Driveline Infection in Left Ventricular Assist Device Patients: Effect of Standardized Protocols, Pathogen Type, and Treatment Strategy

Abstract

Driveline infection (DLI) is common after left ventricular assist device (LVAD). Limited data exist on DLI prevention and management. We investigated the impact of standardized driveline care initiatives, specific pathogens, and chronic antibiotic suppression (CAS) on DLI outcomes. 591 LVAD patients were retrospectively categorized based on driveline care initiatives implemented at our institution (2009-2019). Era (E)1: nonstandardized care; E2: standardized driveline care protocol; E3: addition of marking driveline exit site; E4: addition of "no shower" policy. 87(15%) patients developed DLI at a median (IQR) of 403(520) days. S. aureus and P. aeruginosa were the most common pathogens. 31 (36%) of DLI patients required incision and drainage (I&D) and 5 (5.7%) device exchange. P. aeruginosa significantly increased risk for initial I&D (HR 2.7, 95% CI, 1.1-6.3) and recurrent I&D or death (HR 4.2, 95% CI, 1.4-12.5). Initial I&D was associated with a significant increased risk of death (HR 2.92 (1.33-6.44); P = 0.008) when compared to patients who did not develop DLI. Implementation of standardized driveline care protocol (E2) was associated with increased 2-year freedom from DLI compared to nonstandardized care (HR 0.36, 95% CI, 0.2-0.6, P < 0.01). Additional preventive strategies (E3&E4) showed no further reduction in DLI rates. 57(65%) DLI patients received CAS, 44% of them required escalation to intravenous antibiotics and/or I&D. Presence of P. aeruginosa DLI markedly increased risk for I&D or death. Conditional survival of patients progressing to I&D is diminished. Standardized driveline care protocol was associated with a significant reduction in DLI, while additional preventive strategies require further testing.

Content Validity of the Left Ventricular Assist Device Bathing Assessment

“…Although these protocols were developed and approved by specialized LVAD clinicians and surgeons, the efficacy of the bathing protocols in reducing infection rates is currently unknown. However, to determine if adherence to LVAD bathing protocols reduces rates of infection, clinicians must first be able to assess patients' ability to independently complete the steps of the protocol (Lumish et al, 2022). Thus, this assessment was created an initial step to help determine best practices for bathing with an LVAD.…”

“…One retrospective study found that when LVAD-supported patients were instructed to keep the driveline site dry during showering there were fewer instances of Pseudomonas infections (Aburjania et al, 2017). Although another recent retrospective study did not find a reduction in infection rates after implementing a "no shower" policy, authors noted that they were unable to assess compliance with the bathing protocol other than self-report (Lumish et al, 2022). Prospective research studies that assess participants' ability to keep the driveline site dry while bathing are needed to determine if these methods are effective in preventing infection.…”

“…A multidisciplinary approach is recommended to help patients learn new self-care behaviors related to LVAD management (Kato et al, 2014). Currently, there is no standardized approach in the United States for safe bathing with an LVAD. Each institution decides how they allow a person with an LVAD to clean themselves (Cannon et al, 2012; Lumish et al, 2022). In addition, showering procedures may pose a challenge for patients and their caregivers (Casida et al, 2011; Widmar et al, 2014).…”

“…In one study, more than half the participants reported difficulty keeping the driveline site dry, which can lead to infections (Casida et al, 2021). Some institutions allow complete showers with the driveline exit site protected with a covering and the LVAD controller and batteries contained in a shower bag, while others decide not to allow a person to shower at all (Kato et al, 2014; Lumish et al, 2022). If safe bathing procedures are unclear, patients and caregivers may be confused and come up with their own unique strategies that could lead to infection, safety concerns, and increased hospitalizations.…”

“…There is a need for clarity in the way LVAD patients are taught how to safely bathe or shower themselves. At an urban academic medical and research center, an interdisciplinary team of OTs (including first and third authors), nurses, and doctors developed a protocol to teach patients how to keep the driveline exit site dry while bathing with an LVAD (Lumish et al, 2022). This protocol includes two levels of bathing: Level 1 involves a sponge bath approach, and Level 2 introduces a handheld shower head to wash the lower extremities.…”