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

Abstract

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.

Treatment and Prevention of Cardiovascular Implantable Electronic Device (CIED) Infections

“…Patients who are afebrile, are hemodynamically stable, and have a normal peripheral white blood cell count are unlikely to have bacteremia. 46 Such patients who do not have systemic inflammatory response syndrome (SIRS) criteria (temperature > 38.3 o C or < 36 o C, pulse > 90/min, respirations > 20/min, white blood cell count > 12.0 or < 4.0 × 10 9 /L) or blood pressure with a < 90 mm Hg or > 40 mm Hg drop from baseline may have antibiotic therapy withheld until operative cultures are collected, in order to optimize the intraoperative culture yield. 46 Directed treatment is based upon final culture and susceptibility results.…”

Imaging of Cardiac Device-Related Infection

“…In cases where there is any concern of infection involvement beyond the superficial pocket site, as evidenced by positive blood cultures, systemic inflammatory response syndrome, purulent drainage and/or site erosion, one should suspect lead infection and further imaging work up with TTE and TEE is indicated to determine extent of infection ( 1 , 9 ).…”

“…In cases where there is any concern of infection involvement beyond the superficial pocket site, as evidenced by positive blood cultures, systemic inflammatory response syndrome, purulent drainage and/or site erosion, one should suspect lead infection and further imaging work up with TTE and TEE is indicated to determine extent of infection (1,9). FIGURE 2 | Fifty nine year-old male with a historyof ischemic cardiomyopathy (EF 35%) s/p ICD for primary prevention of sudden cardiac death who presented with fever and MSSE bacteremia.…”

Bacteremia due to non–Staphylococcus aureus gram-positive cocci and risk of cardiovascular implantable electronic device infection

“… 2 , 3 , 4 Bacteremia from certain organisms in patients with CIED is a serious concern because it could be a manifestation of CIED infection or predispose to hematogenous seeding of the device. 5 , 6 Staphylococcus aureus bacteremia (SAB) is associated with a 20% to 80% risk of CIED infection, 7 , 8 , 9 , 10 , 11 while the rate of CIED infection following gram-negative bacteremia is only 6% to 17%. 9 , 12 , 13 In contrast to SAB and gram-negative bacteremia, the data on the risk of CIED infection following non– S. aureus gram-positive cocci (non-SA GPC) bacteremia are both limited and dated.…”