Cardiovascular implantable electronic device infection
From IDWiki
Background
- Ranges from local pocket infection to bacteremia to endocarditis
Definitions
- 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
Microbiology
- Gram-positive bacteria (80%)1
- Staphylococcus species (75%)
- Staphylococcus aureus (30%), often with acute onset
- Coagulase-negative staphylococci (40%), most common cause of device pocket infections
- Others (5%): Enterococcus species, viridans group streptococci, Streptococcus pneumoniae
- Staphylococcus species (75%)
- 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%)
- Culture-negative (5%)
Epidemiology
- Occurs in about 2 per 1000 device-years
Risk Factors
- 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
- Organism-related: highly virulent bacteria such as staphylococci
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
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
Suspected or confirmed pocket infection
- If early superficial site infection within 30 days of device placement and without systemic signs like fever
- Oral antibiotics
- If clinical signs of pocket infection, need blood cultures and TEE
- Remove CIED, including generator and all leads
- If no bacteremia: treat 2 weeks
- 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
Suspected or confirmed CIED infection
- Management depends on blood culture findings ± TEE
- If bacteremia, get TEE
- If no bacteremia but high clinical suspicion, get TEE
- If bacteremia (or received 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
- TEE positive: treat as above
- 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
Bacteremia without focus
- Remove all non-CIED sources
- If ongoing concern for CIED infection:
- For Staphylococcus aureus, coagulase-negative staphylococci, Cutibacterium acnes, or Candida species: remove CIED
- For alpha- or beta-hemolytic streptococci, or Enterococcus species: consider CIED removal or close observation
- For Gram-negative bacilli or Streptococcus pneumoniae: close observation without CIED removal is reasonable
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
References
- ^ Muhammad R. Sohail, Daniel Z. Uslan, Akbar H. Khan, Paul A. Friedman, David L. Hayes, Walter R. Wilson, James M. Steckelberg, Sarah Stoner, Larry M. Baddour. Management and Outcome of Permanent Pacemaker and Implantable Cardioverter-Defibrillator Infections. Journal of the American College of Cardiology. 2007;49(18):1851-1859. doi:10.1016/j.jacc.2007.01.072.
