DEVICE INFECTION: MANAGEMENT STRATEGIES
Case presented by:
A 67-year-old woman presented with fever and chills. Her past medical history was significant for diabetes mellitus type II requiring insulin, morbid obesity (body mass index = 55 kg/m2), chronic obstructive pulmonary disease, and diverticulosis with recurrent lower gastrointestinal bleed requiring multiple transfusions. She also had history of sick sinus syndrome for which she underwent a permanent pacemaker implantation 8 years prior to her presentation. The device pocket was benign with no signs of inflammation. Two sets of blood cultures were sent and came back positive for enterococcus faecalis. Transesophageal echocardiography (TEE) showed evidence of vegetation on the pacing lead measuring 1.7 × 1.2 cm (Figure 64.1). It also showed evidence of small patent foramen ovale (PFO) with bidirectional flow, confirmed with bubble study (Figure 64.2). She was deemed not to be a surgical candidate due to her body habitus and comorbidities.
Question No. 1: Which of the following statements is correct?
A.Cardiac implantable electronic devices (CIED) infection is a common complication, affecting 25% of all implants.
B.CIED infections are usually benign and are rarely associated with any significant morbidity and mortality.
C.The lack of evidence of pocket inflammation rules out CIED infection.
D.CIED infection is rare, but the rate of increase in CIED infections each year has been out of proportion to the rate of increase in newly implanted devices.
Question No. 2: Which of the following statements is correct?
A.New (first-time) CIED implant is associated with higher risk of infection than pulse generator change.
B.Pulse generator change is associated with higher risk of infection than new CIED implant.
C.The infection risk is the same for new CIED implant and pulse generator change.
D.Pacemakers have a higher infection rate than implantable cardioverter-defibrillators (ICDs).
Question No. 3: Which of the following tests is not recommended?
A.Obtain blood cultures prior to initiating antibiotic therapy.
B.If present, aspirate any fluid in the pocket and send it for gram stain and cultures.
C.Consider a TEE, especially in cases associated with bacteremia.
D.Obtain chest x-ray to identify the number and location of the leads.
Question No. 4: In the management of CIED infections, which of the following statements is correct?
A.When the diagnosis of CIED infection is made, complete removal of all hardware is recommended regardless of whether it is a device pocket infection or endovascular infection.
B.CIED endocarditis can be managed conservatively with long-term antibiotic therapy.
C.CIED pocket infection can be managed by debriding the pocket along with antibiotic therapy without extracting the leads.
D.No need for antibiotic therapy as long as the CIED is removed.
Figure 64.1. TEE view showing the largest vegetation on the pacemaker lead measuring 1.7 × 1.2 cm.
Figure 64.2. TEE view showing a PFO documented by bubble study.
Discussion
Due to the growing evidence of the importance of CIEDs in improving both quality of life and survival among patients with heart disease, the number of newly implanted CIEDs has increased significantly over the last 2 decades. With this surge of CIED implants has come an increased recognition of associated complications, and infection is among the most important ones. Device-related infection is uncommon, but is associated with significant morbidity and mortality. The infection rate for patients with implanted CIEDs varies widely, but in general it ranges between 1 to 2%. The rate of increase in CIED infections each year has been out of proportion to the rate of increase in newly implanted devices. Multiple studies have identified several patient characteristics associated with increased risk for CIED infections. These include diabetes, renal dysfunction, heart failure, steroid use, and the presence of more than 2 leads. Additionally, several procedural characteristics could be associated with increased risk for CIED infections; these include pulse generator change (as opposed to new device implant), use of temporary pacing prior to the permanent device, and early reintervention. Pectoral transvenous device implant, perioperative antimicrobial prophylaxis, and physician experience are associated with lower risk for CIED infections.
The increasing number of CIED-related infections will continue to challenge both electrophysiologists and infectious disease specialists. The challenge begins with determining the diagnosis, as patients with CIED infections can present with a variety of manifestations. The diagnosis is clear when a patient presents with device pocket that is grossly infected (erythema, tenderness, drainage, erosion, etc.), which could be associated with systemic signs and symptoms (fever, chills, malaise, etc.) and occasionally positive blood cultures. On the other hand, the diagnosis might be delayed when a patient presents with only systemic signs and symptoms, with or without positive blood cultures, and a device pocket that appears grossly intact.
Despite these differences in presentations, it is important to recognize that the extent of infection could be underestimated in patients presenting with a localized pocket infection. Many of these patients (up to 20%) can have positive blood cultures and sometimes have evidence of vegetations on the leads. Therefore, it is not clinically useful to consider pocket infections separate from endovascular infection but better to consider an infected system in totality, with a component of the system in contact with endocardium and bloodstream. These findings also support the consensus that conservative management often is not optimal, and device removal is needed to eradicate the infection.
Etiology and Pathogenesis
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