Nonvalvular cardiovascular device-related infections
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.
- Pacemaker: 0.13% to 19.9%
- Defibrillator: 0% to 3.2%
- LVAD: 25% to 70%
- Ventriculoatrial shunt: 2.4% to 9.4%
- Vascular grafts: 1% to 6%
- Intra-aortic balloon pumps: 5% to 26%
- Arterial closure device: 1.9%
- Vena cava filter: rare
- Coronary artery stents: rare
- Peripheral stent: rare
- PDA, ASD, VSD occlusion device: rare
Risk Factors
- Revision of a pocket is associated with a 4 to 6 times higher rate of infection.
- Automatic implantable cardiac defibrillators (AICDs) are associated with a higher rate of infection than permanent pacemakers: 8.9/1,000 device years versus 1.0/1,000 device years (p<0.001)
- Hematoma formation
- Warfarin use
- Re-intervention at the pocket site
- Renal failure
- Lack of primary prophylaxis during the initial insertion of the device
Natural History, Complications, Prognosis
Complications of the device extraction that is necessary in CIED infection include:
- Bleeding
- Tricuspid valve trauma
- Pulmonary embolism
- Myocardial infarction
- Death
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
- ↑ Sohail et al. Clin Infect Dis 2007; 45:166-173