Nonvalvular cardiovascular device-related infections: Difference between revisions
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{{SI}} | {{SI}} | ||
{{CMG}} | {{CMG}} | ||
==Overview== | ==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<ref>Sohail et al. Clin Infect Dis 2007; 45:166-173</ref>== | |||
*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 graft]]s: 1% to 6% | |||
*[[Intra-aortic balloon pump]]s: 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]] ([[AICD]]s) 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== | ==References== | ||
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[[Category:Cardiology]] | [[Category:Cardiology]] | ||
Latest revision as of 18:13, 18 September 2017
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