Infections of cardiac implantable electronic devices: a retrospective multicenter observational study

Clinical Approach to Evaluation of Underlying Cardiac Device Infection in Patients Hospitalized with Bacteremia

More than 400,000 cardiac implantable electronic devices (CIEDs), including permanent pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices, are implanted every year in the United States (US). Infection is a serious complication of CIED therapy and is associated with high morbidity and mortality. While CIED pocket infection can be diagnosed based on clinical exam findings, positive blood culture may be the only manifestation of CIED lead infection. Thus, management of bacteremia in patients living with CIEDs requires special consideration. This review summarizes contemporary data in the context of the recently updated 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis. We have synthesized these data into an algorithmic approach to streamline the diagnostic evaluation of CIED infection in patients presenting with bacteremia.

Prevention of device-related infections in patients with cancer: Current practice and future horizons

Over the past several years, multifaceted advances in the management of cancer have led to a significant improvement in survival rates. Throughout patients' oncological journeys, they will likely receive one or more implantable devices for the administration of fluids and medications as well as management of various comorbidities and complications related to cancer therapy. Infections associated with these devices are frequent and complex, often necessitating device removal, increasing health care costs, negatively affecting quality of life, and complicating oncological care, usually leading to delays in further life-saving cancer therapy. Herein, the authors comprehensively review multiple evidence-based recommendations along with best practices, expert opinions, and novel approaches for the prevention of diverse device-related infections. The authors present many general principles for the prevention of these infections followed by specific device-related recommendations in a systematic manner. The continuous involvement and meaningful cooperation between regulatory entities, industry, specialty medical societies, hospitals, and infection control-targeted interventions, along with primary care and consulting health care providers, are all vital for the sustained reduction in the incidence of these preventable infections.

Salvage of Infected Cardiac Implantable Electrical Devices with Subpectoral Plane Pocket Revision

Introduction Infection of cardiac implantable electrical devices (CIEDs) may lead to serious complications. Complete CIED explantation is expensive, requires expertise, not free from complications, and may not be an option in patients with device dependence.

Aim To highlight that carefully selected infected CIEDs can be salvaged by placing the device in a subpectoral pocket below the pectoralis major muscle. We conducted a retrospective descriptive observational study.

Material and Methods Twelve patients (10 male and two female) with erosion, exposure or infection of infraclavicular, subcutaneously placed CIED were treated over a 30-month period between July 2018 and December 2020. The technique involved debridement and excision of a peridevice capsule, creating a subpectoral pocket beneath the pectoralis major muscle, and placing the CIED in a new pocket with total muscle coverage and closure of skin without tension.

Results Twelve patients ( m = 10; f = 2) with a mean age of 65 years (range, 46–82 years) presented with infection of CIED within 9 months of implantation. None had sepsis or endocarditis. In nine patients, CIEDs were successfully salvaged with relocation to subpectoral pocket. Mean follow-up was 20 months (range, 8–30 months). Three out of 12 developed reinfection that ultimately required CIED explantation. There was no mortality.

Conclusion In the absence of sepsis or endocarditis, infected CIEDs may be attempted at salvage by subpectoral pocket placement. This obviates the need for potentially risky explantation or replacement of expensive CIEDs.

Influence of the type of pathogen on the clinical course of infectious complications related to cardiac implantable electronic devices

The specific role of the various pathogens causing cardiac implantable electronic devices-(CIEDs)-related infections requires further understanding. The data of 1241 patients undergoing transvenous lead extraction because of lead-related infective endocarditis (LRIE-773 patients) and pocket infection (PI-468 patients) in two high-volume centers were analyzed. Clinical course and long-term prognosis according to the pathogen were assessed. Blood and generator pocket cultures were most often positive for methicillin-sensitive Staphylococcus aureus (MSSA: 22.19% and 18.13% respectively), methicillin-sensitive Staphylococcus epidermidis (MSSE: 17.39% and 15.63%) and other staphylococci (11.59% and 6.46%). The worst long-term prognosis both in LRIE and PI subgroup was in patients with infection caused by Gram-positive microorganisms, other than staphylococci. The most common pathogens causing CIED infection are MSSA and MSSE, however, the role of other Gram-positive bacteria and Gram-negative organisms is also important. Comparable, high mortality in patients with LRIE and PI requires further studies.

The emergence of Staphylococcus aureus as the primary cause of cardiac device-related infective endocarditis

BACKGROUND

Increasing use of cardiovascular implantable electronic devices (CIED), as permanent pacemakers (PPM), implantable cardioverter defibrillators (ICD), or cardiac resynchronization therapy (CRT), is associated with the emergence of CIED-related infective endocarditis (CIED-IE). We aimed to characterize CIED-IE profile, temporal trends, and prognostic factors.

METHODS

CIED-IE diagnosed at Rennes University Hospital during years 1992-2017 were identified through computerized database, and included if they presented all of the following: (1) clinical signs of infection; (2) microbiological documentation through blood and/or CIED lead cultures; (3) lead or valve vegetation, or definite IE according to Duke criteria. Data were retrospectively extracted from medical charts. The cohort was categorized in three periods: 1992-1999, 2000-2008, and 2009-2017.

RESULTS

We included 199 patients (51 women, 148 men, median age 73 years [interquartile range, 64-79]), with CIED-IE: 158 PPMs (79%), 24 ICD (12%), and 17 CRT (9%). Main pathogens were coagulase-negative staphylococci (CoNS: n = 86, 43%), Staphylococcus aureus (n = 60, 30%), and other Gram-positive cocci (n = 28, 14%). Temporal trends were remarkable for the decline in CoNS (P = 0.002), and the emergence of S. aureus as the primary cause of CIED-IE (24/63 in 2009-2017, 38%). Factors independently associated with one-year mortality were chronic obstructive pulmonary disease (COPD: hazard ratio 3.84 [1.03-6.02], P = 0.03), left-sided endocarditis (HR 2.25 [1.09-4.65], P = 0.03), pathogens other than CoNS (HR 3.16 [1.19-8.39], P = 0.02), and CIED removal/reimplantation (HR 0.41 [0.20-0.83], P = 0.01).

CONCLUSIONS

S. aureus has emerged as the primary cause of CIED-IE. Left-sided endocarditis, COPD, pathogens other than CoNS, and no CIED removal/reimplantation are independent risk factors for one-year mortality.

Cardiovascular implantable electronic device infections due to enterococcal species: Clinical features, management, and outcomes

BACKGROUND

Enterococcal cardiovascular implantable electronic device (CIED) infections are not well characterized.

METHODS

Data from the Multicenter Electrophysiologic Device Infection Cohort, a prospective study of CIED infections, were used for descriptive analysis of adults with enterococcal CIED infections.

RESULTS

Of 433 patients, 21 (4.8%) had enterococcal CIED infection. Median age was 71 years. Twelve patients (57%) had permanent pacemakers, five (24%) implantable cardioverter defibrillators, and four (19%) biventricular devices. Median time from last procedure to infection was 570 days. CIED-related bloodstream infections occurred in three patients (14%) and 18 (86%) had infective endocarditis (IE), 14 (78%) of which were definite by the modified Duke criteria. IE cases were classified as follows: valvular IE, four; lead IE, eight; both valve and lead IE, six. Vegetations were demonstrated by transesophageal echocardiography in 17 patients (81%). Blood cultures were positive in 19/19 patients with confirmed results. The most common antimicrobial regimen was penicillin plus an aminoglycoside (33%). Antibiotics were given for a median of 43 days. Only 14 patients (67%) underwent device removal. There was one death during the index hospitalization with four additional deaths within 6 months (overall mortality 24%). There were no relapses.

CONCLUSIONS

Enterococci caused 4.8% of CIED infections in our cohort. Based on the late onset after device placement or manipulation, most infections were likely hematogenous in origin. IE was the most common infection syndrome. Only 67% of patients underwent device removal. At 6 months follow-up, no CIED infection relapses had occurred, but overall mortality was 24%.

Cardiac implantable electronic device infections: Observational data from a tertiary care center in Lebanon

With increasing rates of device implantation, there is an increased recognition of device infection. We conducted a retrospective observational study in a tertiary care center in Lebanon, with data collected from medical records of patients presenting with cardiac implantable electronic device (CIED) infection from 2000 to 2017 with the purpose of identifying etiologies, risk factors and other parameters, and comparing them to available data from the rest of the world. We identified a total of 22 CIED infections. The most common microbial etiologies, including involvement in polymicrobial infection, were coagulase-negative staphylococci (45.5%) and Staphylococcus aureus (22.7%). Rare cases of Brucella melitensis, Sphingomonas paucimobilis, and Kytococcus schroeteri device infection were seen. Heart failure was seen in 77.3% of patients, hypertension in 68.2%, and chronic kidney disease in 50%. Skin changes were the most common presenting symptoms (86.4%). Antibiotics were given to all patients and all had their devices removed, with 36.4% undergoing new device implantation. This is the first study of CIED infections in Lebanon and the Middle East. Local epidemiology and occupational exposure must be considered while contemplating the microbial etiology of infection. Close monitoring after device implantation is important in preventing device infection that carries high risk of morbidity and mortality.

Infection Management

Cardiovascular implantable electronic devices (CIEDs) and the indications for their use have significantly risen over the past decades to include patients who are older with more medical comorbidities. Predictably, the rates of CIED infection have increased substantially. CIED infection is associated with high morbidity, mortality, and financial costs. This article discusses the appropriate management of CIED infections, which is imperative to limit the problems associated with infection.

Cardiac Implantable Electronic Device Infections-Decision-Making Process in Complex Patients: Report of 3 Cases

Cardiac implantable electronic devices infections are becoming increasingly frequent with more of these devices being implanted in elderly patients with multiple comorbidities. They carry high morbidity and mortality if not treated promptly, which often entails removal of the entire system. Early recognition is paramount, and a multidisciplinary team is required. In this case report, we go through unique and challenging presentations of such patients with cardiac implantable electronic devices–related issues who presented to our institution, and we describe individual approaches to management and review the literature.

Attempted salvage of infected cardiovascular implantable electronic devices: Are there clinical factors that predict success?

BACKGROUND

Published guidelines mandate complete device removal in cases of cardiovascular implantable electronic device (CIED) infection. Clinical predictors of successful salvage of infected CIEDs have not been defined.

METHODS

Data from the Multicenter Electrophysiologic Device Infection Collaboration, a prospective, observational, multinational cohort study of CIED infection, were used to investigate whether clinical predictors of successful salvage of infected devices could be identified.

RESULTS

Of 433 adult patients with CIED infections, 306 (71%) underwent immediate device explantation. Medical management with device retention and antimicrobial therapy was initially attempted in 127 patients (29%). "Early failure" of attempted salvage occurred in 74 patients (58%) who subsequently underwent device explantation during the index hospitalization. The remaining 53 patients (42%) in the attempted salvage group retained their CIED. Twenty-six (49%) had resolution of CIED infection (successful salvage group) whereas 27 patients (51%) experienced "late" salvage failure. Upon comparing the salvage failure group, early and late (N = 101), to the group experiencing successful salvage of an infected CIED (N = 26), no clinical or laboratory predictors of successful salvage were identified. However, by univariate analysis, coagulase-negative staphylococci as infecting pathogens (P = 0.0439) and the presence of a lead vegetation (P = 0.024) were associated with overall failed salvage.

CONCLUSIONS

In patients with definite CIED infections, clinical and laboratory variables cannot predict successful device salvage. Until new data are forthcoming, device explantation should remain a mandatory and early management intervention in patients with CIED infection in keeping with existing expert guidelines unless medical contraindications exist or patients refuse device removal.

Risk Factors and Outcomes of Endocarditis Due to Non-HACEK Gram-Negative Bacilli: Data from the Prospective Multicenter Italian Endocarditis Study Cohort

The objective of this study was to investigate predisposing factors and outcomes of infective endocarditis (IE) caused by non-HACEK Gram-negative bacilli (GNB) in a contemporary multicenter cohort. Patients with IE due to GNB, prospectively observed in 26 Italian centers from 2004 to 2011, were analyzed. Using a case-control design, each case was compared to three age- and sex-matched controls with IE due to other etiologies. Logistic regression was performed to identify risk factors for IE due to GNB. Factors associated with early and late mortality were assessed by Cox regression analysis. The study group comprised 58 patients with IE due to GNB. We found that Escherichia coli was the most common pathogen, followed by Pseudomonas aeruginosa and Klebsiella pneumoniae The genitourinary tract as a source of infection (odds ratio [OR], 13.59; 95% confidence interval [CI], 4.63 to 39.93; P < 0.001), immunosuppression (OR, 5.16; 95% CI, 1.60 to 16.24; P = 0.006), and the presence of a cardiac implantable electronic device (CIED) (OR, 3.57; 95% CI, 1.55 to 8.20; P = 0.003) were factors independently associated with IE due to GNB. In-hospital mortality was 13.8%, and mortality rose to 30.6% at 1 year. A multidrug-resistant (MDR) etiology was associated with in-hospital mortality (hazard ratio [HR], 21.849; 95% CI, 2.672 to 178.683; P = 0.004) and 1-year mortality (HR, 4.408; 95% CI, 1.581 to 12.287; P = 0.005). We conclude that the presence of a genitourinary focus, immunosuppressive therapy, and an indwelling CIED are factors associated with IE due to GNB. MDR etiology is the major determinant of in-hospital and long-term mortality.

Microbial diagnosis of infection and colonization of cardiac implantable electronic devices by use of sonication

OBJECTIVES

The clinical utility of sonication as an adjunctive diagnostic tool for the microbial diagnosis of cardiac implantable device-associated infections (CIDAIs) was investigated.

METHODS

The implants of 83 subjects were investigated, 15 with a CIDAI and 68 without a clinical infection. Clinical data were analyzed prospectively and sonication fluid cultures (83 patients, 100%) and traditional cultures (31 patients, 37.4%) were performed

RESULTS

Generator pocket infection and device-related endocarditis were found in 13 (86.7%) and four (26.7%) subjects, respectively. The mean numbers of previous technical complications and infections were higher in the infected patients compared to the non-infected patients (8 vs. 1, p<0.001; 2 vs. 0, p<0.031, respectively). The sensitivity and specificity for detecting CIDAI was 73.3% (11/15) and 48.5% (33/68) for sonication fluid culture, and 26.7% (4/15) and 100% (16/16) for traditional culture (p<0.001), respectively. A higher number of organisms were identified by sonication fluid than by tissue culture (58 vs. 4 specimens; p<0.001). The most frequent organisms cultured were Gram-positive cocci (66.1%), mainly coagulase-negative staphylococci (35.5%). Thirty-five (51.5%) non-infected subjects were considered colonized due to the positive identification of organisms exclusively through sonication fluid culture.

CONCLUSIONS

Sonication fluid culture from the removed cardiac implants has the potential to improve the microbiological diagnosis of CIDAIs.

Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management

Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.

Clinical manifestations of lead-dependent infective endocarditis: analysis of 414 cases

It is important to identify clinical manifestations of lead-dependent infective endocarditis (LDIE), as it begins insidiously with the slow development of nonspecific symptoms. Clinical data from 414 patients with the diagnosis of LDIE according to Modified Duke Lead Criteria (MDLC) were analyzed. Patients with LDIE had been identified in a population of 1,426 subjects submitted to transvenous lead extraction (TLE) in the Reference Clinical Cardiology Center in Lublin between 2006 and 2013. The symptoms of LDIE and pocket infection were detected in 62.1 % of patients. The mean duration of LDIE symptoms prior to referral for TLE was 6.7 months. Fever and shivers were found in 55.3 % of patients, and pulmonary infections in 24.9 %. Vegetations were detected in 67.6 % of patients, and positive cultures of blood, lead, and pocket in 34.5, 46.4, and 30.0 %, respectively. The most common pathogens in all type cultures were coagulase-negative staphylococci (CNS), with Staphylococcus epidermidis domination; the second most common organism was Staphylococcus aureus. 76.3 % of patients were treated with empirical antibiotic therapy before hospitalization due to TLE. In the laboratory tests, the mean white blood cell count was 9,671 ± 5,212/μl, mean erythrocyte sedimentation rate 43 mm, C-reactive protein (CRP) 46.3 mg/dl ± 61, and procalcitonin 1.57 ± 4.4 ng/ml. The multivariate analysis showed that the probability of LDIE increased with increasing CRP. The diagnosis of LDIE based on MDLC may be challenging because of a relatively low sensitivity of major criteria, which is associated with early antibiotic therapy and low usefulness of minor criteria. The important clinical symptoms of LDIE include fever with shivering and recurrent pulmonary infections. The most specific pathogens were Staphylococcus epidermidis and Staphylococcus aureus. Laboratory tests most frequently revealed normal white blood cell count, relatively rarely elevated procalcitonin level, and significantly increased erythrocyte sedimentation rate (ESR) and CRP. This constellation of signs should prompt a more thorough search for LDIE.