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Address reprint requests and correspondence: Bruce L. Wilkoff, M.D., F.A.C.C., F.A.H.A., F.H.R.S., Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Desk F15, Cleveland, Ohio 44195.
The incidence of device-related infections depends directly on the definition employed.
The lack of precision is also compounded by the latency between the initiation and
manifestation of the infection. It is not rare for there to be some erythema at the
incision site during the first week of healing, and it is not clear that this represents
infection. Less frequent, but still common, there can be a small, superficial stitch
abscess, which will respond to local measures. When the diagnosis of device system
infection is made, it should be made on the basis of pocket cellulitis, erosion, abscess,
persistent bacteremia, or endocarditis with or without vegetation on the lead. Although
not all device system infections develop in direct relationship to a device operation,
this is by far the most common situation
(FIGURE 1, FIGURE 2). Since there is often (1) no pain, erythema, or thinning of the subcutaneous tissue
when there is an abscess or endocarditis; (2) no pus, pain, erythema, or bacteremia
with an erosion; or (3) only pain without erythema, abscess, or sepsis, the definitive
diagnosis is difficult (Table 1).
An instructive observation comes from culturing the capsular tissue from around the
device at the time of device change. Almost 50% of clinically uninfected patients
have positive cultures for bacteria consistent with clinical device infection pathogens.
This finding may explain why primary device implantations have been associated with
an infection rate of 0.5% or less and that device replacement or upgrade surgeries
are associated with infection rates of 2–7%. Secondary infections (hematogenous seeding)
may occur from catheter bloodstream infections, intravascular catheters (e.g., dialysis
catheters), decubitus ulcers, septic arthritis, urosepsis, or diverticulitis but are
less common. Sustained bloodstream infections should always raise the possibility
of an endovascular focus, and this includes pacemaker and defibrillator devices. These
infections are rarely cured without the removal of the entire system, both the leads
and device.
FIGURE 1Superficial cellulitis and remodeling of the anterior chest wall tissues caused by
fat necrosis due to a pacemaker pocket infection. There is a small amount of bruising
in the middle of the erythema.
FIGURE 2Erosion of the ICD with part of the header and can visible. There is also a sinus
tract over the leads medial to the device. There is evidence of drainage of purulent
material and blood from both eruptions. Note the lack of cellulitis. There is a slight
bluish discoloring of tissues immediately medial to the exposed header.
