Rising Rates of Cardiac Rhythm Management Device Infections in the United States: 1996 through 2003

Abstract

To the Editor: Clinical indications for cardiac rhythm management devices (CRMDs) have expanded dramatically. The impact of this expansion upon rates of CRMD infection, a complication of device therapy that often requires system explantation (1), has not been clearly defined.We hypothesized that the current growth in implantable cardioverter defibrillator (ICD) utilization would impact rates of CRMD infection, both by expanding and changing the demographics of the population at risk. We analyzed a nationally representative database to compare trends in rates of new CRMD implants with rates of hospitalization for CRMD infection. We also sought to define the rates of in-hospital mortality associated with such events.We collected files from the National Hospital Discharge Survey (NHDS) from 1996 to 2003. Cases with a primary discharge diagnosis of pacemaker (PM) or ICD infection (International Classification of Diseases-9th Revision-Clinical Modification [ICD-9-CM] code 996.61) were identified. In addition, patients with device explantation (ICD-9-CM codes 37.77, 37.79, 37.89, or 37.99) and a primary discharge diagnosis of sepsis (ICD-9-CM code 038 or 785.59), bacteremia (ICD-9-CM code 790.7), endocarditis (ICD-9-CM codes 421.0, 421.9, or 424.90), cellulitis (ICD-9-CM code 682.9), or fever (ICD-9-CM code 780.6) were defined as having CRMD infection. New CRMD implantations were identified by ICD-9-CM procedural codes 377.0 to 377.6.In order to determine the clinical predictors for in-hospital mortality among patients with CRMD infection, a control group with previously implanted PM or ICD who did not have CRMD infection was identified. This much larger group included patients with PM or ICD in situ (ICD-9-CM codes V45.01 or V45.02, respectively) who were discharged with diagnoses other than CRMD infection. Demographic factors were recorded. Other characteristics were identified, including presence of diabetes (ICD-9-CM codes 250.00 to 250.02 or 250.70 to 250.72), renal failure (ICD-9-CM codes 585, 593.9, or V56.0), and hospital size.Univariate analysis was performed using 1-way analysis of variance for continuous variables and the chi-square test for categoric variables. Multivariate analysis using a binary logistic regression test was undertaken to determine the independent predictors of in-hospital mortality. Cases were weighed using the "weight" variable for derivation of national estimates according to

Complications of Pacemaker Implantation

“…Along with the increase in device implantation, the incidence of device infections has also been increasing, but at a faster rate. (Voight et al, 2006). In the USA, data from Medicare recipients from 1990 to 1999 showed an increase in the number of device infections from 0.94 per 1000 recipients to 2.11 per 1000 recipients, an increase of 124%; the estimated rate of infection of endocardial leads being between 1 and 2%, but varying from 0.13 to 12.6%.…”

“…In the USA, data from Medicare recipients from 1990 to 1999 showed an increase in the number of device infections from 0.94 per 1000 recipients to 2.11 per 1000 recipients, an increase of 124%; the estimated rate of infection of endocardial leads being between 1 and 2%, but varying from 0.13 to 12.6%. (Cabell et al, 2004;Voight et al, 2006). Grimm et al (1993) reported an incidence of ICD system infection ranging from 2 to 8%.…”

Antibiotic Prophylaxis for Patients with a History of Total Joint Replacement

“…While comparing infections of cardiac devices to total joint replacements following dental procedures may be inappropriate, it may serve as a good area of investigation for the AAOS going forward in making potentially improved recommendations regarding prophylaxis. 35 Patients receiving CIEDs tend to be older and suffer from more comorbidities than the population as a whole. 36 The increased prevalence of CIEDs, coupled with their presence in older, sicker patients, has led to an increased incidence of CIED infection.…”

“…33,34 Notably, the number of hospitalizations resulting from CIED infections increased 3.1-fold between 1996 and 2003, significantly outstripping the increase in CIED prevalence. 35 Endocarditis and device-related infections are the most common types of infections complicating CIED placement. 33,34 Between 60% to 80% of these infections are caused by Staphylococcus species; 42% are caused by coagulase-negative Staphylococcus alone.…”

“…34,37 CIED infections tend to be characterized by high rates of morbidity and mortality. 34,35 A 2009 study, for example, found an 18% all-cause mortality from CIED infections at 6 months. 38 Given the high risks associated with these infections, the AHA recommends the use of prophylactic antibiotics in all patients, regardless of prosthetic joint status, before CIED placement.…”