Cardiovascular implantable electronic device infection - Revision history

Aidan: Text replacement - " species]]" to "]]"

2022-02-19T15:05:48Z

Text replacement - " species]]" to "]]"

Aidan: /* Suspected or Confirmed Pocket Infection */

2021-01-09T14:53:28Z

Suspected or Confirmed Pocket Infection

← Older revision		Revision as of 14:53, 9 January 2021
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	**If no bacteremia: treat 2 weeks		**If no bacteremia: treat 2 weeks
	**If bacteremia but TEE negative: treat 2 weeks (or 4 weeks for [[Staphylococcus aureus]])		**If bacteremia but TEE negative: treat 2 weeks (or 4 weeks for [[Staphylococcus aureus]])
	**If TEE positive: treat 4 weeks if native ~~vale~~ and 6 weeks if prosthetic valve or endocarditis		**If TEE positive: treat 4 weeks if native valve and 6 weeks if prosthetic valve or endocarditis

	===Suspected or Confirmed CIED Infection===		===Suspected or Confirmed CIED Infection===

Aidan: /* Management */

2021-01-09T14:52:48Z

Management

← Older revision		Revision as of 14:52, 9 January 2021
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	==Management==		==Management==

	* The primary treatment is CIED removal, with adjunctive antibiotics		*The primary treatment is CIED removal, with adjunctive antibiotics
	** Lead extraction within 3 days of admission is associated with lower mortality		**Lead extraction within 3 days of admission is associated with lower mortality

	===Suspected or ~~confirmed~~ ~~pocket~~ ~~infection~~===		===Suspected or Confirmed Pocket Infection===

	*If early superficial site infection within 30 days of device placement and without systemic signs like fever		*If early superficial site infection within 30 days of device placement and without systemic signs like fever
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	**If TEE positive: treat 4 weeks if native vale and 6 weeks if prosthetic valve or endocarditis		**If TEE positive: treat 4 weeks if native vale and 6 weeks if prosthetic valve or endocarditis

	===Suspected or ~~confirmed~~ CIED ~~infection~~===		===Suspected or Confirmed CIED Infection===

	*Management depends on blood culture findings ± TEE		*Management depends on blood culture findings ± TEE
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	***No pocket site infection: monitor		***No pocket site infection: monitor

	===Bacteremia ~~without~~ ~~focus~~===		===Bacteremia Without Focus===

	*Remove all non-CIED sources		*Remove all non-CIED sources
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	**For Gram-negative bacilli or [[Streptococcus pneumoniae]]: close observation without CIED removal is reasonable		**For Gram-negative bacilli or [[Streptococcus pneumoniae]]: close observation without CIED removal is reasonable

	=== Reimplantation ===		===Reimplantation===

	* After device removal, patients who are pacemaker- or defibrillator-dependent should have a temporary device inserted		*After device removal, patients who are pacemaker- or defibrillator-dependent should have a temporary device inserted
	** Epicardial pacing is associated with higher mortality		**Epicardial pacing is associated with higher mortality
	* For isolated pocket infection, it is reasonable to reimplant on the same day		*For isolated pocket infection, it is reasonable to reimplant on the same day
	* For all others, reimplantation of a permanent device should be delayed until:		*For all others, reimplantation of a permanent device should be delayed until:
	** Blood cultures are negative at 72 hours, and		**Blood cultures are negative at 72 hours, and
	** All source control is complete (such as drainage of deep abscesses, etc.)		**All source control is complete (such as drainage of deep abscesses, etc.)
	* The device should be reimplanted at a site distant from the first		*The device should be reimplanted at a site distant from the first

	==Further Reading==		==Further Reading==

Aidan: /* Management */

2020-07-30T15:00:19Z

Management

@@ Line 36: / Line 36: @@
 *Often starts with generator pocket infection, then infection tracts back up the leads to intravascular and intracardiac parts
 **Local signs of infection followed by fevers, chills, malaise, fatigue, or anorexia
 *Can be '''early''' (within 6 months) or '''late''' (more than 6 months)
 **Early is more likely to present with pocket infection
@@ Line 48: / Line 49: @@
 ==Management==
 *Management depends on blood culture findings ± TEE
@@ Line 72: / Line 76: @@
 ***Pocket site infection or erosion: remove CIED and treat for 2 weeks
 ***No pocket site infection: monitor
-=== Bacteremia without focus ===
+===Bacteremia without focus===
 ==Further Reading==

Aidan: /* Management */

2020-07-30T14:47:33Z

Management

@@ Line 48: / Line 48: @@
 ==Management==
-*If bacteremia or prior antibiotics
+** Oral antibiotics
 **Valve vegetation ± bacteremia: remove CIED and treat as endocarditis
 **Lead vegetation ± bacteremia: remove CIED and treat for 2 weeks, or 4 weeks for [[Staphylococcus aureus]]
 **Negative TEE: consider CIED removal depending on microbiology and treat for 2 weeks
-*If no bacteremia but TEE positive, treat as above
+*If no bacteremia
-**No pocket site infection: monitor
+***Pocket site infection or erosion: remove CIED and treat for 2 weeks
 *CIED can be reimplanted when blood cultures are negative for at least 72 hours
 ==Further Reading==

Aidan: /* Microbiology */ added more bacteria

2020-07-30T14:38:51Z

Microbiology: added more bacteria

← Older revision		Revision as of 14:38, 30 July 2020
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	*Ranges from local pocket infection to bacteremia to endocarditis		*Ranges from local pocket infection to bacteremia to endocarditis

	=== Definitions ===		===Definitions===

	*'''Isolated pocket erosion:''' device or lead exposed through the skin, with or without signs of infection		*'''Isolated pocket erosion:''' device or lead exposed through the skin, with or without signs of infection
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	*'''Lead infection:''' lead vegetation with positive blood cultures		*'''Lead infection:''' lead vegetation with positive blood cultures

	=== Microbiology ===		===Microbiology===

	* Gram-positive bacteria (80%)[[CiteRef::sohail2007ma]]		*Gram-positive bacteria (80%)[[CiteRef::sohail2007ma]]
	** [[Staphylococcus species]] (75%)		**[[Staphylococcus species]] (75%)
	*** [[Staphylococcus aureus]] (30%), often with acute onset		***[[Staphylococcus aureus]] (30%), often with acute onset
	*** [[Coagulase-negative staphylococci]] (40%), most common cause of device pocket infections		***[[Coagulase-negative staphylococci]] (40%), most common cause of device pocket infections
	** Others (5%): [[Enterococcus species]], [[viridans group streptococci]], [[Streptococcus pneumoniae]]		**Others (5%): [[Enterococcus species]], [[viridans group streptococci]], [[Streptococcus pneumoniae]]
	* Gram-negative bacteria (10%): [[Klebsiella pneumoniae]], [[Serratia marcescens]]		*Gram-negative bacteria (10%): [[Klebsiella pneumoniae]], [[Serratia marcescens]], [[Pseudomonas aeruginosa]], [[Strenotrophomonas maltophilia]], [[Acinetobacter xylosoxidans]], [[Acinetobacter baumannii]], [[Citrobacter koseri]], [[Morganella morganii]], [[Haemophilus influenzae]], [[Moraxella catarrhalis]]
			*Fungi (2%): [[Candida albicans]], [[Aspergillus fumigatus]]
	* Polymicrobial (5%)
	* ~~Fungi~~ (2%)		*Polymicrobial (5%)
	* Culture-negative (5%)		*Culture-negative (5%)

	===Epidemiology===		===Epidemiology===
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	*Occurs in about 2 per 1000 device-years		*Occurs in about 2 per 1000 device-years

	=== Risk Factors ===		===Risk Factors===

	* '''Patient-related:''' age, [[CKD]], [[hemodialysis]], [[diabetes mellitus]], [[heart failure]], [[COPD]], preprocedure fever, [[malignancy]], skin disorder, immunosuppression, prior CIED infection, [[anticoagulation]]		*'''Patient-related:''' age, [[CKD]], [[hemodialysis]], [[diabetes mellitus]], [[heart failure]], [[COPD]], preprocedure fever, [[malignancy]], skin disorder, immunosuppression, prior CIED infection, [[anticoagulation]]
	* '''Procedure-related:''' pocket intervention (including generator change, upgrade, or lead or pocket revision), pocket hematoma, longer procedure, inexperienced operator, [[ICD]] (compared to [[pacemaker]]), no prophylactic antibiotics		*'''Procedure-related:''' pocket intervention (including generator change, upgrade, or lead or pocket revision), pocket hematoma, longer procedure, inexperienced operator, [[ICD]] (compared to [[pacemaker]]), no prophylactic antibiotics
	* '''Organism-related:''' highly virulent bacteria such as [[staphylococci]]		*'''Organism-related:''' highly virulent bacteria such as [[staphylococci]]

	==Clinical Manifestations==		==Clinical Manifestations==

Aidan: /* Background */ added microbiology and definitions sections

2020-07-30T14:35:18Z

Background: added microbiology and definitions sections

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 *Ranges from local pocket infection to bacteremia to endocarditis
 ===Epidemiology===
 *Occurs in about 2 per 1000 device-years
 ==Clinical Manifestations==
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 **Early is more likely to present with pocket infection
 **Late more often has bacteremia and endocarditis
 ==Investigations==

Aidan: /* Clinical Manifestations */

2020-07-30T14:23:14Z

Clinical Manifestations

← Older revision		Revision as of 14:23, 30 July 2020
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	== Background ==		==Background==

	* Ranges from local pocket infection to bacteremia to endocarditis		*Ranges from local pocket infection to bacteremia to endocarditis

	=== Epidemiology ===		===Epidemiology===

	* Occurs in about 2 per 1000 device-years		*Occurs in about 2 per 1000 device-years

	== Clinical Manifestations ==		==Clinical Manifestations==

			*Frequently infected at time of implantation, replacement, or surgical manipulation
⚫	* Isolated generator pocket infection: localized erythema, swelling, pain, tenderness, warmth, or drainage, with negative blood cultures
			*Often starts with generator pocket infection, then infection tracts back up the leads to intravascular and intracardiac parts
⚫	* Isolated pocket erosion: device or lead exposed through the skin, with or without signs of infection
			**Local signs of infection followed by fevers, chills, malaise, fatigue, or anorexia
⚫	* Lead infection: lead vegetation with positive blood cultures
			*Can be '''early''' (within 6 months) or '''late''' (more than 6 months)
			**Early is more likely to present with pocket infection
			**Late more often has bacteremia and endocarditis
		⚫	*'''Isolated pocket erosion:''' device or lead exposed through the skin, with or without signs of infection
		⚫	*'''Isolated generator pocket infection:''' localized erythema, swelling, pain, tenderness, warmth, or drainage, with negative blood cultures
		⚫	*'''Lead infection:''' lead vegetation with positive blood cultures

	==Investigations==		==Investigations==
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	*Pacemaker pocket swab at time of removal		*Pacemaker pocket swab at time of removal

	== Management ==		==Management==

	* Management depends on blood culture findings		*Management depends on blood culture findings
	** If positive, get TEE		**If positive, get TEE
	** If negative but high clinical suspicion, get TEE		**If negative but high clinical suspicion, get TEE
	* If bacteremia or prior antibiotics		*If bacteremia or prior antibiotics
	** Valve vegetation ± bacteremia: remove CIED and treat as endocarditis		**Valve vegetation ± bacteremia: remove CIED and treat as endocarditis
	** Lead vegetation ± bacteremia: remove CIED and treat for 2 weeks, or 4 weeks for [[Staphylococcus aureus]]		**Lead vegetation ± bacteremia: remove CIED and treat for 2 weeks, or 4 weeks for [[Staphylococcus aureus]]
	** Negative TEE: consider CIED removal depending on microbiology and treat for 2 weeks		**Negative TEE: consider CIED removal depending on microbiology and treat for 2 weeks
	* If no bacteremia but TEE positive, treat as above		*If no bacteremia but TEE positive, treat as above
	* If no bacteremia and no TEE or TEE negative		*If no bacteremia and no TEE or TEE negative
	** Pocket site infection or erosion: remove CIED and treat for 2 weeks		**Pocket site infection or erosion: remove CIED and treat for 2 weeks
	** No pocket site infection: monitor		**No pocket site infection: monitor
	* CIED can be reimplanted when blood cultures are negative for at least 72 hours		*CIED can be reimplanted when blood cultures are negative for at least 72 hours

	==Further Reading==		==Further Reading==

Aidan at 03:28, 30 July 2020

2020-07-30T03:28:58Z

@@ Line 1: / Line 1: @@
 ==Investigations==
-*Blood cultures
+*Blood cultures, ideally before antibiotics
-*Transesophageal echocardiogram
+*Transesophageal echocardiogram in most cases (in strong preference to transthoracic echocardiogram)
 *Pacemaker pocket swab at time of removal
-== Further Reading ==
+== Management ==
-* 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. ''Heart Rhythm''. 2017;14(12):e503-e551. doi: [https://doi.org/10.1016/j.hrthm.2017.09.001 10.1016/j.hrthm.2017.09.001]
+*2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. ''Heart Rhythm''. 2017;14(12):e503-e551. doi: [https://doi.org/10.1016/j.hrthm.2017.09.001 10.1016/j.hrthm.2017.09.001]
 [[Category:Infectious diseases]]

Aidan at 01:13, 30 July 2020

2020-07-30T01:13:41Z

← Older revision		Revision as of 01:13, 30 July 2020
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	== Investigations ==		==Investigations==

	* Blood cultures		*Blood cultures
	* Transesophageal echocardiogram		*Transesophageal echocardiogram
	* Pacemaker pocket swab at time of removal		*Pacemaker pocket swab at time of removal

			== Further Reading ==

			* 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. ''Heart Rhythm''. 2017;14(12):e503-e551. doi: [https://doi.org/10.1016/j.hrthm.2017.09.001 10.1016/j.hrthm.2017.09.001]

	[[Category:Infectious diseases]]		[[Category:Infectious diseases]]

← Older revision		Revision as of 15:05, 19 February 2022
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	*Gram-positive bacteria (80%)[[CiteRef::sohail2007ma]]		*Gram-positive bacteria (80%)[[CiteRef::sohail2007ma]]
	**[[Staphylococcus ~~species~~]] (75%)		**[[Staphylococcus]] (75%)
	***[[Staphylococcus aureus]] (30%), often with acute onset		***[[Staphylococcus aureus]] (30%), often with acute onset
	***[[Coagulase-negative staphylococci]] (40%), most common cause of device pocket infections		***[[Coagulase-negative staphylococci]] (40%), most common cause of device pocket infections
	**Others (5%): [[Enterococcus ~~species~~]], [[viridans group streptococci]], [[Streptococcus pneumoniae]]		**Others (5%): [[Enterococcus]], [[viridans group streptococci]], [[Streptococcus pneumoniae]]
	*Gram-negative bacteria (10%): [[Klebsiella pneumoniae]], [[Serratia marcescens]], [[Pseudomonas aeruginosa]], [[Strenotrophomonas maltophilia]], [[Acinetobacter xylosoxidans]], [[Acinetobacter baumannii]], [[Citrobacter koseri]], [[Morganella morganii]], [[Haemophilus influenzae]], [[Moraxella catarrhalis]]		*Gram-negative bacteria (10%): [[Klebsiella pneumoniae]], [[Serratia marcescens]], [[Pseudomonas aeruginosa]], [[Strenotrophomonas maltophilia]], [[Acinetobacter xylosoxidans]], [[Acinetobacter baumannii]], [[Citrobacter koseri]], [[Morganella morganii]], [[Haemophilus influenzae]], [[Moraxella catarrhalis]]
	*Fungi (2%): [[Candida albicans]], [[Aspergillus fumigatus]]		*Fungi (2%): [[Candida albicans]], [[Aspergillus fumigatus]]
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	*Remove all non-CIED sources		*Remove all non-CIED sources
	*If ongoing concern for CIED infection:		*If ongoing concern for CIED infection:
	**For [[Staphylococcus aureus]], [[coagulase-negative staphylococci]], [[Cutibacterium acnes]], or [[Candida ~~species~~]]: remove CIED		**For [[Staphylococcus aureus]], [[coagulase-negative staphylococci]], [[Cutibacterium acnes]], or [[Candida]]: remove CIED
	**For alpha- or beta-hemolytic [[streptococci]], or [[Enterococcus ~~species~~]]: consider CIED removal or close observation		**For alpha- or beta-hemolytic [[streptococci]], or [[Enterococcus]]: consider CIED removal or close observation
	**For Gram-negative bacilli or [[Streptococcus pneumoniae]]: close observation without CIED removal is reasonable		**For Gram-negative bacilli or [[Streptococcus pneumoniae]]: close observation without CIED removal is reasonable