The burden of left ventricular assist device (LVAD) infections on costs, lengths of stay, antimicrobial consumption and resistance: a prospective case control approach.

Abstract

Background: Congestive heart failure has reached pandemic levels, and left-ventricular assist devices (LVAD) are increasingly used to treat refractory heart failure. Infection is a leading complication of LVADs. Despite numerous reports (most being retrospective), several knowledge gaps pertaining to the epidemiology and burden of an LVAD-associated infection (LVADi) remain. We sought to address these gaps using a prospective, case-control design.

Methods: All patients who received an LVAD from November 1, 2018 to August 31, 2023 (n = 110) were included and prospectively monitored until death. Data were extracted from clinical encounters and medical records in real-time or near real-time and imported to Excel and REDcap electronic data capture tools. An LVADi was ascertained using definitions from the mechanical circulatory support academic research consortium in conjunction with and the U.S. National Health Safety Network. All meeting those definitions were included as 'cases.' Patients with no LVADi were controls. Excess lengths-of-stays (LOS) and direct costs were calculated from billing records using a commercial cost accounting software platform (Strata^®, Chicago, IL).

Results: The amount of healthcare contact before implantation and discharge to a rehabilitation or skilled nursing facility instead of home were the primary risks for infection, resulting in mean excesses of 25 hospital and 60 antibiotic-days and $43,000 per event. One-third occurred > 1 year after implantation. 35% developed > 1 infection. Gram-negative, fungal, and antimicrobial-resistant organisms predominated deep or repeat infections. 7.2% developed ≥ 3 infections. Organisms became increasingly antimicrobial resistant with subsequent infections, leading to extensive or pan-drug resistance in 4.5% of patients. The burden of an LVADi was 1862 excess hospital days, 3960 excess antibiotic days, and $3.4 million.

Conclusions: Patients with LVADis had significant increases in costs, LOS, readmissions, and antibiotic usage. Antimicrobial resistance varied directly with the number of repeat infections and antibiotic exposure. Identification of factors associated with LVADi, and quantification of the burden of LVADi can inform prevention efforts and lead to reduced infection rates. As preventing infections in the first place is also important for limiting the emergence of antimicrobial resistance, we offer strategies to avoid LVADis.

Trial registry: Not applicable.