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Nonvalvular Cardiovascular Device–Related Infections

AHA Scientific Statement:. Nonvalvular Cardiovascular Device–Related Infections.

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Nonvalvular Cardiovascular Device–Related Infections

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  1. AHA Scientific Statement: Nonvalvular Cardiovascular Device–Related Infections Larry M. Baddour, Michael A. Bettmann, Ann F. Bolger, Andrew E. Epstein, Patricia Ferrieri, Michael A. Gerber, Michael H. Gewitz, Alice K. Jacobs, Matthew E. Levison, Jane W. Newburger, Thomas J. Pallasch, Walter R. Wilson, Robert S. Baltimore, Donald A. Falace, Stanford T. Shulman, Lloyd Y. Tani, Kathryn A. Taubert From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, American Heart Association Circulation. 2003;108:2015-2031.

  2. Nonvalvular Cardiovascular Device-Related Infections • AHA scientific statement • Circulation 2003;108:2015-2031 • First edition • “Encyclopedic” • Excludes intravascular catheters • Full statement available on the web at http://circ.ahajournals.org/cgi/content/full/108/16/2015

  3. Nonvalvular Cardiovascular Device-Related Infections Type of DevicesIncidence of Infection % IntracardiacPacemakers………………………………….. 0.13-19.9Defibrillators…………………………………. 0.00-3.2LVADs…………………………………………. 25-70Total artificial hearts (TAH)……………. To be determinedVentriculoatrial shunts…………………….. 2.4-9.4Pledgets………………………………………. RarePatent ductus arteriosus (PDA) occlusion devices…………………………. RareAtrial septal defect (ASD) and ventricular septal defect (VSD) closure devices……. RareConduits………………………………………. RarePatches………………………………………… Rare Circulation 2003;108:2015-2031

  4. Nonvalvular Cardiovascular Device-Related Infections Type of Devices Incidence of Infection % Intra-arterialPeripheral vascular stents…………………… RareVascular grafts, including hemodialysis………………………………….. 1.0-6Intra-aortic balloon pumps…………………… < 5-26Angioplasty/angiography-related bacteremias……………………………………. < 1*Coronary artery stents………………………… RarePatches…………………………………………… 1.8 IntravenousVena caval filters……………………………….. Rare *Closure device use < 1.9% Circulation 2003;108:2015-2031

  5. Nonvalvular Cardiovascular Device-Related InfectionsAHA Scientific Statement -- Specific devices • Intracardiac • Intra-arterial • Intravenous Two broad sections: --General principles • Clinical manifestations • Microbiology • Pathogenesis • Diagnosis • Treatment • Prevention Circulation 2003;108:2015-2031

  6. Nonvalvular Cardiovascular Device-Related InfectionsPathogenesis • Pathogen virulence factors • Adhesions (MSCRAMM) • Biofilm • Host response to the artificial device • Abnormal flow • Immunologic effects • Physical/chemical device characteristics • Platelet, fibrinogen attachment Circulation 2003;108:2015-2031

  7. Nonvalvular Cardiovascular Device-Related InfectionsClinical Manifestations • Depend on location of infected portion of device • Local • Systemic Circulation 2003;108:2015-2031

  8. Nonvalvular Cardiovascular Device-Related InfectionsMicrobiology • Staphylococcal species predominate • Multidrug resistance, including oxacillin - frequent • Aerobic gram-negative bacilli • Pseudomonas, Acinetobacter, Serratia species • Fungi • Candida species - most common among fungi • Aspergillus species - reported Circulation 2003;108:2015-2031

  9. Vascular graft site infection in a hemodialysis patient due to methicillin-resistant S aureus. The patient suffered bacteremia in addition to focal skin and soft tissue changes at the graft site, including erythema, swelling, warmth, and pain. Circulation 2003;108:2015-2031

  10. Nonvalvular Cardiovascular Device-Related InfectionsDiagnosis • Laboratory • Specimen (blood, drainage, device) cultures • Radiologic • Echocardiographic Circulation 2003;108:2015-2031

  11. Transesophageal echocardiographic view of the left atrium (LA) and right atrium (RA). A pacemaker lead (filled arrow) is seen as it crosses the tricuspid valve. The lead is thickened by infective material, and there is a round mobile vegetation (open arrow) attached to its right atrial portion. Circulation 2003;108:2015-2031

  12. Nonvalvular Cardiovascular Device-Related Infections Manifestation of Infection Initial Imaging Modality Endocarditis TEEPacemakers (temporary and permanent)DefibrillatorsLVADsVentriculoatrial shuntsPledgetsASD closure devicesPatches Conduits PDA occlusion devices Pericarditis TTE or TEECoronary artery stentsPledgets TTE or TEE Circulation 2003;108:2015-2031

  13. Nonvalvular Cardiovascular Device-Related Infections Manifestation of Infection Initial Imaging Modality Endocarditis TEEPacemakers (temporary and permanent)DefibrillatorsLVADsVentriculoatrial shuntsPledgetsASD closure devicesPatches Conduits PDA occlusion devices Pericarditis TTE or TEECoronary artery stentsPledgets TTE or TEE Circulation 2003;108:2015-2031

  14. Nonvalvular Cardiovascular Device-Related Infections Manifestation of Infection Initial Imaging Modality Perivasculitis CT or MRIPeripheral vascular stentsVascular grafts, including hemodialysisAngioplasty/angiography-related bacteremiasCoronary artery stentsPatches Aneurysm or pseudoaneurysm AngiographyPledgetsCoronary artery stentsPatchesAngioplasty/angiography-related bacteremiasVascular grafts, including hemodialysis Circulation 2003;108:2015-2031

  15. Nonvalvular Cardiovascular Device-Related Infections Manifestation of Infection Initial Imaging Modality Infected thrombosis UltrasoundVena caval filterVascular grafts, including hemodialysis Pocket site infections UltrasoundPacemakers (permanent)DefibrillatorsLVADsTotal artificial hearts Circulation 2003;108:2015-2031

  16. Nonvalvular Cardiovascular Device-Related Infections Treatment • Antimicrobial • Acute (induction) • Long-term (lifelong) suppressive • Device replacement impregnation • Device removal • “Percutaneous” • Surgical Circulation 2003;108:2015-2031

  17. Nonvalvular Cardiovascular Device-Related InfectionsTreatment • Acute (induction) • Bactericidal/fungicidal • Parenteral • Selection • Based on pathogen identification/susceptibility testing • Host factors • Duration • Variable depending on type of device and location of infection Circulation 2003;108:2015-2031

  18. Nonvalvular Cardiovascular Device-Related Infections Treatment • Long-term (lifelong) suppressive therapy • Infected device removal - not an option • Response to acute treatment - clinically and microbiologically • Cardiovascular status - stable Circulation 2003;108:2015-2031

  19. Nonvalvular Cardiovascular Device-Related Infections Primary prophylaxis • Modeled after surgical site infection prophylaxis. • Because of the low incidence of infection for many of the devices, without evidence-based data. • Routinely used: electrophysiological cardiac devices, VAD, TAH, VA shunts, pledgets, vascular grafts, and arterial patches. Circulation 2003;108:2015-2031

  20. Nonvalvular Cardiovascular Device-Related Infections Secondary prophylaxis • Antibiotic prophylaxis is not recommended for patients who undergo dental, respiratory, gastrointestinal or genitourinary procedures. • It is recommended for patients if they undergo incision and drainage of infection at other sites (eg, abscess) or replacement of an infected device. • It is recommended for patients with residual leak after device placement for attempted closure of the leak associated with PDA, ASD, or VSD Circulation 2003;108:2015-2031

  21. Electrophysiologic Devices • Pacemakers • Incidence of infection, 0.13%-19.9% • Implantable cardioverter-defibrillators (ICDs) • Incidence of infection, 0%-0.8% Circulation 2003;108:2015-2031

  22. Electrophysiologic Devices • Generator pocket - most common infection site • Lead infection • “Pacemaker endocarditis” • ~10% of pacemaker infections • Most often due to generator pocket infection Circulation 2003;108:2015-2031

  23. Electrophysiologic Devices • Infection sources • Generator pocket contamination at implantation • Cutaneous erosion of generator • Hematogenous seeding (“late - onset infection”) Circulation 2003;108:2015-2031

  24. Electrophysiologic Devices • Treatment • Duration of therapy • No evidence-based data • Limited to generator site - ~ 10 days • Lead infection - 2 to 6 weeks • Device removal • Paramount Reduce risk of infection relapse and mortality • Device replacement • Timing • Varied recommendations - at least wait until bacteremia/fungemia cleared • Some may not require/want device replacement Circulation 2003;108:2015-2031

  25. Electrophysiologic Devices • Lead removal • Greater difficulty if prolonged implantation time • Techniques (nonsurgical) • 81%-93% successful • 0%-3.3% complications • 0%-0.8% mortality • Locking stylet • Telescoping sheath • Laser sheath Circulation 2003;108:2015-2031

  26. Left Ventricular Assist Devices • Incidence of infection; 13%-80% • 85% of infections occur > 2 weeks after LVAD placement • Mean duration of LVAD use = 73 days • Statistical association - postoperative hemodialysis • Clin Infect Dis 2002;34:1295-1300 Circulation 2003;108:2015-2031

  27. Left Ventricular Assist Devices • Three infection syndromes • Driveline infection (most common) • LVAD pocket site infection • LVAD endocarditis (least common) • Not mutually exclusive Circulation 2003;108:2015-2031

  28. Left Ventricular Assist Devices • Immunologic effects • Aberrant state of CD4 • T-cell activation - apoptosis • Cutaneous anergy - recall antigens • Lower T-cell proliferative responses • Higher surface expression of CD95 • B-cell hyperactivity and dysregulated immunoglobulin synthesis Circulation 2003;108:2015-2031

  29. Left Ventricular Assist Devices • Persistent bacteremia/fungemia not a contraindication to cardiac transplantation • Transplantation is life-saving for some patients with uncontrollable LVAD infection Circulation 2003;108:2015-2031

  30. Total Artificial Heart • 1980s - Jarvik-7 • Infectious/noninfectious complications • January 2001 - FDA (USA) approval - Abiomed • Totally implantable except external battery and lead to electrical inductor coil • 10 patients (3/10/03) • Blood clotting problems, CVAs • No infectious complications, 7 patients • No data, 3 patients Circulation 2003;108:2015-2031

  31. Ventriculoatrial (VA) Shunts • VP > VA use • Incidence of infection < 10% • Large majority within six months of placement • CONS > S. aureus • Clinical manifestations • Infection site dependent, virulence of organism, +/- shunt malfunction • Varied, though meningitis unusual • Remember immunologic sequelae Circulation 2003;108:2015-2031

  32. Ventriculoatrial (VA) Shunts • Diagnosis of infection • Findings • Presence of fever and > 10% PMNs in ventricular fluid • Treatment • Two-staged exchange Circulation 2003;108:2015-2031

  33. Cardiac Suture Line Pledgets • Teflon pledgets commonly used • Three infection syndromes • Chest wall or epigastric involvement • Draining sinuses, sub-q masses, pain • Bronchopulmonary infection • Recurrent hemoptysis, bronchiectasis, pneumonia with empyema • Endocardial infection • Bacteremia or fungemia Circulation 2003;108:2015-2031

  34. Occlusion Devices • Patent ductus arteriosus, atrial septal defect, and ventricular septal defect • Extremely rare infections (n=2) • Left atrial appendage occluders • Pending more extensive evaluation Circulation 2003;108:2015-2031

  35. Prosthetic Vascular Grafts • Incidence of infection 1%-6% (> 5 yrs) • Location - related • Aortic < 1% • Aortofemoral 1.5%-2% • Infrainguinal < 6% (originate in groin) • Intraoperative or perioperative contamination • Majority of cases • Incubation period - < 2 months • Longer for indolent (CONS) pathogens Circulation 2003;108:2015-2031

  36. Prosthetic Vascular Grafts • Purported risk factors • Groin incisions • Emergent surgery • Invasive intervention (local) • Before/after placement • Contiguous infection • Medical conditions (diabetes mellitus, obesity, chronic renal disease, immunocompromised host) Circulation 2003;108:2015-2031

  37. Prosthetic Vascular Grafts • Clinical presentations • Distal (extremity) infections • Focal inflammatory changes • Intracavitary infections • Nonspecific, difficult to diagnose • Magnified if years after placement • GI bleed Circulation 2003;108:2015-2031

  38. Prosthetic Vascular Grafts • Diagnostic modalities • Blood cultures • Radiologic/nuclear medicine • CT scanning Sensitivity/specificity - 94%/95% • MRI • Sensitivity/specificity - 85%/100% • Indium WBC, gallium - lower specificity Circulation 2003;108:2015-2031

  39. Prosthetic Vascular Grafts • Management • 4 tenets • Excision of graft (foreign body) • Wide/complete debridement of devitalized, infected tissue • Maintain or establish vascular flow • Institute prolonged systemic antimicrobial therapy Circulation 2003;108:2015-2031

  40. Hemodialysis Prosthetic Vascular Grafts • Epidemiologic factors • Immunocompromised state • Repetitive needle puncture at graft site • Increased carriage of S. aureus • 3.2 infections/100 patient-months • CDC national surveillance system • AV fistulas - 0.56 • Synthetic AV grafts - 1.36 • Cuffed catheters - 8.42 • Non-cuffed catheters - 11.98 Circulation 2003;108:2015-2031

  41. Hemodialysis Prosthetic Vascular Grafts • Microbiology • Access-related bacteremia (fistulas or grafts) • S. aureus - 53% • CONS - 20.3% • MDR commonplace • MRSA (VISA, VRSA) • MRSE • VRE Circulation 2003;108:2015-2031

  42. Hemodialysis Prosthetic Vascular Grafts • Management • Complex issues, including available vascular access • Old, nonfunctioning AV grafts • Cause of “delayed” sepsis • Prevention • Mupirocin • Increased AV fistula use • Cryopreserved human femoral vein allograft • Vaccines Circulation 2003;108:2015-2031

  43. Endovascular Stents and Stent-Grafts • >400,000 patients in US undergo stent placement annually • Incidence of infection <1/10,000 • Early (<4 weeks) presentation • Predominant pathogen • S. aureus Circulation 2003;108:2015-2031

  44. Endovascular Stents and Stent-Grafts • Complications • Pseudoaneurysms • Others (abscess formation, arterial necrosis, septic emboli, refractory sepsis, amputation requirement, death) • Treatment • Excision with extra-anatomic revascularization • Prevention • Primary prophylaxis - “selected” patients Circulation 2003;108:2015-2031

  45. Intra-aortic Balloon Counterpulsation Catheters (IABP) • Incidence of infection • Wound infection < 5% • Bacteremia < 2.2% • Purported risks • Obesity • Emergent placement • Surgical insertion • Longer duration of use • Done in areas outside OR or cath lab • Larger diameter catheters (used in past) Circulation 2003;108:2015-2031

  46. Coronary Angiography and PTCA • ~900,000 annually worldwide • Stents used in 80%-85% • Incidence of infection < 1% • Multiple infectious complications are described • Bacteremia • Mycotic aneurysm, septic arthritis, endarteritis Circulation 2003;108:2015-2031

  47. Coronary Angiography and PTCA • Risk factors • Brachial artery access • Cutdown approach • Repeat puncture (ipsilateral) • Prolonged indwelling FA sheath • Pressurized heparin solution • Older age • CHF Circulation 2003;108:2015-2031

  48. Coronary Angiography and PTCA • Microbiology • Staphylococcus species - Most common • Diagnosis • CT scan or angiography • Persistent sepsis, septic emboli, and abdominal flank pain • Treatment • Aneurysms require resection or ligation • Rupture propensity Circulation 2003;108:2015-2031

  49. Coronary Artery Stents • Infection extremely rare • Only 5 cases described in English literature • Acute infection • Pathogens • S. aureus - 3; P. aeruginosa - 2 • 3/5 patients died Circulation 2003;108:2015-2031

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