Nonvalvular cardiovascular device-related infections

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

All implanted cardiac devices can become infected which generally requires removal of the entire device (including pacing leads).

Pathophysiology

A biofilm forms on the surface of the device and this surface facilitates the attachment of the infectious agent. Antibiotics are ineffective in treating the infection of a biofilm as there is no blood flow into the biofilm.

Causes[1]

  • Coagulase negative staphylococci: 42%
  • Methicillin sensitive staph aureus: 25%
  • Gram negative bacilli: 9%
  • Culture negative: 7%
  • Polymicrobial: 7%
  • Other gm + cocci: 4%
  • Methicillin resistant staph aureus: 4%
  • Fungal: 2%

Epidemiology and Demographics

There is a rise in the number of cases of CIED infections due to a larger number of devices being implanted, the frequency with which they are being replaced, and the comorbidities of patients in whom the devices are implanted.

Risk Factors

Natural History, Complications, Prognosis

Complications of the device extraction that is necessary in CIED infection include:

Risk factors for complications with device extraction include older age and co-morbidities.

Diagnosis

Echocardiography

TEE sensitivity is 95% TTE sensitivity is <30%

Treatment

  • Complete device extraction including the leads is required.
  • The biofilm cannot be treated with antibiotics.
  • Antibiotics directed at the pathogen should be administered, but there is no data to guide the route and the duration of treatment.
  • There is no data to guide decisions regarding the implantation of a new device.

Prevention

  • Perioperative antibiotic therapy during the initial insertion of the device has been associated with prevention of CIED infection (trial stopped prematurely due to a RR of 0.19, p=0.016).

References

  1. Sohail et al. Clin Infect Dis 2007; 45:166-173