Single versus multi‐drug antimicrobial surgical infection prophylaxis for left ventricular assist devices: A systematic review and meta‐analysis

Patel, Sinal; Choi, Jae Hwan; Escrivá, E; Rizvi, Syed S.; Maynes, Elizabeth J.; Samuels, Louis E.; Luc, Jessica G.Y.; Morris, Rohinton J.; Massey, H. Todd; Tchantchaleishvili, Vakhtang; Aburjania, Nana

doi:10.1111/aor.13441

Cited by 9 publications

(6 citation statements)

References 33 publications

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“…A meta‐analysis by Patel and colleagues evaluated 14 studies which included 1311 patients to compare the effectiveness on clinical outcomes between a single‐drug SIP, defined as use of vancomycin, cefazlin or combinations of either versus a multi‐drug SIP, which was defined as the addition of other antimicrobial agents to the single‐drug regimen. The study found no significant difference in incidence of LVAD‐specific infections between the groups; however, a significantly lower survival rate was seen in patients who received multidrug SIP 12 . These findings, along with the findings of our study, suggest there is no advantage to multidrug regimens in comparison to a narrow SIP regimen.…”

Section: Discussionsupporting

confidence: 59%

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Impact of narrowing perioperative antibiotic prophylaxis for left ventricular assist device implantation

Allen

Bartash

Minamoto

et al. 2022

Transplant Infectious Dis

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Background Although infections are a significant potential complication among patients undergoing left ventricular assist device (LVAD) implantation, standardized surgical infection prophylaxis (SIP) regimens are not well defined. At Montefiore Medical Center, a 4‐drug SIP regimen containing fluconazole, ciprofloxacin, rifampin, and vancomycin was previously utilized. In January 2020, the antimicrobial stewardship program implemented a 2‐drug SIP regimen of vancomycin and cefazolin to limit exposure to broad‐spectrum antibiotics. This study evaluated LVAD‐associated infection rates prior to and following the SIP revision. Methods A retrospective review of patients who underwent LVAD implantation from 1/2018 to 4/2021 was performed. Infections were classified using the International Society for Heart and Lung Transplantation definitions. Infection rates at 2 weeks, 30 days, and 90 days post‐implantation in the 4‐drug SIP regimen (1/2018‐12/2019) and the 2‐drug SIP regimen (1/2020 to 4/2021) were compared. Results A total of 71 patients were included. The number of patients with LVAD‐associated infections (including surgical site infections) was not significantly different in either SIP group at 2 weeks (9% vs. 4%, p = .64), 30 days (9% vs. 11%, p = .99), or 90 days (19% vs. 14%, p = .75). There was no statistically significant difference in 30 or 90‐day mortality. LVAD‐associated gram‐negative (7% vs. 7%; p > .99) and fungal (5% vs. 0%; p = .51) infections were uncommon. The most common organism isolated was Staphylococcus aureus, and the most common type of infection was pneumonia in both SIP groups. Conclusion No significant difference in LVAD‐associated infections or infection‐related mortality was observed with de‐escalation of perioperative antibiotics. Additional studies with larger sample sizes are needed to endorse the findings of this study.

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Section: Discussionsupporting

confidence: 59%

“…The study found no significant difference in incidence of LVAD-specific infections between the groups; however, a significantly lower survival rate was seen in patients who received multidrug SIP. 12 These findings, along with the findings of our study, suggest there is no advantage to multidrug regimens in comparison to a narrow SIP regimen.…”

Section: Allergy 1supporting

confidence: 68%

Impact of narrowing perioperative antibiotic prophylaxis for left ventricular assist device implantation

Allen

Bartash

Minamoto

et al. 2022

Transplant Infectious Dis

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“…These findings support that for uncomplicated cases, broad spectrum antimicrobial coverage does not impact outcomes 13 . Similarly, a meta‐analysis involving 14 studies comparing the efficacy of a single‐drug SIP to a multi‐drug SIP in patients undergoing LVAD implantation found no significant difference in the overall incidence of LVAD‐specific infections 14 . Both aforementioned studies demonstrated no survival advantage of a multi‐drug SIP regimen over a single‐drug regimen at both 90 days and 1‐year post device implantation.…”

Section: Commentsupporting

confidence: 62%

Surgical infection prophylaxis prior to left ventricular assist device implantation: A survey of clinical practice

et al. 2020

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Background Short duration, antimicrobial prophylaxis that includes antistaphylococcal activity is recommended at the time of left ventricular assist device (LVAD) implantation to reduce infection‐related complications. There continues to be wide variability in surgical infection prophylaxis (SIP) regimens among implantation centers. The aim of this study is to characterize current SIP regimens at different LVAD centers. Methods A survey study was conducted from 26 September 2017 to 25 October 2017. Surveys were distributed electronically to LVAD coordinators and infectious diseases specialists at 75 US medical centers identified as having an LVAD program. Data collection included information about antimicrobial selection, duration, Staphylococcus aureus screening, and decolonization procedures. Results We received 29 survey responses. The majority of surveys were completed by infectious diseases physicians (72.4% [21 out of 29]). Most responding centers reported LVAD programs established for greater than 10 years (20 out of 29 [69%]). Cardiac transplantation was performed in 28 out of 29 (96%) centers. Of centers reporting a defined SIP regimen for non‐penicillin allergic patients (96% [28 out of 29]), 17.9% (5 out of 28) reported a four‐drug regimen, 35.7% (10 out of 28) reported a three‐drug regimen, and 46.4% (13 out of 28) reported a two‐drug regimen, while no centers reported a single‐drug regimen. Empiric fluconazole was common (50% [14 out of 28]) and 96.4% (27 out of 28) of regimens included vancomycin. Duration of antimicrobial prophylaxis (24 hours to 5 days), S. aureus screening, decolonization procedures, and alterations due to drug allergies varied across participating centers. Conclusions Our survey results indicate wide variation in SIP regimens among participating LVAD centers. These results highlight the need for studies evaluating the implications of SIP regimens, and whether clinical factors that prolong antimicrobial duration impact postoperative infection rates.

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“…One recent meta-analysis found no difference in rates of LVAD-specific infections when institutions used multidrug compared with single-drug surgical infection prophylaxis, highlighting the need for further insight into optimal perioperative protocols. 19 Interestingly, we observed higher frequencies of MDRO colonization and lower frequencies of VAD infections in VADs implanted before the June 2013 transition from vancomycin, levofloxacin, rifampin, and fluconazole perioperative antimicrobial prophylaxis to vancomycin and cefuroxime, possibly reflective of the broader spectrum antibiotic use in the earlier cohort.…”

Section: Discussionmentioning

confidence: 65%

Colonization with Multidrug-resistant Organisms in Patients with Ventricular Assist Devices

Nam

Kumar

et al. 2021

ASAIO Journal

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Infection is a leading cause of morbidity and mortality in patients with ventricular assist devices (VAD). The impact of colonization with multidrug-resistant organisms (MDRO) on outcomes in this cohort is unknown. Patients on VAD support from July 2008 to September 2018 at a single site were evaluated for MDRO colonization after implantation. MDROs included methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus species, and extended-spectrum beta-lactamase producing gram-negative bacteria. 378 patients with 433 VADs were included. 42.6% (n = 161) of patients were colonized with an MDRO throughout the duration of VAD support. Eighty-two VAD infections occurred, 74.4% (n = 61) of whom were MDRO colonized before infection. MDRO colonization was associated with an increased risk of a subsequent VAD infection (hazard ratio 3.704, p < 0.001). MDRO colonization is common after VAD implantation and is associated with future VAD infections. Further study is needed to determine best management strategies for VAD recipients with MDRO colonization given this increased risk.

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Single versus multi‐drug antimicrobial surgical infection prophylaxis for left ventricular assist devices: A systematic review and meta‐analysis

Cited by 9 publications

References 33 publications

Impact of narrowing perioperative antibiotic prophylaxis for left ventricular assist device implantation

Impact of narrowing perioperative antibiotic prophylaxis for left ventricular assist device implantation

Surgical infection prophylaxis prior to left ventricular assist device implantation: A survey of clinical practice

Colonization with Multidrug-resistant Organisms in Patients with Ventricular Assist Devices

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