Health-care practice patterns in patients with cardiac implantable electronic devices and concomitant staphylococcus aureus bacteraemia

Abstract Background Clinical guidelines advocate for the use of echocardiography as first-line imaging to rule out infectious endocarditis (IE) in patients with Staphylococcus aureus bacteraemia (SAB), particularly those who have cardiac implantable electronic devices (CIEDs). EHRA 2020 guidelines additionally recommend device extraction in the case of SAB irrespective of signs of CIED infection. Importantly, patients with SAB may access healthcare services through various pathways, and thus the diagnostic routes, practice patterns, and associated treatments may differ accordingly. Purpose We aimed to map the diagnostic routes and practice patterns in patients with CIED and concomitant first SAB. Secondly, we aimed to compare clinical management of these patients to contemporary recommendations within the field. Methods We conducted a retrospective review of electronic medical records of all patients with CIED and SAB through the years 2016-2020 in Region Zealand, Denmark, covering approx. 850,000 inhabitants. Patients were identified from The Danish Pacemaker and ICD register and The National Danish Staphylococcus aureus Bacteriemia Database. Information on symptoms at the time of SAB, admission department, cardiac consultation, imaging and clinical outcomes were examined. Results Over the course of 5 years, 97 episodes of SAB in patients with CIED were identified, of which 83 were available for review (no information in medical record: n=9, re-infection: n=3, misclassification: n=2). Median age at the time of SAB was 81 years IQR: 73-87, 57 (69%) were males, and 74 (89%) had a pacemaker implanted. The median admission time was 17 days IQR: 11-26.5). The most frequent admission department was internal medicine (IM, n=46 55%), followed by cardiology (CAR, n=20 24%), surgery (SUR, n=14 17%, and other/none (n=3 4%)). Clinical characteristics at baseline are presented in Table 1. Seventy patients (84%) had a cardiac consultation with 69 (83%) having an echocardiography performed (IM n=39 85%, CAR n=19 95%, SUR n=10 71%). PET-CT was performed in 16 patients (IM n=11 23.9%, CAR n=4 20.0%, SUR n=1 7.1%). We observed 7 cases (8.4%) of valvular IE, and 8 cases (9.6%) of device IE. One patient presented with concomitant valvular and CIED IE. Eleven patients (13%) underwent CIED extraction with a median of 5 days IQR: 2.5-7.5 from positive blood culture. 24 patients (IM n=13 28%; CAR n=4 20%; SUR n=5 36%) died during the admission (median time to death: 5.5 days IQR: 5-11). The diagnostic routes are depicted in Figure 1. Conclusions In a heterogeneous cohort of patients with CIED and SAB, the majority were admitted to non-cardiology departments. Among those hospitalized in internal medicine and surgical units, 15% and 29%, respectively, did not receive a cardiac consultation or had an echocardiography performed. Furthermore, the rate of device extraction was low, indicating suboptimal adherence to contemporary recommendations.Sankey diagram of diagnostic routes Characteristics and outcomes