PMC:6640909 / 49612-57519 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/6640909","sourcedb":"PMC","sourceid":"6640909","source_url":"https://www.ncbi.nlm.nih.gov/pmc/6640909","text":"Recommendations for prevention and treatment of infections preimplant and postimplant\nRecommendations Class Level References\nInfection prevention prior to LT-MCS implant\nIf time and clinical status permit, removal or exchange of all central venous catheters, pulmonary vein catheters and urine catheter prior to LT-MCS device implantation is recommended. I C [474, 482–484]\nIf time and clinical status permit, a dental assessment and therapy if required prior to LT-MCS device implantation, are recommended. I C [485]\nA nasal and groin screen for methicillin-resistant Staphylococcus aureus and, if positive, treatment with topical antibiotics prior to LT-MCS device implantation, are recommended. I C [486, 487]\nAntibiotic prophylaxis\nPreoperative antimicrobial prophylaxis targeted at Staphylococcus sp. and methicillin-resistant S. aureus (in patients with positive test results) is recommended. I C [478–480]\nThe inclusion of antifungal treatment in routine preoperative antimicrobial prophylaxis is not recommended. III C [488, 489]\nIt is recommended that antibiotic prophylaxis be administered within 60 min of the first incision, remain in the therapeutic range throughout its use and not be extended beyond 24 h after surgery. I C [479, 490]\nManaging active infection preimplant\nIn patients with active infections prior to LT-MCS device implantation, antibiotic therapy as directed by an infectious disease expert is recommended. I C [363]\nInfective endocarditis treatment preimplant\nDocumented clearance (negative blood culture results) of patients who have had bacteraemia prior to LT-MCS device implantation is recommended. I C\nIn patients with bacteraemia, antimicrobial therapy for at least 7 days prior to implantation of a mechanical circulatory support device is recommended. I C\nIn patients with bloodstream infections not related to infective endocarditis, removal of sources (if known) and antimicrobial treatment are recommended. I C\nLT-MCS implantation in patients with untreated acute infective endocarditis with active bacteraemia is not recommended. III C\nPreventing infection postimplant\nIt is recommended that the velour part of the driveline not exit the body. I C [259]\nStabilization of the driveline immediately after the device is implanted and continuing throughout the duration of support is recommended. I C [491]\nA dressing change protocol initiated immediately postoperatively is recommended. I B [491, 492]\nSecondary antibiotic prophylaxis for the prevention of infectious events during routine procedures and dental work due to the risk of bacteraemia should be considered. IIa C [71, 493, 494]\nEvaluation of patients with mechanical circulatory support with a suspected infection\nIn all patients, a complete blood count, chest radiographic images and blood cultures are recommended. I C [363]\nIt is recommended to draw at least 3 sets of blood cultures over 24 h, with at least 1 culture from any indwelling central venous catheter. I C [363]\nFor those with a suspected pump cannula or driveline infection, obtaining a sample for gram stain, the KOH test and routine bacterial and fungal cultures are recommended. I C [363]\nWhen clinically indicated, an aspirate from other potential sources, as dictated by presenting symptoms and examination, is recommended. I C [363]\nDirected radiographic studies based on presenting symptoms and examination are recommended. I C [363]\nErythrocyte sedimentation rate or serial C-reactive protein should be considered. IIa C [363]\nRoutine computed tomography of the chest, abdomen and pelvis is not recommended. III C [363]\nLeucocyte radiolabelled scintigraphy may be considered to identify deep infections but by itself lacks anatomical specificity. IIb C [495]\nCombining single positron emission tomography/computed tomography scans with radiolabelled leucocytes has increased the sensitivity for detection of infection and retained the specificity for anatomical location of the MCS infection; it can also identify distal foci if infected emboli are present and should be considered. IIa C [496, 497]\nTreatment of patients with mechanical circulatory support with a suspected infection of the driveline exit site or the driveline itself\nA full evaluation as outlined above should be performed in all patients prior to treatment before commencing antimicrobial treatment even if only superficial infection is suspected. I C [363]\nIn patients with a superficial driveline exit site infection but without a BSI or systemic illness, it is recommended that antibiotic therapy be deferred until culture results are known. I C [71, 498, 499]\nIn patients with clinical signs of driveline exit site infection but with negative culture results, initiation of empirical oral antibiotic therapy and evaluation based on clinical response are recommended. I C\nIn the presence of systemic illness and/or sepsis, initiation of empirical intravenous antibacterial therapy always covering Staphylococcus, Pseudomonas and Enterobacteriaceae species, also taking local institutional epidemiology and colonization (e.g. methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci) into consideration, is recommended. I C\nRifampicin should usually be avoided due to its significant impact on the international normalized ratio, but it may be considered in rare cases. IIb C [500]\nIt is recommended that the duration of antimicrobial treatment be guided by the clinical response, type of infection, pathogen(s), transplant status and the opinion of an infectious disease expert. I C\nIt is recommended that the treatment of a superficial infection without an associated BSI last at least 2 weeks. I C\nFor deep infections, treatment for at least 6 weeks, depending on the pathogen, time to clearance of the BSI, the clinical response and the expert opinion of an infection disease expert, are recommended. I C [26]\nSingle positron emission tomography/computed tomography combined with radiolabelled leucocytes for the detection of location of infection and infected emboli should be considered. IIa C [496, 497]\nLeucocyte radiolabelled scintigraphy for identification of deep infection may be considered. IIb C [495]\nIf the infection is not eradicated despite debridement and 6 weeks of systemic intravenous antibiotic treatment, specific surgical treatment of the infections should be considered, including driveline relocation, pump exchange, prolonged treatment of the ventricular assist device, wrapping driveline with omentum and a heart transplant. IIa C\nLifelong antibiotic treatment for complicated S. aureus infection should be considered unless there is an option to remove the device. IIa C\nTreatment of patients with mechanical circulatory support with a suspected infection of the pump\nIn all patients with mechanical circulatory support, a full evaluation for any suspected infection as outlined above should be performed before commencing antimicrobial treatment. I C [26, 363]\nIn the case of a persistent bloodstream infection, pump seeding or endovascular infection should be suspected. It is recommended that intravenous antimicrobial therapy be initiated after microbiological samples have been taken. I C\nFor infection in patients with mechanical circulatory support at the time of device exchange or heart transplant, it is recommended that antimicrobial therapy be continued for at least 6 weeks, depending on the pathogen and the clinical course, to minimize the risk of relapse. I C [26]\nAfter failure of eradication of infection with debridement and 6 weeks of systemic intravenous antibiotic treatment, specific surgical treatment of infections including pump exchange and a heart transplant should be considered. IIa C\nLT-MCS: long-term mechanical circulatory support; BSI: bloodstream 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