1 00:00:14,760 --> 00:00:15,690 Sara Dong: Hello, everyone. 2 00:00:15,720 --> 00:00:20,400 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:20,820 --> 00:00:25,920 We use consult questions to dive into ID clinical reasoning, diagnostics and anti-microbial management. 4 00:00:26,490 --> 00:00:29,610 I am your host, Sara Dong, a Med-Peds ID fellow. 5 00:00:29,880 --> 00:00:35,155 Here on Febrile, we use patient cases and chat with ID consultants to learn about high yield ID topics. 6 00:00:35,965 --> 00:00:39,025 I am very excited to introduce our guest today, Dr. 7 00:00:39,025 --> 00:00:40,045 Rebecca Kumar. 8 00:00:40,555 --> 00:00:48,385 She is a physician and assistant professor at MedStar Georgetown University Hospital and the Division of Infectious Diseases and Tropical Medicine. 9 00:00:48,865 --> 00:00:58,825 She previously completed her internal medicine residency at MedStar Georgetown in Washington, DC followed by her fellowship in infectious diseases at Northwestern University in Chicago. 10 00:00:59,380 --> 00:01:00,910 Welcome to Febrile, Rebecca! 11 00:01:00,940 --> 00:01:02,140 Thanks so much for coming. 12 00:01:02,530 --> 00:01:04,179 Rebecca Kumar: Thank you so much for having me. 13 00:01:04,420 --> 00:01:05,830 I'm super excited to be here! 14 00:01:06,310 --> 00:01:16,040 Sara Dong: I am still, before we jump into the case, going to ask as everyone's favorite culture podcast, we would love to hear about a little piece of culture that brings you joy or happiness. 15 00:01:16,604 --> 00:01:17,565 Rebecca Kumar: Yeah, of course. 16 00:01:17,595 --> 00:01:23,865 So I really love music and enjoy listening to my Spotify account all the time. 17 00:01:24,435 --> 00:01:30,554 A band that I'm super into right now is Pinkshift, and then another one that I'm really into is Sorry, Mom. 18 00:01:30,615 --> 00:01:44,015 They're both kind of like riot girls / pop-punk bands that are great to just like jam out to, well, you know, chart reviewing or writing notes or like, you know, actually doing fun stuff. 19 00:01:44,045 --> 00:01:53,045 And once, once, um, you know, things are lifted, I really hope that I'm able to see both of them live. 20 00:01:53,195 --> 00:01:53,585 Sara Dong: Yeah. 21 00:01:53,645 --> 00:01:55,655 It'll be nice to go to concerts again. 22 00:01:55,835 --> 00:01:56,435 Rebecca Kumar: I agree. 23 00:01:57,515 --> 00:02:06,515 Sara Dong: One day, well today's consult question is assistance and workup of fever and purulent drainage from a drive-line exit site of a VAD. 24 00:02:06,830 --> 00:02:09,410 Ooh, we're doing something a little different. 25 00:02:09,410 --> 00:02:11,600 We're going to talk about VAD infections. 26 00:02:11,600 --> 00:02:14,990 Today is not necessarily a diagnostic mystery. 27 00:02:15,380 --> 00:02:21,530 Um, but before we jump into the case, I thought we could do a quick introduction, talk quickly about VADs. 28 00:02:21,560 --> 00:02:24,740 So these are implantable ventricular assist devices. 29 00:02:24,920 --> 00:02:31,600 Because I know we have listeners that may not have cared for patients with a VAD before, and it would help to have a little bit of orientation. 30 00:02:32,190 --> 00:02:41,040 So, a VAD is a mechanical pump that provides circulatory support by augmenting the ability of a failing heart to deliver blood flow. 31 00:02:41,070 --> 00:02:54,150 So in patients with refractory heart failure, this can help with improving survival, functional status, quality of life, and they can be implanted in the right or left ventricle, but vast majority are going to be left. 32 00:02:54,150 --> 00:02:56,400 So people may hear the term LVADs. 33 00:02:57,030 --> 00:03:01,545 And so these are continuous flow pumps, pretty much all of them for the most part now. 34 00:03:01,545 --> 00:03:10,195 And so I've put some names of devices that you may hear, which are Heartmate II, Heartmate III, HVAD, and JarvikHeart. 35 00:03:10,215 --> 00:03:15,645 Those are just ones that we hear of, and you'll probably hear the same ones at whatever institution you're at. 36 00:03:16,215 --> 00:03:20,445 Um, and so the pumps are these centrifugal pumps that. 37 00:03:20,990 --> 00:03:25,430 It's almost, I, this is how it's described to me that it's like a rotor floating between two magnets. 38 00:03:25,430 --> 00:03:26,870 So there's not really friction. 39 00:03:26,870 --> 00:03:34,520 And they last longer and have less hemolysis than the earlier pulsatile pumps, which had more sort of thrombotic complications. 40 00:03:34,910 --> 00:03:40,160 And the VAD can use different speeds to mimic increases or decreases in flow. 41 00:03:40,820 --> 00:03:53,520 And the nice thing about the newer ones as they're also smaller and implanted directly into the pericardium and so we'll talk about the structure of the VADs, but previously there were these preperitoneal pump pockets. 42 00:03:53,520 --> 00:03:56,190 So if people look up pictures, you'll see the difference there. 43 00:03:56,609 --> 00:04:01,470 And the newer ones have improved small caliber drive lines that are more durable. 44 00:04:01,890 --> 00:04:14,660 And so we're going to put some pictures in the Consult Notes for this episode on the website, but you can also easily find these on the internet, but Rebecca, can you mention some of these sort of key components of the VAD for an ID person to know? 45 00:04:14,850 --> 00:04:16,150 Rebecca Kumar: Yeah, of course I'd love to. 46 00:04:16,150 --> 00:04:26,320 So essentially there is the inflow cannula which is the part that connects the pump itself to the heart and allows blood to flow into the pump. 47 00:04:26,880 --> 00:04:35,500 From the pump, then you have a outflow cannula which then, um, sort of exits through and pumps the blood out to the rest of the body. 48 00:04:35,640 --> 00:04:39,380 Attached to the pump itself is a, is the drive line. 49 00:04:39,650 --> 00:04:55,605 And so that drive line ends up snaking through the chest, into the abdomen and exiting at the lower part of the abdomen and ends up connecting to a controller set, which is where the cardiologists will then adjust the amount of blood flow that occurs, et cetera. 50 00:04:55,875 --> 00:05:02,025 And this is the component that will alarm if there is detection of like outflow obstruction or anything else like that. 51 00:05:02,655 --> 00:05:08,775 And from the controller, you then have the cords leading to the battery pack, which is also external. 52 00:05:08,835 --> 00:05:16,995 The drive line itself just of note has sort of a piece of velour which sort of attached to it near the exit site. 53 00:05:17,265 --> 00:05:22,635 And this usually should sit inside of the like, uh, like peritoneal space not be exposed. 54 00:05:23,055 --> 00:05:35,475 And that exists because of the fact that it helps with granulation tissue formation, and really just helps, um, create sort of like a nice seal around the drive line and the patient's skin. 55 00:05:36,070 --> 00:05:48,730 One of the big issues though, is that if it ever gets pulled out or exposed a little bit, it's a great place for bacteria to sort of commense and live on because it's providing the bacteria huge area, surface area to survive off of. 56 00:05:49,540 --> 00:05:56,530 Sara Dong: And the last thing that I was going to mention before we jump into the case was sort of, what do we know about how these patients do. 57 00:05:57,315 --> 00:05:58,965 More of a bird's eye view. 58 00:05:58,965 --> 00:06:19,945 And so there are some large databases or, people may find INTERMACS or Interagency Registry for Mechanically Assisted Circulatory Support database, but basically they're over 4,000 cases of LVADs that have been followed in this database, but I think there's over 20,000 patients in the actual registry. 59 00:06:19,975 --> 00:06:25,015 And so they put out these annual reports that tell us a little bit about how these patients are doing. 60 00:06:25,585 --> 00:06:35,825 And so survival with the VAD is now about 80% at one year, somewhere alittle over 70% at two years, and then 35% at five years. 61 00:06:36,425 --> 00:06:44,344 And the average time that patients live with device support has changed from about 120 days to almost a year now. 62 00:06:44,405 --> 00:06:54,390 And so I think the other very helpful thing for us to think about is almost half of patients who receive VADs are considered destination therapy. 63 00:06:54,870 --> 00:07:00,990 And about 57% are VADs that are placed in those who are listed or under evaluation for heart transplant. 64 00:07:01,320 --> 00:07:03,859 And so people will hear the term bridge to transplant. 65 00:07:04,760 --> 00:07:13,710 So I think it's important to know the difference between that for patients who are actively moving towards transplant versus destination therapy, just to provide them support. 66 00:07:14,369 --> 00:07:20,840 And then about 40% of heart transplant recipients have been supported with the LVAD prior to their transplant. 67 00:07:21,910 --> 00:07:30,280 And so for us, in ID, infection is one of the most common complications of VADs and does contribute to mortality on the transplant wait list. 68 00:07:30,310 --> 00:07:36,880 But I have to also say that many patients, even those with infections, get transplanted and have excellent outcomes. 69 00:07:36,880 --> 00:07:43,800 And so we just really wanted to talk about VAD infections today, how to approach them and think about them. 70 00:07:44,190 --> 00:07:46,710 Um, anything I missed Rebecca before we jump in? 71 00:07:46,920 --> 00:07:48,480 Rebecca Kumar: No, you did an amazing job. 72 00:07:50,040 --> 00:07:50,820 Sara Dong: Um, all right. 73 00:07:50,820 --> 00:07:53,340 So Rebecca today we have a 70 year old male. 74 00:07:53,610 --> 00:08:05,849 He has a history of coronary artery disease, had a CABG in the past, and has ischemic heart failure with reduced EF with a left ventricular ejection fraction of 15-20%. 75 00:08:06,435 --> 00:08:11,775 He had a HeartMate II LVAD placed in 2017 as destination therapy. 76 00:08:12,164 --> 00:08:18,645 And he came in today with fever as well as pain and purulence from his drive-line site for about 2 days.. 77 00:08:19,125 --> 00:08:24,525 He has not had chills, chest pain, GI symptoms, rash.. 78 00:08:24,525 --> 00:08:30,735 He says he hasn't had any issues with VAD alarms, or recent trauma to the drive-line that he can remember. 79 00:08:31,920 --> 00:08:37,490 He had a fever to 101.8 Fahrenheit in the emergency department, but otherwise is stable. 80 00:08:38,180 --> 00:08:50,540 I will just mention for his post VAD implant course, he has had some recurrent GI bleeding with AVMs or angioectasias is that were thought to be related to the VAD, which is a complication that is seen. 81 00:08:51,439 --> 00:09:00,950 He's had one prior episode of erythema, tenderness, and purulent drainage from his driveline exit site about a year after his LVAD was placed. 82 00:09:01,310 --> 00:09:04,220 So several years ago from now. 83 00:09:04,250 --> 00:09:10,760 at the time he had a surface wound culture that had no polys, but heavy growth of MSSA. 84 00:09:11,240 --> 00:09:16,850 And he completed several week course of cephalexin and then stopped antibiotics. 85 00:09:17,600 --> 00:09:22,515 And so today on exam, there is an LVAD hum, his lungs are clear. 86 00:09:22,785 --> 00:09:28,275 His abdominal drive-line exit site had some yellow / purulent drainage on the gauze. 87 00:09:28,635 --> 00:09:45,185 And he's complaining of pain at sort of the two o'clock position like if you're looking at his tube and I will mention here, I don't know if this is different other centers, but at least for us many places prefer that there are specific nurse practitioners or physicians who remove the drive-line dressing. 88 00:09:45,185 --> 00:09:50,285 So if you don't know, it's always good to ask the VAD or transplant team just to make sure. 89 00:09:50,785 --> 00:09:55,535 Because you certainly don't want to expose the wound of someone if perhaps just changed the dressing. 90 00:09:55,954 --> 00:09:56,694 Rebecca Kumar: Exactly. 91 00:09:56,795 --> 00:10:02,464 And the other thing you can do also is just ask the team if they took a picture, that's another way to like, get a look at. 92 00:10:03,255 --> 00:10:05,445 It's just been dressed or something else, you know? 93 00:10:05,565 --> 00:10:05,985 Sara Dong: Yeah. 94 00:10:06,315 --> 00:10:08,685 I feel like these patients are followed so closely in clinic. 95 00:10:08,685 --> 00:10:09,375 That's really nice. 96 00:10:09,375 --> 00:10:14,175 They tend to have great pictures or images when symptoms are developing. 97 00:10:14,325 --> 00:10:15,585 Rebecca Kumar: They definitely do. 98 00:10:15,585 --> 00:10:24,285 And we as ID, one of the things that we can do to help out is take the serial photos as well if you're trained in taking care of the driveline. 99 00:10:24,945 --> 00:10:28,290 Sara Dong: Yeah, so we do have some labs. 100 00:10:28,290 --> 00:10:33,450 He had a white count of 16,000 with a diff having 85% neutrophils. 101 00:10:33,870 --> 00:10:36,060 He does have some baseline CKD. 102 00:10:36,060 --> 00:10:39,450 His current creatinine is 2, up from a baseline of 1.4. 103 00:10:40,500 --> 00:10:43,050 He has blood cultures that are sent and pending. 104 00:10:43,410 --> 00:10:47,850 Their primary team has also sent a swab of his drive-line exit site. 105 00:10:48,210 --> 00:10:56,580 And they've gotten initial ultrasound, which showed no clear evidence of abscess in the superficial soft tissues near the exit site. 106 00:10:57,210 --> 00:11:01,950 And so now we have the general story, but I'm going to take a step back and ask. 107 00:11:02,620 --> 00:11:08,849 Where do we even start when thinking about VAD infections and can you walk us through the definition of infection? 108 00:11:08,849 --> 00:11:11,410 Because I think that really informs how we make our plan. 109 00:11:11,860 --> 00:11:13,420 Rebecca Kumar: Yeah, that totally makes sense. 110 00:11:13,480 --> 00:11:17,560 So essentially we can divide our patients who have VADs. 111 00:11:18,010 --> 00:11:25,060 We can divide their infections into three sort of categories, three broad categories, you have VAD specific infections. 112 00:11:25,060 --> 00:11:28,480 So those are infections related to the VAD itself. 113 00:11:29,220 --> 00:11:33,720 We can define them further as a pump or a cannula infection. 114 00:11:33,740 --> 00:11:43,680 So that essentially means that the mechanical, like the pump itself or the inflow cannula or the outflow cannula, there is an infection somewhere within that system. 115 00:11:44,190 --> 00:11:46,080 You can also have a pocket infection. 116 00:11:46,350 --> 00:11:58,839 This was sort of a bigger issue back when the pumps used to site like in the preperitoneal space, but now, um, since they're closer to the heart, um, and much smaller, this comes up less as an issue. 117 00:11:59,380 --> 00:12:20,435 Um, and then finally the most common type of infection, which I believe you mentioned earlier, which is a drive-line exit site infection, and those are further categorized into either superficial infections (so really just involving the exit site itself), or a deeper infection (which can involve the musculature or just track along the drive line itself). 118 00:12:20,585 --> 00:12:31,685 Then we have our VAD related infections, so these, the way that I like to think about it are they are infections that are complicated by the presence of a VAD. 119 00:12:32,045 --> 00:12:39,005 So that would mean any sort of bloodstream infection, any sort of mediastinitis, any sort of endocarditis. 120 00:12:39,035 --> 00:12:47,170 So infections that essentially you or me could get, but if we had a VAD, it would just be that much harder to take care of. 121 00:12:47,859 --> 00:12:51,109 And then finally we have our non-VAD infections. 122 00:12:51,130 --> 00:12:59,160 So that's like C diff or a UTI, anything along those lines that really just doesn't involve the VAD directly. 123 00:12:59,505 --> 00:12:59,834 Sara Dong: Great. 124 00:12:59,865 --> 00:13:02,834 And so we had gotten some blood cultures and labs. 125 00:13:03,224 --> 00:13:09,974 What is sort of your initial workup approach when you have at least this initial information gathered? 126 00:13:10,214 --> 00:13:13,755 Do we need to think about imaging or other tools? 127 00:13:14,444 --> 00:13:14,745 Rebecca Kumar: Yeah. 128 00:13:14,745 --> 00:13:20,474 So if you look at the guidelines, they do recommend like a UA, they recommend a chest x-ray. 129 00:13:20,505 --> 00:13:30,820 My personal practice preference would be to get the blood cultures, like you said, which are part of the guidelines and to get a CBC, which you had also mentioned and is part of the guidelines. 130 00:13:30,910 --> 00:13:37,960 I actually will generally jump straight to CT scan, which may not be necessarily "choosing wisely". 131 00:13:38,550 --> 00:13:45,060 But I do think that it gives you a degree of information that is helpful beyond just an x-ray. 132 00:13:45,780 --> 00:13:50,890 Specifically, I look for fluid collections around, um, the drive line exit site. 133 00:13:51,130 --> 00:13:55,870 You could also accomplish something similar with an ultrasound. 134 00:13:56,319 --> 00:14:00,280 The other thing to consider getting as well as an echocardiogram as well. 135 00:14:00,280 --> 00:14:04,359 But that's more just to look for evidence of vegetations, et cetera. 136 00:14:05,745 --> 00:14:06,075 Sara Dong: Yeah. 137 00:14:06,915 --> 00:14:14,715 And so when we met our patient, you know, there was some concern for deeper infection because of the fevers and the white count. 138 00:14:14,775 --> 00:14:29,775 And so while we're waiting on the imaging, he's been placed on empiric vanc, pip-tazo, but I want to see what you think about antibiotic selection and what organisms do we need to have at the top of our list for these VAD-specific infections? 139 00:14:30,065 --> 00:14:44,625 Rebecca Kumar: So the organisms that I worry about the most are Staph aureus or any of the Staph species, um, particularly because a lot of these, so the most common type of VAD infection will be the driveline exit site infection. 140 00:14:44,625 --> 00:14:48,734 So you worry about skin flora, things like that causing an infection. 141 00:14:48,734 --> 00:14:51,064 So that's why Staph is important to cover for. 142 00:14:51,555 --> 00:15:02,545 For this patient, in particular, you had mentioned that he had had a history of MSSA, which for this patient in particular, the MSSA is going to go to the top of my differential. 143 00:15:02,925 --> 00:15:06,705 An additional concern is Pseudomonas and other gram negatives. 144 00:15:07,125 --> 00:15:09,375 The pip-tazo is a reasonable option. 145 00:15:09,405 --> 00:15:16,515 I think you could get away with cefepime because anaerobes aren't commonly drivers of these VAD infections. 146 00:15:16,655 --> 00:15:24,075 Sara Dong: I think one thing that is tough is we are usually getting these sort of like surface/skin micro swab. 147 00:15:24,105 --> 00:15:30,105 I don't know how you have any like, tips for thinking about separating out what's skin versus really causing infection. 148 00:15:30,165 --> 00:15:32,375 And I think the answer is that "it depends." 149 00:15:33,435 --> 00:15:34,630 Rebecca Kumar: And I agree with that. 150 00:15:34,630 --> 00:15:51,670 And I think part of it is also sort of getting a, an idea from the patient about how the area has looked, because, you know, in this case, this patient does have some drainage, but there are times when people can develop allergy to the chlorhexadine that we use, um, typically for cleaning the site and you can get skin breakdown. 151 00:15:51,670 --> 00:16:03,944 There can be some inflammation and some erythema, and sort of getting the history of, you know, this is something new that's happened and they're noticing it has worsened and is associated with chlorhexadine. 152 00:16:03,944 --> 00:16:07,845 You can then try giving them or try using iodine instead. 153 00:16:08,235 --> 00:16:13,605 Sara Dong: Well, the patient fortunately does not have another fever after the one in the emergency department. 154 00:16:14,025 --> 00:16:21,255 And after starting antibiotics, says that the areas near his insertion, sorry, his exit site, for the most part resolved. 155 00:16:21,765 --> 00:16:23,204 Our wound culture. 156 00:16:23,235 --> 00:16:27,165 So the swab from the exit site did grow MSSA again. 157 00:16:27,525 --> 00:16:29,985 And fortunately, his blood cultures are negative. 158 00:16:30,255 --> 00:16:36,265 And so around this time he's transitioned from the vanc, pip-tazo to cefazolin. 159 00:16:36,314 --> 00:16:40,035 We do get an echo that looks like it's at baseline for him. 160 00:16:41,250 --> 00:17:04,110 And then there is a CT abdomen, pelvis that doesn't show any evidence of infection in the chest or unusual appearance of the LVAD, but he does have moderate subcutaneous soft tissue stranding along the right anterior abdominal wall (so the driveline insertion site) as well as into some of the underlying mesenteric fat. 161 00:17:04,440 --> 00:17:12,079 And so there fortunately is no fluid collection or organization there, but there's definitely some stranding that extends. 162 00:17:12,740 --> 00:17:16,940 And so you've walked us through the types of VAD specific infection. 163 00:17:17,419 --> 00:17:22,669 And now I want us to get to thinking about antibiotic strategies and how it's different for these. 164 00:17:22,790 --> 00:17:34,100 And so in this case, we decided to treat as sort of a deep drive line infection, but I think it's helpful to think about how things would be different if say his blood cultures were positive. 165 00:17:35,220 --> 00:17:35,550 Rebecca Kumar: Right. 166 00:17:35,550 --> 00:17:45,480 So if his blood cultures were positive, then you would sort of think you'd take a step back and think, is this a VAD related infection or is this a VAD infection? 167 00:17:45,480 --> 00:17:48,390 Specifically, you would worry about a pump infection. 168 00:17:49,110 --> 00:18:00,195 Um, You know, and depending on which of those you thought it was, the duration of antibiotics and your choice of IV versus PO would change. 169 00:18:00,225 --> 00:18:07,365 So if I was worried that this was actually like a pump or a cannula infection, I would treat them for at least six weeks. 170 00:18:07,425 --> 00:18:20,969 Um, probably longer to be honest, um, with IV therapy, if it was a bloodstream infection, you know, technically you could treat them for two weeks, but I think in clinical practice, you don't see that happen very often. 171 00:18:20,969 --> 00:18:23,850 I think we get very worried about the VAD getting seeded. 172 00:18:24,389 --> 00:18:29,370 Um, and that's partially because it's such a big deal if it does get seeded. 173 00:18:29,880 --> 00:18:34,680 It can be very difficult to remove the VAD itself. 174 00:18:35,190 --> 00:18:39,810 They always say that the bravest surgeons are the internal medicine or infectious disease doctors. 175 00:18:39,810 --> 00:18:51,000 So it's easy for us to be like, yeah, like it's affected like "we need source control,", but like from a practical standpoint, it is very difficult to remove this piece of hardware that's attached to your heart. 176 00:18:51,630 --> 00:18:51,930 Sara Dong: Yeah. 177 00:18:52,020 --> 00:18:54,640 And so how long do you think we should treat our patient? 178 00:18:55,440 --> 00:18:59,145 Rebecca Kumar: Honestly, I would probably treat this gentleman for at least four weeks. 179 00:18:59,175 --> 00:19:04,754 And then at that point I would do, and this is obviously not in the guidelines or anything else. 180 00:19:04,754 --> 00:19:07,725 I would repeat the culture as well. 181 00:19:08,175 --> 00:19:15,284 If it's still as positive with the same organism, I would probably then maybe extend out the IV duration. 182 00:19:15,675 --> 00:19:28,615 There's also the fact that this, because this is a deeper infection, this gentleman's probably going to need oral suppressive therapy and generally, we end up keeping these patients because he's a destination VAD, or a destination therapy. 183 00:19:28,945 --> 00:19:32,695 Um, this would be somebody who would likely be on this antibiotic lifelong. 184 00:19:32,935 --> 00:19:39,985 Sara Dong: We kind of had the same thought, had a superficial drive line infection in the past, now here with a deep drive line infection and the same organism. 185 00:19:40,465 --> 00:19:43,425 Um, so made the plan to continue with oral suppression. 186 00:19:44,225 --> 00:19:48,475 That kind of raises sort of one of the final questions that I had was. 187 00:19:49,290 --> 00:19:56,160 How does a patient's future as destination therapy versus bridge to transplant impact how you manage their infection? 188 00:19:57,120 --> 00:20:04,200 You know, does it, maybe it makes no difference, but I think it tends to be part of the conversation when we're figuring out treatment courses. 189 00:20:04,800 --> 00:20:05,130 Rebecca Kumar: Right. 190 00:20:06,145 --> 00:20:19,225 You know, it's hard because it's a big deal to have a ventricular assist device, even though it is providing these patients with a longer lifespan, better like presumably a better quality of life, because they're not as symptomatic, et cetera. 191 00:20:20,065 --> 00:20:24,445 It's an additional burden to ask people to take additional IV antibiotics. 192 00:20:24,445 --> 00:20:33,065 Like for example, I've taken care of patients who have had multi-drug resistant pseudomonas where an oral therapy is not an option and they're a destination VAD. 193 00:20:33,245 --> 00:20:40,774 And so, um, this gentleman was on meropenem for about like nine months and was still growing out the pseudomonas from the driveline exit site. 194 00:20:41,524 --> 00:20:57,120 I think this is a good opportunity to sort of at least discuss almost goals of care with these patients or at least bring up the topic, make sure that they know that what you're doing is mostly mitigation, and not necessarily curing or eradicating the infection. 195 00:20:57,120 --> 00:20:58,889 You're trying to keep it under control. 196 00:20:59,040 --> 00:21:17,010 Sara Dong: And I think, I mean, I think that's kind of what I was thinking too, is I feel like we basically revisit that goals of care type discussion every time, because that's like, yes, if you did develop like an awful reaction to this, then we just sort of have a discussion about it and weigh risk benefits. 197 00:21:17,430 --> 00:21:31,050 Rebecca Kumar: Right, and then the other thing is like, I have stopped therapy for destination VADs in the setting of like somebody wanting to take a trip somewhere, or, you know, like these things that I, we take for granted most of the time. 198 00:21:31,860 --> 00:21:37,080 It's very different for somebody who has to take their refrigerated IV antibiotics with them everywhere. 199 00:21:37,530 --> 00:21:50,760 Um, so it's a lot of like working with the patients, working with the cardiac surgeons or the cardiologists as well to come up with something that everybody kind of feels comfortable with, but that also allows the patient to live their life to some degree. 200 00:21:51,090 --> 00:21:56,100 Sara Dong: And so we'll, I'll, make/have a graphic for this sort of about the management. 201 00:21:56,100 --> 00:21:58,170 Because you talked a little bit about antibiotics. 202 00:21:58,210 --> 00:22:03,810 There's this IV course and then oral suppression in certain cases. 203 00:22:03,810 --> 00:22:08,460 And then I think there's non antibiotic related strategies that we have to think about. 204 00:22:08,460 --> 00:22:13,649 And you've touched on how, obviously we're not just saying, take out the VAD every time. 205 00:22:13,649 --> 00:22:16,170 It's not the same as taking out like a central line. 206 00:22:16,680 --> 00:22:25,889 Um, but I think there's other things sort of like wound care and skincare that probably are helpful for thinking about preventing future infections. 207 00:22:25,889 --> 00:22:27,860 Is there anything that you counsel patients on? 208 00:22:28,650 --> 00:22:35,730 Rebecca Kumar: Yeah, so, um, if I tell them that they noticed that there's like a lot of redness, if it's getting itchy, et cetera, to let us know. 209 00:22:36,300 --> 00:22:45,504 Some of it's a little bit of trial and error in terms of trying out different, like, switching from the chlorhexadine to the iodine and seeing if that makes a difference in their symptoms. 210 00:22:45,715 --> 00:22:53,245 Sometimes, we didn't touch on this, but a lot of times we'll give patients like a separate, almost like it's like a sticker with a hook. 211 00:22:53,605 --> 00:22:55,195 And it's what we call the anchor. 212 00:22:55,195 --> 00:23:18,524 And that sort of helps give an additional bit of slack to the patient because one of the things that can predispose patients to infections is having the driveline tugged upon, or sort of pulled out a little bit, and the anchor almost allows you to create a little bit of slack so that if there's any pulling of the controller or anything else, you have a little bit of extra space. 213 00:23:19,334 --> 00:23:25,034 Um, so just checking to see if that's causing any skin irritation as well. 214 00:23:25,605 --> 00:23:45,570 I think in terms of driveline exit site infections, those can also be very difficult to have surgical intervention upon, but if, if the, um, surgeons are willing to do so, and you think that it would help with clearing the infection, they can always move the driveline exit site. 215 00:23:46,199 --> 00:23:50,189 They also sometimes use wound vacs as well to help with, um, healing. 216 00:23:51,030 --> 00:24:10,500 Sara Dong: Yeah, I think that was a really good learning point for me when I was a fellow was knowing to ask patients who come in with possible driveline infections, if they've had trauma to the line, or if like they accidentally dropped their battery and it like tugged on the drive line, cause that can, that alone could sort of be where your infection's coming from. 217 00:24:10,500 --> 00:24:11,820 And I think we sort of. 218 00:24:12,395 --> 00:24:14,195 Um, it's easy to forget to ask that. 219 00:24:14,195 --> 00:24:22,354 So if, if people want to remember one thing for the first time they meet a patient and they're worried about driveline infection, they can ask about, ask about that. 220 00:24:23,014 --> 00:24:34,715 And so, you know, I think we covered a lot and I, this case is certainly not as complicated, I think as, as many of the ones that we see, but are there any additional learning points you want to make sure we cover? 221 00:24:35,865 --> 00:24:41,625 Rebecca Kumar: I think actually like the dressing site stuff is very important and it can be sort of overlooked at times. 222 00:24:42,105 --> 00:24:49,215 Um, but just making sure that you're familiar with your institution's protocol related to how they take care of the driveline exit site. 223 00:24:50,055 --> 00:24:56,805 And I think that that's probably, honestly, I think that that's probably one of the most important things to, to know, and to understand. 224 00:24:57,345 --> 00:25:10,665 And then also just to make sure that you look at the driveline exit site whenever possible yourself, just because like looking at it in person, I know I had suggested earlier, you can always look at the pictures, but also seeing it with your own two eyes can be very helpful as well. 225 00:25:11,385 --> 00:25:11,775 Sara Dong: Yeah. 226 00:25:12,045 --> 00:25:15,675 I feel like a lot of times they have those sort of clear window dressing. 227 00:25:15,675 --> 00:25:20,565 So even if you can't remove it, you probably can visualize the exit site. 228 00:25:22,455 --> 00:25:25,575 I think that covers most of what I want us to talk about today. 229 00:25:26,055 --> 00:25:32,575 And maybe we can have you come back and talk about a more like complicated gram negative one, or let's say our blood cultures are positive. 230 00:25:32,655 --> 00:25:37,515 Cause that's, that's a whole separate a wormhole that we didn't get into today. 231 00:25:37,965 --> 00:25:40,335 But, um, thank you so much for coming. 232 00:25:40,605 --> 00:25:42,195 Rebecca Kumar: Thank you so much for having me on this show. 233 00:25:43,020 --> 00:25:47,100 I also would like to take this opportunity to thank my mentor, Dr. 234 00:25:47,100 --> 00:25:51,390 Tina Stosor at Northwestern, who really got me into this. 235 00:25:51,390 --> 00:26:00,950 She's super passionate about heart transplants and about ventricular assist device infections that you know, her enthusiasm for it made me very enthusiastic about it. 236 00:26:01,495 --> 00:26:07,075 Um, and I just think that like, having a wonderful mentor has really just shaped my career greatly. 237 00:26:07,135 --> 00:26:09,595 So if she's listening, thank you. 238 00:26:11,605 --> 00:26:11,875 Sara Dong: Yeah. 239 00:26:11,875 --> 00:26:16,965 It makes a huge, huge difference on, on having great mentors. 240 00:26:17,580 --> 00:26:22,750 Thank you so much to Rebecca for joining us for a perfectly timed heart or cardiac related case. 241 00:26:23,040 --> 00:26:32,820 One quick plug for the Febrile survey, we are conducting a research survey to better understand how you use Febrile to teach and learn and what we can do to improve for future episodes. 242 00:26:33,060 --> 00:26:37,170 The survey is voluntary and anonymous, and should only take about 5 to 10 minutes. 243 00:26:37,620 --> 00:26:41,610 You can find the link to the survey on our Twitter page or in the description link for the episode. 244 00:26:42,480 --> 00:26:51,395 Our usual disclaimer, that all presented patients on this podcast are inspired by patient experiences, but cases are constructed or significantly altered and de-identified for learning purposes. 245 00:26:51,965 --> 00:27:02,195 Please, don't forget to check out the website, febrilepodcast.com to find the Consult Notes, which are written compliments to the show with links to references as well as the library of ID infographics. 246 00:27:02,794 --> 00:27:08,175 Please feel free to reach out if you have any suggestions for future shows or just want to be more involved with Febrile! 247 00:27:08,195 --> 00:27:09,004 Thanks for listening. 248 00:27:09,034 --> 00:27:10,564 Stay safe and I'll see you next time.