection. As a result, "The economic consequences, including healthcare resource utilization, of CIED infections are substantial," accord- ing to the American Heart Association. Hospitals may be finan- cially penalized by CMS when a patient undergoing a CIED procedure acquires an infection during their hospital stay. In several studies, CIED infections cost a healthcare facility an average of approximately $52,000, with some costs exceeding well over $100,000. "The big question in the near future is who is going to pay for that," Dr. Ellis notes. The solution may lie in novel perioperative technology Dr. Hanna's practice has taken several approaches to help reduce instances of CIED infections to zero. One tool he has added to his arsenal is the TYRX Absorbable Antibacterial Envelope. FDA-cleared in May 2013, the fully absorbable TYRX Envelope, made from a large-pore knitted mesh coated with a bioab- sorbable polymer holds a CIED securely in place to provide a stable environment when implanted in the body. This stability, studies show, helps keep the CIED from moving or twisting, which can reduce its effectiveness. Within two hours of implantation, the TYRX Envelope elutes ther- apeutic levels of the antibiotics minocycline and rifampin locally into the tissue pocket; this elution of antibiotics continues over Sponsored by:

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