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.

Figure 1.

Two-year freedom from driveline infection stratified by era. (Era 1: nonstandardized driveline care protocol; Era 2: standardized driveline care protocol; Era 3: Era 2 and marking of the positioning of driveline exit site; Era 4: Era 3 and “no shower” policy).

Figure 2.

Distribution of initial pathogen (gram-positive, gram-negative, polymicrobial, culture-negative) stratified by: (A) chronic antibiotic suppression (CAS) use vs. (B) not (No CAS). (C) Antibiotic distribution among patients treated with CAS. CAS, chronic antibiotic suppression: Gram-positive: 21 methicillin-sensitive Staphylococcus aureus, 7 methicillin-resistant Staphylococcus aureus, 2 Diphtheroids, 1 Enterococcus faecalis, 3 coagulase-negative staphylococcus. Gram-negative: 15 Pseudomonas aeruginosa, 6 Serratia marcescens, 4 Klebsiella pneumoniae, 2 Stenotrophomonas maltophilia, 1 Achromobacter xylosoxidans, 1 Acinetobacter baumannii complex, 1 Burkholderia cepacia complex, 1 Enterobacter cloacae, 1 Escherichia coli, 1 Serratia liquefaciens. No CAS: Not on Chronic Antibiotic Suppression: Gram-positive: 7 methicillin-sensitive Staphylococcus aureus, 2 methicillin-resistant Staphylococcus aureus, 1 coagulase-negative staphylococcus, 1 Corynebacterium striatum, 1 Streptococcus viridans. Gram negative: 5 Serratia marcescens, 3 Pseudomonas aeruginosa, 2 Enterobacter cloacae, 2 Enterobacter aerogenes, 2 Stenotrophomonas maltophilia, 1 Acinetobacter baumannii complex, 1 Acinetobacter oitti, 1 Klebsiella pneumoniae

Figure 3.

(A) Driveline infection prevention strategies implemented over time stratified by Era. (B) Impact of chronic antibiotic suppression on DLI outcomes. (C) Impact of pathogen type on DLI outcomes. (D) Two-year Survival Conditioned Upon Survival to 3 months post-LVAD, stratified by clinical course (no DLI, DLI without I&D, DLI with I&D)