Branch-Elliman Westyn
VA Boston Healthcare System, Boston, MA, USA.
Harvard Medical School, Boston, MA, USA.
Curr Infect Dis Rep. 2017 Aug 16;19(10):34. doi: 10.1007/s11908-017-0591-8.
Cardiovascular implantable electronic device (CIED) infections are highly morbid, common, and costly, and rates are increasing (Sohail et al. Arch Intern Med 171(20):1821-8 2011; Voigt et al. J Am Coll Cardiol 48(3):590-1 2006). Factors that contribute to the development of CIED infections include patient factors (comorbid conditions, self-care, microbiome), procedural details (repeat procedure, contamination during procedure, appropriate pre-procedural prep, and antimicrobial use), environmental and organizational factors (patient safety culture, facility barriers, such as lack of space to store essential supplies, quality of environmental cleaning), and microbial factors (type of organism, virulence of organism). Each of these can be specifically targeted with infection prevention interventions.
Basic prevention practices, such as administration of systemic antimicrobials prior to incision and delaying the procedure in the setting of fever or elevated INR, are helpful for day-to-day prevention of cardiac device infections. Small single-center studies provide proof-of-concept that bundled prevention interventions can reduce infections, particularly in outbreak settings. However, data regarding which prevention strategies are the most important is limited as are data regarding the optimal prevention program for day-to-day prevention (Borer et al. Infect Control Hosp Epidemiol 25(6):492-7 2004; Ahsan et al. Europace 16(10):1482-9 2014). Evolution of infection prevention programs to include ambulatory and procedural areas is crucial as healthcare delivery is increasingly provided outside of hospitals and operating rooms. The focus on traditional operating rooms and inpatient care leaves the vast majority of healthcare delivery-including cardiac device implantations in the electrophysiology laboratory-uncovered.
心血管植入式电子设备（CIED）感染具有高发病率、常见且成本高昂的特点，并且感染率正在上升（索海尔等人，《内科学文献》，2011年，第171卷第20期，第1821 - 1828页；沃伊特等人，《美国心脏病学会杂志》，2006年，第48卷第3期，第590 - 591页）。导致CIED感染发生的因素包括患者因素（合并症、自我护理、微生物群）、手术细节（重复手术、手术期间污染、适当的术前准备以及抗菌药物使用）、环境和组织因素（患者安全文化、设施障碍，如缺乏储存必需用品的空间、环境清洁质量）以及微生物因素（生物体类型、生物体毒力）。针对这些因素中的每一个都可以采取特定的感染预防干预措施。
基本的预防措施，如在切开前给予全身抗菌药物以及在发热或国际标准化比值（INR）升高的情况下推迟手术，有助于日常预防心脏设备感染。小型单中心研究提供了概念验证，即综合预防干预措施可以减少感染，特别是在爆发感染的情况下。然而，关于哪些预防策略最为重要的数据有限，关于日常预防的最佳预防方案的数据也有限（博勒等人，《感染控制与医院流行病学》，2004年，第25卷第6期，第492 - 497页；阿桑等人，《欧洲心脏起搏与电生理杂志》，2014年，第16卷第10期，第1482 - 1489页）。随着医疗服务越来越多地在医院和手术室之外提供，将感染预防方案扩展至包括门诊和手术区域至关重要。对传统手术室和住院护理的关注使得绝大多数医疗服务——包括在电生理实验室进行的心脏设备植入术——未得到覆盖。
