Spectrum: Local Antimicrobial Stewardship, for Eastern Health

Infections of IECDs

Note

The diagnosis of endocarditis in patients with Implantable Electronic Cardiac Devices (IECD) is difficult.

Tailored management is critical and device removal including wire extraction may be required.

The Modified Duke Criteria do not have sufficient sensitivity for diagnosis

Consults

Infectious Diseases and Cardiology consults required

Pathogenesis

Microorganisms seed the device at implantation or manipulation, or intravascular parts (i.e. wires) during bacteremia.

Isolated pocket infections vs. deeper infections involving intravascular hardware.

Risk factors

  • Recent device manipulation

  • Immunocompromise (DM, renal failure, corticosteroids)

  • Anticoagulant use and hematoma at pocket site

  • Abdominal device

  • Procedural factors (i.e. prophylactic antimicrobials).

Microbiology

  • 3/4 Staphylococci, coagulase negative Staph > S. aureus

  • Others: Gram positive rods (Propionobacteria, Corynebacteria), gram negative rods including Pseudomonas, other gram positive cocci, Candida species, and polymicrobial infection

  • Rarely other fungi and mycobacteria.

Clinical Presentation

  • Inflammation at pocket site or erosion.

  • Septic pulmonary emboli from wire infection or TV endocarditis

  • Subacute symptoms of bloodstream infection including malaise, anorexia, fever.

Diagnosis

  • Obtain blood culture prior to antimicrobials in any suspected device infection.

  • TEE superior to TTE to assess certain portions of the leads and the left heart.

  • Features of the Modified Duke Criteria are still helpful, with the addition of signs of inflammation at the pocket site.

  • Infection of the leads is essentially right sided IE.

  • S. aureus dramatically increase the probability of device infection, whereas gram negative bacteremia with a known alternate source is less likely to implicate the device.

  • If device removed, tissue from the pocket site and lead tips should be cultured.

Initial Management

  • Initial antimicrobials to cover coagulase negative Staph and S. aureus (i.e. vancomycin), and additional pathogens depending on the acuity and severity of infection.

  • Therapy similar to prosthetic valve endocarditis.

  • Consideration for device removal.

  • Duration of therapy depends on the timing of device removal.