Cardiovascular Implantable Electronic Device Infections

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Key points

  • Cardiac device infection rates are increasing.

  • Staphylococcus spp are the predominant causative organisms.

  • Blood cultures, pocket tissue cultures, lead cultures, and echocardiography are key components of the diagnostic evaluation.

  • Complete device extraction is a key component of management.

  • Duration of antibiotic therapy and timing of device reimplantation vary depending on extent of infection.

Epidemiology and risk factors

With growing evidence to support the use of CIEDs to improve survival among patients with cardiac disease, the last 2 decades have seen a steady growth in implantations of these devices.1 As of the second millennium, more than 3 million people worldwide were living with implanted cardiac electronic devices, including more than 180,000 implantable cardiac defibrillators (ICDs).4 Since then, rates of placement have continued steady upward trends. More than 300,000 new CIEDs per year are placed in

Microbiology

Gram-positive pathogens predominate in CDI, both in early-onset (<1 year from last device manipulation) and late-onset infection. Coagulase-negative staphylococci (CoNS) and Staphylococcus aureus remain the most common pathogens, accounting for 70% to 80% of infections in many series.6, 12, 13, 21, 24, 25, 26, 27 Several studies have suggested an increase in the incidence of methicillin resistance in the isolates causing CDI. For example, a recent study from the Cleveland Clinic showed a 15%

Clinical manifestations

CDI are generally categorized as being either superficial (pocket) or deep (lead and/or valvular). Generator pocket infections are the most common and often present with local signs of inflammation at the generator pocket site, which can include pain, swelling, erythema, warmth, and dehiscence with or without drainage. Although pocket infections can be associated with bacteremia and systemic symptoms, more commonly they present without bacteremia or systemic symptoms.26, 33, 34 Some may present

Diagnosis and diagnostic testing

Diagnosis is fairly straightforward in those patients presenting with overt signs of inflammation, dehiscence, or erosion at the generator pocket site. One caveat is with patients presenting within the first 30 days postimplantation with erythema of the pocket, which can sometimes be reflective of early postimplantation inflammation or superficial incisional infection as opposed to true device infection. In this circumstance, if there is no purulent exudate, dehiscence, fluctuance, or systemic

Management

Superficial infections of the skin that do not involve the pocket can be managed with oral antibiotics alone without device removal. In these cases, patients can be treated with 7 to 10 days of an oral antibiotic regimen with antistaphylococcal activity, coupled with close observation to ensure no signs or symptoms of deeper extension develop.26, 32, 33, 40, 42 For all confirmed CDIs, complete device extraction is recommended as first-line therapy.33 Multiple studies have shown higher clinical

Prevention

Periprocedural antimicrobial prophylaxis has been shown in multiple studies to reduce risk of subsequent infection.4, 26, 32, 33, 64, 65 One large randomized, double-blind, placebo-controlled trial of preprocedural cefazolin was halted early when an interim analysis showed a substantial benefit (0.63% vs 3.28% infection rate).65 The antibiotic chosen should have staphylococcal activity, and most investigators advocate for the continued use of first-generation cephalosporins. Vancomycin provides

Summary

Infections associated with CIEDs are increasing and are associated with significant morbidity and mortality. These infections are predominantly caused by gram-positive organisms, particularly staphylococci. Staphylococcus aureus bacteremia in the setting of a cardiac device often indicates CDI and should raise a high index of suspicion for infection. CDI can present as pocket infection with or without systemic symptoms, or as deeper infection involving the device leads and/or cardiac valves.

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  • Disclosure Statement: Dr V.H. Chu reports grants from the National Institutes of Health: 1R34-AI122958-01, 4UL1-TR001117-04, 4R25-HD076475-04, 1R25-HL135304-01A1; consulting for Theravance; and authorship in UpToDate.

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