Diagnostic evaluation and management of culture‐negative cardiovascular implantable electronic device infections

Garrigos, Zerelda Esquer; George, Merit P; Farid, Saira; Saleh, Omar M. Abu; Vijayvargiya, Priya; Mahmood, Maryam; Friedman, Paul A.; Steckelberg, James M.; DeSimone, Daniel C.; Wilson, Walter R.; Baddour, Larry M.; Sohail, M. Rizwan

doi:10.1111/pace.13397

Cited by 9 publications

(3 citation statements)

References 23 publications

(40 reference statements)

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“…The risk of infection appears to be higher in patients undergoing generator replacement, lead or pocket revisions, device upgrades and resynchronization device implantation. Given that 9% of patients presenting with a pocket infection have had a device‐related infection in the past 18 and that a prior infection increases the risk of a future infection by 65%, 19 strategies to reduce the risk of infection recurrence are of paramount importance. Complete hardware removal undoubtedly plays a significant role in reducing this risk of reinfection and is recommended in current guidelines to achieve infection control.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of chlorhexidine lavage without capsulectomy versus complete capsulectomy after lead extraction for the treatment of cardiac implantable electronic device infection

Díaz¹,

Marín

Aristizábal

et al. 2023

Cardiovasc electrophysiol

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Introduction Capsulectomy is recommended in patients with cardiac implantable electronic device (CIED) infection after transvenous lead extraction (TLE) but is time‐consuming and requires extensive tissue debridement. In this study, we describe the outcomes of chlorhexidine gluconate (CHG) lavage in lieu of capsulectomy for the treatment of CIED infections. Methods This retrospective study included patients who underwent TLE for CIED‐related infections in two institutions in Colombia. In the capsulectomy group, complete capsulectomy was performed after hardware removal. In the CHG group, exhaustive lavage of the generator pocket with 20 cc of CHG at 2% followed by irrigation with approximately 500 cc of normal saline (0.9% sodium chloride) was performed. The primary outcomes included reinfection and hematoma formation in the generator pocket. Secondary outcomes included the occurrence of any adverse reaction to chlorhexidine, the need for reintervention, infection‐related mortality, and total procedural time. Results A total of 102 patients (mean age 67.2 ± 13 years, 32.4% female) underwent CIED extraction with either total capsulectomy (n = 54) or CHG (n = 48) lavage. Hematoma formation was significantly higher in the capsulectomy group versus the CHG group (13% vs. 0%, p = .014), with no significant differences in the reinfection rate. Capsulectomy was associated with longer procedural time (133.7 ± 78.5 vs. 89.9 ± 51.8 min, p = .002). No adverse reactions to CHG were found. Four patients (4.3%) died from worsening sepsis: three in the capsulectomy group and one in the CHG group (p = .346). Conclusions In patients with CIED infections, the use of CHG without capsulectomy resulted in a lower risk of hematoma formation and shorter procedural times without an increased risk of reinfection or adverse events associated with CHG use.

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Section: Discussionmentioning

confidence: 99%

Outcomes of chlorhexidine lavage without capsulectomy versus complete capsulectomy after lead extraction for the treatment of cardiac implantable electronic device infection

Díaz¹,

Marín

Aristizábal

et al. 2023

Cardiovasc electrophysiol

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“…This approach is concerning from a stewardship perspective, as routine administration of empiric antibiotics in stable patients, with no risk factors for underlying BSI, can negatively impact the yield of blood and operative specimen cultures. Consequently, pathogen-specific therapy is not an option in patients with negative cultures, who are often treated with broad-spectrum antimicrobial therapy [9]. Such approach opposes current efforts to minimize antibiotic overuse in an attempt to reduce antimicrobial resistance.…”

Section: Discussionmentioning

confidence: 99%

“…Considering that majority of CIED infections are caused by staphylococci, and given the prevalence of oxacillin resistance among these organisms [6], vancomycin is often initiated empirically until culture results are available [7]. However, administration of antibiotics before device extraction frequently leads to negative intraoperative pocket and device cultures [8, 9], resulting in continuation of broad-spectrum antibiotic therapy after extraction. Unnecessary use of broad-spectrum antibiotics has been associated with emergence of antimicrobial resistance, one of the biggest medical challenges in modern times and a substantial threat to public health [10].…”

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confidence: 99%

Predictors of Bloodstream Infection in Patients Presenting With Cardiovascular Implantable Electronic Device Pocket Infection

Garrigos

George

Khalil

et al. 2019

Open Forum Infectious Diseases

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Background Generator pocket infection is the most frequent presentation of cardiovascular implantable electronic device (CIED) infection. We aim to identify predictors of underlying bloodstream infection (BSI) in patients presenting with CIED pocket infection. Methods We retrospectively reviewed all adults with CIED pocket infection cared for at our institution from January 2005 through January 2016. The CIED pocket infection cases were then subclassified as with or without associated BSI. Variables with P values <.05 at univariate analysis were included in a multivariable model to identify independent predictors of underlying BSI. Results We screened 429 cases of CIED infection, and 95 met the inclusion criteria. Of these, 68 cases (71.6%) were categorized as non-BSI and 27 (28.4%) as BSI. There were no statistically significant differences in patient comorbid conditions or device characteristics between the 2 groups. In multivariable analysis, the presence of systemic inflammatory response syndrome criteria (tachycardia, tachypnea, fever or hypothermia, and leukocytosis or leukopenia) and hypotension were independent predictors of underlying BSI in patients presenting with CIED pocket infection. Overall, patients in the non-BSI group who did not receive pre-extraction antibiotics had a higher frequency of positive intraoperative pocket/device cultures than those with pre-extraction antibiotic exposure (79.4% vs 58.6%; P = .06). Conclusions Patients with CIED pocket infection who meet systemic inflammatory response syndrome criteria and/or are hypotensive at admission are more likely to have underlying BSI and should be started on empiric antibiotics after blood cultures are obtained. If these features are absent, it may be reasonable to withhold empiric antibiotics to optimize yield of pocket/device cultures during extraction.

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Vancomycin

2018

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Diagnostic evaluation and management of culture‐negative cardiovascular implantable electronic device infections

Abstract: Pocket and device cultures in suspected CIED infections may be negative due to preextraction oral antibiotics. However, frequently these patients are managed with broad-spectrum parenteral therapy postextraction.

Cited by 9 publications

References 23 publications

Outcomes of chlorhexidine lavage without capsulectomy versus complete capsulectomy after lead extraction for the treatment of cardiac implantable electronic device infection

Outcomes of chlorhexidine lavage without capsulectomy versus complete capsulectomy after lead extraction for the treatment of cardiac implantable electronic device infection

Predictors of Bloodstream Infection in Patients Presenting With Cardiovascular Implantable Electronic Device Pocket Infection

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