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How to treat and identify device infections

  • Bruce L. Wilkoff
    Correspondence
    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.
    Affiliations
    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
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Published:August 15, 2007DOI:https://doi.org/10.1016/j.hrthm.2007.08.007
      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
      • Da Costa A.
      • Lelievre H.
      • Kirkorian G.
      • Celard M.
      • Chevalier P.
      • Vandenesch F.
      • Etienne J.
      • Touboul P.
      Role of the preaxillary flora in pacemaker infections: a prospective study.
      (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).
      • Chua J.D.
      • Wilkoff B.L.
      • Lee I.
      • Juratli N.
      • Longworth D.L.
      • Gordon S.M.
      Diagnosis and management of infections involving implantable electrophysiologic cardiac devices.
      • Klug D.
      • Lacroix D.
      • Savoye C.
      • Goullard L.
      • Grandmougin D.
      • Hennequin J.L.
      • Kacet S.
      • Lekieffre J.
      Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management.
      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.
      • Dy Chua J.
      • Abdul-Karim A.
      • Mawhorter S.
      • Procop G.W.
      • Tchou P.
      • Niebauer M.
      • Saliba W.
      • Schweikert R.
      • Wilkoff B.L.
      The role of swab and tissue culture in the diagnosis of implantable cardiac device infection.
      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 thumbnail gr1
      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 thumbnail gr2
      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.
      Table 1Signs and symptoms of the 123 patients reported by Chua et al
      • Chua J.D.
      • Wilkoff B.L.
      • Lee I.
      • Juratli N.
      • Longworth D.L.
      • Gordon S.M.
      Diagnosis and management of infections involving implantable electrophysiologic cardiac devices.
      Signs and symptoms n (%)
      Pocket erythema 67 (55)
      Pocket warmth 28 (23)
      Pocket pain 68 (55)
      Erosion 39 (32)
      Sinus tract to pocket 52 (42)
      Sinus tract to pocket (purulent) 28 (32)
      Pocket swollen 44 (36)
      Fever (history) 35 (29)
      Fever (physical exam) 23 (19)
      Chills 27 (22)
      Sepsis 14 (11)
      Tachycardia 10 (8)
      Malaise 26 (21)
      Anorexia 14 (11)
      Nausea 10 (8)

      Keywords

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