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Infective endocarditis related to implanted cardiac devices carries a high mortality risk, researchers found.
Among adults hospitalized with cardiac device infective endocarditis, 14.7% died before discharge and 23.2% died within 1 year, according to Andrew Wang, MD, of Duke University Medical Center in Durham, N.C., and colleagues.
Removal of the device during the initial hospitalization, which occurred in nearly 80% of patients, was associated with a lower risk of dying in that first year (19.9% versus 38.2%, HR 0.42, 95% CI 0.22 to 0.82), the researchers reported in the April 25 issue of the Journal of the American Medical Association.
"The high rates of mortality emphasize the need for improved preventive measures, including optimal skin decontamination and appropriate antibiotic administration at the time of cardiac device insertion or manipulation, as well as careful attention to any invasive or intravascular procedures performed after device implantation," they wrote.
"Given that numbers of cardiovascular implantable electronic devices placed are increasing rapidly, further studies on the prevention and treatment of [device-related infective endocarditis] are needed."
Cardiac device infective endocarditis is a costly complication, with inhospital charges estimated to be at least $146,000 per case. Of all cardiac device infections, the 10% to 23% with endocarditis come with a higher mortality risk.
To examine the characteristics of cardiac device endocarditis, Wang and colleagues looked at data from the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS), which was conducted from June 2000 to August 2006 at 61 centers in 28 countries.
The study included 2,760 adults who were hospitalized with definite infective endocarditis defined by the modified Duke endocarditis criteria. Of those, 6.4% had an implanted cardiac device, either a permanent pacemaker (85.9%), an implantable cardioverter-defibrillator (11.9%), or an unspecified device (2.3%).
Characteristics of the patients with cardiac device infective endocarditis included older age (median 71.2), a high rate of healthcare-associated infection (45.8%), and infections mostly caused by staphylococci -- 35% Staphylococcus aureus and 31.6% coagulase-negative staphylococci.
More than one-third of the patients (37.3%) had coexisting valve involvement, which was associated with a greater likelihood of dying before discharge (OR 3.31, 95% CI 1.71 to 6.39, P=0.004).
Removal of the device and lead during the initial hospitalization was associated with a lower likelihood of dying within 1 year, but was not related to the risk of dying in the hospital, possibly because of low statistical power.
The authors noted that American Heart Association recommendations "strongly support complete device and lead removal for all patients with definite infection as evidenced by valvular vegetations, lead vegetations, or both."
They acknowledged some limitations of the study, including the observational design, the inclusion of centers that participated voluntarily, and the lack of information on device pocket infections. The study also did not evaluate the time from device implantation to removal, the means of removal, the incidence and timing of device reimplantation, and recurrence of infection after hospital discharge.
From the American Heart Association:
The study was supported in part by grants from the Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III, and the Spanish Network for Research in Infectious Diseases. One of the study authors holds an Intensification Research Grant from the Instituto de Salud Carlos III and the Departament de Salut de la Generalitat de Catalunya.
Wang reported providing expert testimony for trial defense; receiving grants or grants pending from Gilead Sciences, Edwards Lifesciences, and Abbott Vascular; receiving payment for lectures from American Physician; receiving royalties for serving as an editor from Springer; and receiving payment for development of educational presentations from the American College of Cardiology Foundation. His co-authors reported relationships with the American Heart Association, Novartis, Cubist, Abbott, Bristol-Myers Squibb, Gilead Sciences, Merck, Pfizer, Theravance, Fondo de Investigaciones Sanitarias, the NIH, RIS-III (Spanish Network for AIDS Research), Boehringer Ingelheim, GlaxoSmithKline, Janssen-Cilag, Merck, Roche, Schering-Plough, ViiV, Astellas, Johnson & Johnson, Galderma, NovaDigm, The Medicines Company, Biosynexus, MedImmune, Cerexa, Advanced Liquid Logic, UpToDate, Arpida, Inhibitex, Targanta, Wyeth, Ortho-McNeil, and Vertex Pharmaceuticals.
- Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
Journal of the American Medical AssociationSource Reference: Athan E, et al "Clinical characteristics and outcome of infective endocarditis involving implantable cardiac devices" JAMA 2012; 307: 1727-1735.