Presentation is loading. Please wait.

Presentation is loading. Please wait.

Nonvalvular Cardiovascular Device–Related Infections Larry M. Baddour, Michael A. Bettmann, Ann F. Bolger, Andrew E. Epstein, Patricia Ferrieri, Michael.

Similar presentations


Presentation on theme: "Nonvalvular Cardiovascular Device–Related Infections Larry M. Baddour, Michael A. Bettmann, Ann F. Bolger, Andrew E. Epstein, Patricia Ferrieri, Michael."— Presentation transcript:

1

2 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 Circulation. 2003;108: AHA Scientific Statement: From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, American Heart Association

3 Nonvalvular Cardiovascular Device-Related Infections AHA scientific statement AHA scientific statement –Circulation 2003;108: u First edition u Encyclopedic u Excludes intravascular catheters u Full statement available on the web at 16/2015

4 Nonvalvular Cardiovascular Device-Related Infections Type of DevicesIncidence of Infection % Intracardiac Pacemakers………………………………… Defibrillators………………………………… LVADs………………………………………… Total artificial hearts (TAH)…………….To be determined Ventriculoatrial shunts…………………… Pledgets……………………………………….Rare Patent ductus arteriosus (PDA) occlusion devices………………………….Rare Atrial septal defect (ASD) and ventricular septal defect (VSD) closure devices…….Rare Conduits……………………………………….Rare Patches…………………………………………Rare Circulation 2003;108:

5 Type of DevicesIncidence of Infection % Intra-arterial Peripheral vascular stents……………………Rare Vascular grafts, including hemodialysis………………………………… Intra-aortic balloon pumps……………………< 5-26 Angioplasty/angiography-related bacteremias…………………………………….< 1* Coronary artery stents…………………………Rare Patches……………………………………………1.8 Intravenous Vena caval filters………………………………..Rare * Closure device use < 1.9% Nonvalvular Cardiovascular Device-Related Infections Circulation 2003;108:

6 Nonvalvular Cardiovascular Device-Related Infections AHA Scientific Statement -- Specific devices u Intracardiac u Intra-arterial u Intravenous Circulation 2003;108: General principles u Clinical manifestations u Microbiology u Pathogenesis u Diagnosis u Treatment u Prevention Two broad sections: Two broad sections:

7 Nonvalvular Cardiovascular Device-Related Infections Pathogenesis Pathogen virulence factors Pathogen virulence factors –Adhesions (MSCRAMM) –Biofilm Host response to the artificial device Host response to the artificial device –Abnormal flow –Immunologic effects Physical/chemical device characteristics Physical/chemical device characteristics –Platelet, fibrinogen attachment Circulation 2003;108:

8 Nonvalvular Cardiovascular Device-Related Infections Nonvalvular Cardiovascular Device-Related Infections Clinical Manifestations Depend on location of infected portion of device Depend on location of infected portion of device –Local –Systemic Circulation 2003;108:

9 Nonvalvular Cardiovascular Device-Related Infections Microbiology Staphylococcal species predominate Staphylococcal species predominate –Multidrug resistance, including oxacillin - frequent Aerobic gram-negative bacilli Aerobic gram-negative bacilli –Pseudomonas, Acinetobacter, Serratia species Fungi Fungi –Candida species - most common among fungi –Aspergillus –Aspergillus species - reported Circulation 2003;108:

10 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:

11 Nonvalvular Cardiovascular Device-Related Infections Diagnosis Laboratory Laboratory –Specimen (blood, drainage, device) cultures Radiologic Radiologic –Echocardiographic Circulation 2003;108:

12 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:

13 Nonvalvular Cardiovascular Device-Related Infections Manifestation of InfectionInitial Imaging Modality EndocarditisTEE Pacemakers (temporary and permanent) Defibrillators LVADs Ventriculoatrial shunts Pledgets ASD closure devices Patches Conduits PDA occlusion devices Pericarditis TTE or TEE Coronary artery stents Pledgets Circulation 2003;108: TTE or TEE

14 Nonvalvular Cardiovascular Device-Related Infections Manifestation of InfectionInitial Imaging Modality EndocarditisTEE Pacemakers (temporary and permanent) Defibrillators LVADs Ventriculoatrial shunts Pledgets ASD closure devices Patches Conduits PDA occlusion devices Pericarditis TTE or TEE Coronary artery stents Pledgets Circulation 2003;108: TTE or TEE

15 Manifestation of InfectionInitial Imaging Modality PerivasculitisCT or MRI Peripheral vascular stents Vascular grafts, including hemodialysis Angioplasty/angiography-related bacteremias Coronary artery stents Patches Aneurysm or pseudoaneurysmAngiography Pledgets Coronary artery stents Patches Angioplasty/angiography-related bacteremias Vascular grafts, including hemodialysis Nonvalvular Cardiovascular Device-Related Infections Circulation 2003;108:

16 Nonvalvular Cardiovascular Device-Related Infections Manifestation of InfectionInitial Imaging Modality Infected thrombosisUltrasound Vena caval filter Vascular grafts, including hemodialysis Pocket site infectionsUltrasound Pacemakers (permanent) Defibrillators LVADs Total artificial hearts Circulation 2003;108:

17 Nonvalvular Cardiovascular Device-Related Infections Treatment Antimicrobial Antimicrobial –Acute (induction) –Long-term (lifelong) suppressive –Device replacement impregnation Device removal Device removal –Percutaneous –Surgical Circulation 2003;108:

18 Nonvalvular Cardiovascular Device-Related Infections Treatment Acute (induction) Acute (induction) –Bactericidal/fungicidal –Parenteral –Selection u Based on pathogen identification/susceptibility testing u Host factors –Duration u Variable depending on type of device and location of infection Circulation 2003;108:

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

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

21 Nonvalvular Cardiovascular Device-Related Infections Secondary prophylaxis Antibiotic prophylaxis is not recommended for patients who undergo dental, respiratory, gastrointestinal or genitourinary procedures. 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 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 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:

22 Electrophysiologic Devices Pacemakers Pacemakers –Incidence of infection, 0.13%-19.9% Implantable cardioverter-defibrillators (ICDs) Implantable cardioverter-defibrillators (ICDs) –Incidence of infection, 0%-0.8% Circulation 2003;108:

23 Electrophysiologic Devices Generator pocket - most common infection site Generator pocket - most common infection site Lead infection Lead infection –Pacemaker endocarditis –~10% of pacemaker infections –Most often due to generator pocket infection Circulation 2003;108:

24 Electrophysiologic Devices Infection sources Infection sources –Generator pocket contamination at implantation –Cutaneous erosion of generator –Hematogenous seeding (late - onset infection) Circulation 2003;108:

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

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

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

28 Left Ventricular Assist Devices Three infection syndromes Three infection syndromes –Driveline infection (most common) –LVAD pocket site infection –LVAD endocarditis (least common) –Not mutually exclusive Circulation 2003;108:

29 Immunologic effects 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 Left Ventricular Assist Devices Circulation 2003;108:

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

31 Total Artificial Heart 1980s - Jarvik s - Jarvik-7 –Infectious/noninfectious complications January FDA (USA) approval - Abiomed January 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:

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

33 Diagnosis of infection Diagnosis of infection – Findings u Presence of fever and > 10% PMNs in ventricular fluid –Treatment u Two-staged exchange Circulation 2003;108: Ventriculoatrial (VA) Shunts

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

35 Occlusion Devices Patent ductus arteriosus, atrial septal defect, and ventricular septal defect Patent ductus arteriosus, atrial septal defect, and ventricular septal defect Extremely rare infections (n=2) Extremely rare infections (n=2) Left atrial appendage occluders Left atrial appendage occluders –Pending more extensive evaluation Circulation 2003;108:

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

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

38 Prosthetic Vascular Grafts Clinical presentations Clinical presentations –Distal (extremity) infections u Focal inflammatory changes –Intracavitary infections u Nonspecific, difficult to diagnose Magnified if years after placement –GI bleed Circulation 2003;108:

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

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

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

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

43 Management Management –Complex issues, including available vascular access –Old, nonfunctioning AV grafts u Cause of delayed sepsis Prevention Prevention –Mupirocin –Increased AV fistula use –Cryopreserved human femoral vein allograft –Vaccines Hemodialysis Prosthetic Vascular Grafts Circulation 2003;108:

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

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

46 Intra-aortic Balloon Counterpulsation Catheters (IABP) Incidence of infection Incidence of infection –Wound infection < 5% –Bacteremia < 2.2% Purported risks 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:

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

48 Risk factors Risk factors –Brachial artery access u Cutdown approach –Repeat puncture (ipsilateral) –Prolonged indwelling FA sheath u Pressurized heparin solution –Older age –CHF Coronary Angiography and PTCA Circulation 2003;108:

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

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

51 Vascular Closure Devices (VCD) FDA (USA) approval - 5 devices FDA (USA) approval - 5 devices Favored over manual compression or compression devices Favored over manual compression or compression devices –Decrease time to hemostasis, increased patient comfort Incidence of infection < 1.9% Incidence of infection < 1.9% –Two concerns u VCD > manual compression u Infections more severe, more difficult to treat (often surgical intervention) Circulation 2003;108:

52 Vascular Closure Devices (VCD) Microbiology Microbiology –S. aureus u Methicillin-resistant Risk Risk –Diabetes mellitus? u Prophylaxis for this group and for vascular access per prosthetic graft Circulation 2003;108:

53 Dacron Carotid Patches Incidence of infection = 0.33% - 1.8% Incidence of infection = 0.33% - 1.8% Local (cervical) findings Local (cervical) findings –Early (< 3 months) u Cellulitis, abscess, sepsis, pseudoaneurysm, massive hemorrhage, patch dehiscence –Late u Sinus tracts with drainage, pseudoaneurysm Circulation 2003;108:

54 Dacron Carotid Patches Microbiology Microbiology –Both viridans group streptococci and S.aureus predominate early; late infections - coagulase-negative staphylococci Treatment Treatment –Surgical u Usually patch removal Outcome Outcome –Overall good Circulation 2003;108:

55 Vena Caval Filters ~30 years in use, 10 filters available (USA) ~30 years in use, 10 filters available (USA) Infection extremely rare Infection extremely rare –3 proven, 2 suspect –Staphylococcal species - all 5 cases –4 with bacteremia, 2 with spondylodiscitis –3 cures with device removal –1 sepsis death, 1 long-term suppressive therapy Circulation 2003;108:

56 Conclusions M Medical devices enhance ability to care for patients with CVD Device infections complicate patient care Cure of infection may be difficult to achieve without device removal Future developments should be directed toward: -- devices more resistant to infection -- antimicrobial agents with enhanced activity in clearing infection -- staphylococcal vaccines Circulation 2003;108:

57


Download ppt "Nonvalvular Cardiovascular Device–Related Infections Larry M. Baddour, Michael A. Bettmann, Ann F. Bolger, Andrew E. Epstein, Patricia Ferrieri, Michael."

Similar presentations


Ads by Google