Omer W. Sultan, MBBS, Katherine Y. Le, MD, MPH, Larry M. Baddour, MD, MD, Salwa Hussain, MBBS, Christine M. Lohse, MS, Paul A. Friedman, MD, David L. Hayes MD, Walter R. Wilson, MD, James M. Steckelberg, MD and Muhammad R. Sohail, MD for the Mayo Cardiovascular Infections Study Group

Mayo Clinic, Rochester, MN

Impact of Diabetes Mellitus on Clinical Presentation and Outcome of Patients with Cardiovascular Implantable Electronic Device Infections

Infection is a serious complication of Cardiovascular implantable electronic device (CIED) implantation and is associated with significant morbidity and mortality. Diabetes mellitus (DM) is a frequent comorbid condition in CIED recipients. Hyperglycemia is known to impair host immune response by interfering with leukocyte migration and function. In this investigation, we sought to examine the differences in clinical presentation and outcome of patients with cardiovascular implantable electronic device (CIED) infection with and without diabetes mellitus.

Background

Figure 2. Microbiology

•  Patients with diabetes are more likely to present with systemic manifestations of CIED infection and associated complications compared to non-diabetics.

•  Although short-term infection-related morality between the two groups is similar, diabetics had poor long-term survival compared to non- diabetics

Conclusions

1.  Sohail MR, Henrikson CA, Braid-Forbes MJ, Forbes KF, Lerner DJ. Mortality and Cost Associated With Cardiovascular Implantable Electronic Device Infections. Arch Intern Med. 2011.

2.  Sohail MR, Uslan DZ, Khan AH, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol. 2007;49(18):1851–1859.

3.  Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121(3):458–477.

References

Erosion of infected CIED in a diabetic patient (From Sohail MR, Sultan OW, Raza SS. Contemporary management of cardiovascular implantable electronic device infections. Expert Rev Anti Infect Ther. 2010;8(7):831–839.

Figure 1. Clinical Presentation

© 2011 Mayo Foundation for Medical Education and Research

Results

•  We Identified 415 patients admitted to Mayo Clinic Rochester between 1991- 2008 with CIED infections .

•  There were 115 (28%) patients with diabetes and 300 patients (72%) without it. •  Male and female ratio was similar in both groups. •  Patients with diabetes, as expected, had higher BMI compared to non-diabetics (31

vs. 27.6, P <0.001 ). •  Comorbid conditions were more frequent in patients with diabetes compared to non-

diabetics. (Average Charlson comorbidity index of 1.7 in non-DM cases vs. 3.5 in diabetics, P <0.001).

•  Prevalence of renal disease was in 34 (30%) in diabetics vs. 43 (14%) in non-diabetics (P 0.001).

•  Coronary artery disease affected 81 (70%) diabetics vs. 156 (52.2%) patients without diabetes (P < 0.001). Similarly, peripheral vascular disease was present in 21 (28%) patients with diabetes compared to 22 (7%) without it (P 0.001).

•  Thirty-six (31%) patients with Diabetes presented with pocket infection whereas pocket infection was the presenting feature in 152 (51)% of non- diabetics (P 0.002). Figure 1.

•  Patients with diabetes were more likely to present with blood stream infection (61% vs. 41%, p<0.001) compared to non-diabetics. Consequently, fever (50% vs. 37%, p=0.01) and chills (39% vs. 27%, P=0.02) were more common in patients with diabetes compared to non-diabetics, who were more likely to present with swelling (49% vs. 36%, P=0.01) and drainage (43% vs. 28%, P=0.005) from the generator pocket.

•  CIED- infective endocarditis was present in 59 (20%) in non-diabetics vs. 30 (26% ) in diabetics (P 0.15)

•  Patients with diabetes were also more likely to have distant metastatic foci on infection (10% vs. 3%, p=0.005).

•  Interestingly, diabetics had higher frequency of Staphylococcus aureus infection (39% vs. 28%, P=0.03) compared to non- diabetics. Differences in microbiology of patients with diabetes and those without diabetes are summarized in figure 2.

•  While 30-day survival between the two groups was similar, diabetics had poor long-term survival compared to non- diabetics (p=0.013). Figure 4.

•  We performed a retrospective review of all patients admitted to Mayo Clinic Rochester from 1991 to 2008 with diagnosis of CIED infection.

•  CIED infection was defined by clinical and microbiologic criteria published earlier.

•  Comparison of features between patients with and without Diabetes were evaluated using Wilcoxan Rank Sum , Chi Square and Fisher’s Exact tests.

•  Overall survival was estimated using the Kaplan-Meier Method and compared between patients with and without diabetes using a log-rank test

•  Statistical analyses were performed using SAS software package .

•  All statistical tests were two sided and p-values < 0.05 were considered statistically significant .

Patients and Methods

This work was supported, in part, with a Career Development Award to Dr. Sohail from the Department of Medicine, Mayo Foundation for Medical Education and Research. Disclosure: All <$10,000 PAF: Honoraria/Consultant: Medtronic, Guidant, Astra Zeneca; Sponsored research: Medtronic, Astra Zeneca via Beth Israel, Guidant, St. Jude, Bard; Intellectual

property rights: Bard EP, Hewlett Packard, Medical Positioning, Inc. DLH: Honoraria: Medtronic, Boston Scientific, St. Jude Medical, ELA Medical, Biotronik; Royalty

payments: UpToDate; Wiley-Blackwell; Medical advisory board: Boston Scientific, St. Jude Medical, Pixel Velocity; Steering committee

member: Medtronic, St. Jude Medical LMB: Royalty payments: UpToDate; Editorship: Massachusetts Medical Society (Journal Watch

Infectious Diseases); ACP/PIER editorial consultant MRS: Honoraria/Consultant: TyRx Pharma, Inc. All other authors: No disclosures. Conflict of interest: None for all authors.

Disclosures

Overall survival for CIED infection patients with and without diabetes.

Figure 3. Pocket infection

Figure 4. Survival analysis