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JOURNAL OF CARDIOVASCULAR DISEASE
ISSN: 2330-4596 (Print) / 2330-460X (Online)
VOL.3 NO.3
MAY 2015
http://www.researchpub.org/journal/jcvd/jcvd.html
Antibiotic Bead Therapy for Implantable Left
Ventricular Device Pocket Infection
Talar Tatarian, MD, Nicholas C. Cavarocchi, MD and Hitoshi Hirose, MD*
 Abstract
Infectious complications of left ventricular assist devices
(LVAD) are associated with increases in morbidity,
mortality, and hospital costs. Traditional treatment options
include intravenous antibiotics, operative debridement,
and pump exchange. Herein, we report the case of a
70-year-old female who developed a LVAD pocket infection
two weeks after implantation and was successfully treated
with antibiotic beads within the LVAD pocket, after the
failure of traditional therapies. Antibiotic beads may be a
useful adjunct in the treatment and salvage of an infected
LVAD.
Keywords — ventricular assist device, infection, antibiotics.
Cite this article as: Tatarian T, Cavarocchi, NC, and Hirose H.
Antibiotic bead therapy for implantable left ventricular device
pocket infection. JCvD 2015;3(3): 357-358.
I. INTRODUCTION
D
espite the advances in the design of LVADs, infectious
complications remain an inherent and serious risk to both
patients and the healthcare system [1, 2, 3]. To date, there is no
well-defined guideline in the management of such infections.
The traditional treatment options of intravenous antibiotics,
operative washout and debridement, and “re-pocketing” the
device are not always successful. Herein, we present the case of
a patient with a LVAD pocket infection successfully salvaged
with antibiotic beads, after the failure of traditional treatments.
Proteus mirabilis and sensitivity-targeted intravenous
antibiotic therapy was initiated. A week later, after the removal
of both drains, the patient developed a recurrent pericardial
effusion. This was drained in the operating room, with purulent
fluid evacuated from the pericardial space and LVAD pocket.
The space was irrigated with antibiotic solution and a vacuum
assisted closure (VAC) negative pressure wound therapy
system (KCI, San Antonio, Texas) was applied. Over the
course of the next few weeks, the patient returned to the
operating room multiple times for washout of the LVAD pocket
and exposed device using antibiotic irrigation. Informed
consent was obtained prior to each procedure. Despite these
efforts, fluid culture from the LVAD pocket was persistently
positive for Proteus mirabilis. At this point, salvage therapy
was initiated considering the risk of pump-housing infection.
Tobramycin powder was mixed with polymethylmethacrylate
(PMMA), strung on a prolene suture (Figure 1) and placed
throughout the pocket to cover the LVAD device (Figure 2). A
VAC was re-applied over top the antibiotics beads. Subsequent
VAC changes were completed three times per week at the
bedside while the antibiotic beads were kept in the pocket.
Serum tobramycin levels were checked weekly to ensure that
systemic levels did not become toxic to the patient. The patient
was eventually discharged to a sub-acute rehabilitation facility
with combined VAC therapy and intravenous antibiotics. Over
the next three months, with improvement in the patient’s
general and nutritional condition, the LVAD pocket infection
was cleared, as confirmed by negative wound cultures.
II. OUR EXPERIENCE
A 70-year-old female with a ten-year history of
chemotherapy-induced
non-ischemic
cardiomyopathy
presented with progressively worsening symptoms and cardiac
functions. After thorough evaluation, she was deemed an
appropriate candidate for LVAD destination therapy. Informed
consent was obtained and a HeartMate II (Thoratec,
Pleasanton, CA) was implanted uneventfully. Two weeks after
the procedure, the patient developed symptomatic pericardial
and left pleural effusions, which were managed with
percutaneous drainage. Fluid cultures from both sites grew
Received on 23 August 2014.
From Department of Surgery, Thomas Jefferson University Hospital, 1025
Walnut Street, Room 605, Philadelphia, PA 19107, USA.
Conflict of interest: none.
*Correspondence to Dr. Hitoshi Hirose: Hitoshi.Hirose@jefferson.edu
Fig. 1. Tobramycin beads strung on a prolene suture.
357
JOURNAL OF CARDIOVASCULAR DISEASE
ISSN: 2330-4596 (Print) / 2330-460X (Online)
VOL.3 NO.3
MAY 2015
http://www.researchpub.org/journal/jcvd/jcvd.html
Fig. 2. LVAD device is exposed due to pocket infection. Antibiotic beads are
seen surrounding the LVAD device.
She returned to operating room three months after the initial
operation for definitive flap coverage. All antibiotic beads were
removed, the pocket was irrigated with antibiotic solution,
tissue was debrided, and an omental pedicle flap was used for
coverage the device and pocket. The patient did well
post-operatively without further infectious complications and is
currently doing well 36 months out from the initial operation.
III. DISCUSSION
Infectious complications are an inherent risk in implantable
devices, such as LVAD. These complications may include
driveline
infections,
pump-pocket
infections,
or
LVAD-associated endocarditis leading to bacteremia and
sepsis [1]. LVAD-associated infections are obviously a driving
force for increased morbidity, mortality, and hospital costs [2].
Oz et al predicted the cost of hospitalization for LVAD
implantation to double in the setting of pump housing infection
and increase fivefold when sepsis develops [3].
To date, there is no well-accepted guideline in the
management of LVAD housing infection. Commonly used
therapies include intravenous antibiotics, operative irrigation
and debridement, and pump relocation or exchange. Antibiotic
bead therapy is well described in the orthopedic literature for
the treatment of chronic osteomyelitis and is often utilized in
the salvage of infected hardware [4, 5]. PMMA is a commonly
used bone cement formed by an exothermic polymerization
reaction between a powdered polymer and a liquid monomer
[5,6]. Powdered antibiotic is mixed and suspended in the
cement and gradually eluted into tissues over the course of
weeks or months [6]. The choice of antibiotic must be
heat-stable and hydrophilic (i.e. gentamicin, tobramycin, and
vancomycin) [5]. In the event of antibiotic resistance and
incompatibility with PMMA, bone graft substitutes have
included calcium sulfate and fibrin sealant [5].
With the exception of select case reports and small case
series, there have been no large studies evaluating the use of
antibiotic-impregnated beads in cardiac surgery. McKellar et
al. was among the first to describe the use of
antibiotic-impregnated PMMA beads to control a pump
infection [7]. Tobramycin, vancomycin, and PMMA powders
were mixed into cement, placed as beads onto stainless steel
wire, and packed around the infected device. These were
removed at the time of cardiac transplantation. The largest
study to date by Kretlow et al. studied twenty-six patients who
were treated for LVAD-related infections
using
antibiotic-impregnated PMMA beads, calcium sulfate beads, or
fibrin sealant. After an average of 2.1 weekly or bi-weekly bead
exchanges, 65.4% of infections were cleared with a recurrence
rate of 17.6% [8].
In our patient, traditional therapies (antibiotics and
debridement) were initiated at the time of LVAD pocket
infection. After the failure of both intravenous antibiotics and
operative irrigation, a novel approach was utilized. Antibiotic
beads allowed us to obtain high concentrations of antibiotic
locally, while avoiding systemic complications. The beads
were left in place over the course of several VAC changes until
adequate source control was maintained, as confirmed by
negative wound cultures. In addition, we elected for delayed
omental flap closure due to the risk of flap failure in the setting
of uncontrolled infection. This ultimately allowed us to
preserve the original LVAD, presumably resulting in decreased
risk, morbidity, and cost to the patient.
Although our experience with antibiotic beads was a positive
one, more data is needed before a strong conclusion and
recommendation can be made. Our study is limited in that it
repots only a single case. The largest study to date in cardiac
patients evaluated twenty-six patients. It would be prudent to
establish a multi-center study for stronger evidence and
conclusions regarding the efficacy and impact on morbidity,
mortality, and hospital costs, although it is difficult to do.
Additionally, our study evaluated the response of a single
pathogen, Proteus mirabilis, to tobramycin impregnated
PMMA beads. Different pathogens and antibiotic resistance
patterns may preclude the use of PMMA beads and warrant
alternative treatment modalities.
Given these data, antibiotic bead therapy may serve as an
adjunct to the established use of systemic antibiotics, surgical
debridement, and pump relocation.
REFERENCES
[1] Maiar S, Kondareddy S, Topkara VK. Left ventricular device-related
infections: past, present, and future. Expert Rev Med Devices 2011;8
(5):627-34.
[2] Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW,
Dembitsky W, Long JW, Ascheim DD, Tierney AR, Levitan RG, Watson
JT, Meier P; Randomized Evaluation of Mechanical Assistance for the
Treatment of Congestive Heart Failure (REMATCH) Study Group.
Long-tern use of a left ventricular assist device for end-stage heart failure.
N Engl J Med 2001;345 (20):1435-43.
[3] Oz MC, Gelijns AC, Miller L, Wang C, Nickens P, Arons R, Aaronson K,
Richenbacher W, van Meter C, Nelson K, Weinberg A, Watson J, Rose
EA, Moskowitz AJ. Left ventricular assist devices as permanent heart
failure therapy: the price of progress. Ann Surg 2003;238 (4):577–583.
[4] Prasarn ML, Zych G, Ostermann PAW. Wound Management for Severe
Open Fractures: Use of Antibiotic Bead Pouches and Vacuum-Assisted
Closure. Am J Orthop 2009;38(11):559-63.
[5] Gogia JS, Meehan JP, Di Cesare PE, Jamali AA. Local Antibiotic Therapy
in Osteomyelitis. Semin Plast Surg 2009;23:100-107.
[6] Calhoun JH, Mader JT. Antibiotic Beads in the Management of Surgical
Infections. Am J Surg 1989;157:443-449.
[7] McKellar SH, Allred BD, Marks JD, Cowley CG, Classen DC, Gardner SC,
Long JW. Treatment of Infected Left Ventricular Assist Device Using
Antibiotic-impregnated Beads. Ann Thorac Surg 1999;67 (2):554-5.
[8] Kretlow JD, Brown RH, Wolfswinkel EM, Xue AS, Hollier Jr LH, Ho JK,
Mallidi HR, Gregoric ID, Frazier OH, Izaddoost SA. Salvage of Infected
Left Ventricular Assist Device with Antibiotic Beads. Plast Reconstr Surg
2014;133(1):28e-38e.
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