Cardiovascular implantable electronic device infection: Difference between revisions
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==Background== |
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*Ranges from local pocket infection to bacteremia to endocarditis |
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===Epidemiology=== |
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*Occurs in about 2 per 1000 device-years |
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==Clinical Manifestations== |
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*Frequently infected at time of implantation, replacement, or surgical manipulation |
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*Often starts with generator pocket infection, then infection tracts back up the leads to intravascular and intracardiac parts |
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**Local signs of infection followed by fevers, chills, malaise, fatigue, or anorexia |
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*Can be '''early''' (within 6 months) or '''late''' (more than 6 months) |
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**Early is more likely to present with pocket infection |
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**Late more often has bacteremia and endocarditis |
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==Investigations== |
==Investigations== |
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*Pacemaker pocket swab at time of removal |
*Pacemaker pocket swab at time of removal |
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==Management== |
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*Management depends on blood culture findings |
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**If positive, get TEE |
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**If negative but high clinical suspicion, get TEE |
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*If bacteremia or prior antibiotics |
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**Valve vegetation ± bacteremia: remove CIED and treat as endocarditis |
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**Lead vegetation ± bacteremia: remove CIED and treat for 2 weeks, or 4 weeks for [[Staphylococcus aureus]] |
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**Negative TEE: consider CIED removal depending on microbiology and treat for 2 weeks |
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*If no bacteremia but TEE positive, treat as above |
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*If no bacteremia and no TEE or TEE negative |
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**Pocket site infection or erosion: remove CIED and treat for 2 weeks |
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**No pocket site infection: monitor |
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*CIED can be reimplanted when blood cultures are negative for at least 72 hours |
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==Further Reading== |
==Further Reading== |
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Revision as of 14:23, 30 July 2020
Background
- Ranges from local pocket infection to bacteremia to endocarditis
Epidemiology
- Occurs in about 2 per 1000 device-years
Clinical Manifestations
- Frequently infected at time of implantation, replacement, or surgical manipulation
- 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
- 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
- Blood cultures, ideally before antibiotics
- Transesophageal echocardiogram in most cases (in strong preference to transthoracic echocardiogram)
- Pacemaker pocket swab at time of removal
Management
- Management depends on blood culture findings
- If positive, get TEE
- If negative but high clinical suspicion, get TEE
- If bacteremia or prior 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 and no TEE or TEE negative
- Pocket site infection or erosion: remove CIED and treat for 2 weeks
- No pocket site infection: monitor
- CIED can be reimplanted when blood cultures are negative for at least 72 hours
Further Reading
- 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14(12):e503-e551. doi: 10.1016/j.hrthm.2017.09.001
