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Nonvalvular Cardiovascular Device–Related Infections

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2 Nonvalvular Cardiovascular Device–Related Infections
AHA Scientific Statement: Nonvalvular Cardiovascular Device–Related Infections From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, American Heart Association 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 This presentation reviews key aspects of nonvalvular cardiovascular device-related infections that are outlined in an AHA Scientific Statement published October 15, 2003 in Circulation. Circulation. 2003;108:

3 Nonvalvular Cardiovascular Device-Related Infections
AHA scientific statement Circulation 2003;108: First edition “Encyclopedic” Excludes intravascular catheters Full statement available on the web at This is the first time that the Committee has addressed nonvalvular cardiovascular device-related infections. The document reviews the different types of devices currently in use and describes distinct infection syndromes. Because intravascular catheters are thoroughly reviewed in other publications, they were not included in the Scientific Statement.

4 Nonvalvular Cardiovascular Device-Related Infections
Type of Devices Incidence 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 There is a growing number of different types of devices that are being placed in the cardiovascular system. Infection risks varies widely depending on type of device. The devices that are placed in the intracardiac location are shown in this slide. Circulation 2003;108:

5 Nonvalvular Cardiovascular Device-Related Infections
Type of Devices Incidence 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% Both intra-arterial and intravenous devices are listed here. The incidence of infection among the devices is wide-ranging. Circulation 2003;108:

6 Nonvalvular Cardiovascular Device-Related Infections AHA Scientific Statement
Two broad sections: -- General principles Clinical manifestations Microbiology Pathogenesis Diagnosis Treatment Prevention -- Specific devices Intracardiac Intra-arterial Intravenous The Statement is divided into two broad sections. In the first section, general principles of infection that are commonly shared among the different devices are examined. In the second section, the unique features of infection for each device is discussed. Circulation 2003;108:

7 Nonvalvular Cardiovascular Device-Related Infections Pathogenesis
Pathogen virulence factors Adhesions (MSCRAMM) Biofilm Host response to the artificial device Abnormal flow Immunologic effects Physical/chemical device characteristics Platelet, fibrinogen attachment There are three important areas of infection pathogenesis that are shared by infection of cardiovascular devices. These include microbial virulence factors, host response to the device, and physical and chemical characteristics of the device surface. Each of these three aspects influence the likelihood of device infection. Circulation 2003;108:

8 Nonvalvular Cardiovascular Device-Related Infections Clinical Manifestations
Depend on location of infected portion of device Local Systemic Clinical signs and symptoms of device infection are either local or systemic or both and which are manifest depend on the portion of the device infected. Circulation 2003;108:

9 Nonvalvular Cardiovascular Device-Related Infections Microbiology
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 Most nonvalvular cardiovascular device infections are due to staphylococcal species. A variety of other organisms, some of which are shown here, can also cause device infection. 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 Specimen (blood, drainage, device) cultures Radiologic Echocardiographic Both laboratory and radiologic procedures are frequently used diagnostically in patients with clinical manifestations of possible device infection. Specimen cultures are helpful in not only identifying the infecting pathogen(s) but also provide an isolate for antimicrobial susceptibility testing to assist the the selection of appropriate medical treatment. 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 Infection Initial Imaging Modality Endocarditis TEE 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 TTE or TEE This and the next two slides outline device infection syndromes and list the most appropriate diagnostic radiologic tool to be employed. Circulation 2003;108:

14 Nonvalvular Cardiovascular Device-Related Infections
Manifestation of Infection Initial Imaging Modality Endocarditis TEE 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 TTE or TEE This and the next two slides outline device infection syndromes and list the most appropriate diagnostic radiologic tool to be employed. Circulation 2003;108:

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

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

17 Nonvalvular Cardiovascular Device-Related Infections Treatment
Antimicrobial Acute (induction) Long-term (lifelong) suppressive Device replacement impregnation Device removal “Percutaneous” Surgical Treatment consists of both antimicrobial therapy and device removal. There are three different approaches to medical therapy: acute or induction therapy; long-term or lifelong suppressive therapy; and antimicrobial impregnation of the device. Circulation 2003;108:

18 Nonvalvular Cardiovascular Device-Related Infections Treatment
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 The choice of acute or induction therapy should include a “cidal” regimen that is usually administered parenterally. The specific choice of agents is based on pathogen identification and in vitro antimicrobial susceptibility results. Duration of treatment varies from device to device and location of device infection. Circulation 2003;108:

19 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 Long-term or lifelong suppressive therapy is reserved for patients who are not candidates for device removal. These patients are cardiovascularly stable and have had a microbiologic response to acute treatment. Circulation 2003;108:

20 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. Primary prophylaxis, or prophylaxis administered at the time of device placement, is modeled after that used for surgical prophylaxis. For the majority of cardiovascular devices, there are no evidence-based data that demonstrate the efficacy of prophylaxis. There are such data for prosthetic vascular graft and pacemaker placements. 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. 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 Secondary prophylaxis, or that used following device placement and administered prior to certain invasive procedures is not recommended, with few exceptions as listed on this slide. Circulation 2003;108:

22 Electrophysiologic Devices
Pacemakers Incidence of infection, 0.13%-19.9% Implantable cardioverter-defibrillators (ICDs) Incidence of infection, 0%-0.8% Implantable devices for electrophysiologic indications include pacemakers and implantable cardioverter defibrillators, also known as ICDs. The incidence of infection with these devices reportedly varies from as low as 0% for ICDs to near 20% for pacemakers. Both of these extremes are not in keeping with current practice. The incidence of infection for both devices is approximately 1% to 2%. Higher infection rates are associated with longer operative times. Pulse generator replacement may also be an infection risk factor. Circulation 2003;108:

23 Electrophysiologic Devices
Generator pocket - most common infection site Lead infection “Pacemaker endocarditis” ~10% of pacemaker infections Most often due to generator pocket infection The generator pocket is the most common site of electrophysiologic device infection. Lead infection is much less common and when it occurs it represents extension of infection from the generator pocket site. Circulation 2003;108:

24 Electrophysiologic Devices
Infection sources Generator pocket contamination at implantation Cutaneous erosion of generator Hematogenous seeding (“late - onset infection”) There are three sources of infection for electrophysiologic devices. The pocket may be contaminated at the time of device placement. The generator may erode through the skin postoperatively and result in device contamination. Hematogenous seeding of the device can occur and usually presents as late-onset device infection. Circulation 2003;108:

25 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 There are no evidence-based data to indicate the most appropriate duration of antimicrobial therapy. For infections limited to the generator site, antimicrobials are usually given for at least 10 days following device removal. For infections involving the leads or presence of bacteremia or lead-associated vegetations, at least 2 weeks of therapy or longer are used. Removal of the entire device is critical in reducing infection relapse and mortality rates. Timing of device replacement varies from institution to institution. Waiting at least 3 to 5 days to make sure that bacteremia or fungemia has cleared is a minimum before device replacement. For a small portion of patients, device replacement may not be required or the patient may refuse replacement. Circulation 2003;108:

26 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 Although pacemaker and ICD generators can be removed with little difficulty, lead removal is more problematic. Furthermore, the longer the time the device has been implanted, the greater the difficulty in removing the leads. In the past, surgical resection of leads was required. More recently, however, new nonsurgical techniques have increased the success rate of lead removal to >90% with a lower risk of complications. The use of locking stylets which stabilize the distal lead tip, telescoping sheaths that allow lysis of adhesions of the body of the lead, and lasers that cut through adhesions have all enhanced the rate of successful nonsurgical lead removal. Lead extraction is associated with a complication rate up to 3.3% and a mortality rate of 1%. Circulation 2003;108:

27 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: Prolonged use of a left ventricular assist device increases the risk of device infection. Postoperative hemodialysis has also been linked to device infection. Circulation 2003;108:

28 Left Ventricular Assist Devices
Three infection syndromes Driveline infection (most common) LVAD pocket site infection LVAD endocarditis (least common) Not mutually exclusive Patients with left ventricular assist device infection present with one or more of three clinical syndromes. Driveline infection is the most common presentation and patients typically develop exit site drainage and erythema. Systemic toxicity and bloodstream infection is not seen. Pocket site infection usually causes local pain and may be associated with fever. LVAD-associated endocarditis is characteristic of endocarditis involving cardiac valves and causes systemic toxicity, bacteremia or fungemia and embolic complications. Circulation 2003;108:

29 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 The presence of a LVAD can impact the immune system in a variety of ways. This has been linked to increased infection risk (not limited to LVAD infection) and difficulties with tissue typing for cardiac transplantation due to dysregulated Ig synthesis. Circulation 2003;108:

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

31 Total Artificial Heart
1980s - Jarvik-7 Infectious/noninfectious complications 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 There were great expectations for the Jarvik-7 total artificial heart in the 1980s but infectious and non-infectious device-related complications prompted discontinuance of its use. More recently, Abiomed received FDA approval for use of its model of a total artificial heart. Unlike the Jarvik-7 and other early models, the Abiomed heart is totally implantable except for an external battery and lead to an electronic conductor coil. Because of these changes, infection risk with use of the Abiomed heart should be much less. We await further study with this device to determine whether this device is characterized by a lower risk of device-associated infection. Circulation 2003;108:

32 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 The incidence of VA shunt infection is <10% and coagulase-negative staphylococci are the most common causes of infection. Clinical manifestations vary, although meningitis is unusual. Circulation 2003;108:

33 Ventriculoatrial (VA) Shunts
Diagnosis of infection Findings Presence of fever and > 10% PMNs in ventricular fluid Treatment Two-staged exchange The presence of fever and >10% polymorphonuclear leukocytes in ventricular fluid are predictive of VA shunt infection. Treatment usually consists of a two-staged exchange of the shunt and is combined with systemic therapy. Intraventricular antibiotics, particularly vancomycin, is also used. Circulation 2003;108:

34 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 Cardiac suture line pledget infection presents as one of three different syndromes. These include chest wall or epigastric involvement, bronchopulmonary infection and endocarditis. Circulation 2003;108:

35 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 Cardiac occlusive devices rarely become infected. The infection risk of left atrial appendage occluders has yet to be defined. Circulation 2003;108:

36 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 The incidence of prosthetic vascular graft infection is variable and depends on the location of the graft. In the majority of cases and despite the use of perioperative antibiotics, intraoperative or perioperative contamination occurs and accounts for the majority of graft infections. Circulation 2003;108:

37 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) There are several purported risk factors for prosthetic vascular graft infection, but no multivariate analysis has been conducted to date to statistically evaluate these factors. Circulation 2003;108:

38 Prosthetic Vascular Grafts
Clinical presentations Distal (extremity) infections Focal inflammatory changes Intracavitary infections Nonspecific, difficult to diagnose Magnified if years after placement GI bleed Clinical presentations of graft infection vary. Distal infection that involves a lower extremity presents as a focal inflammatory process and is more easily diagnosed. Intracavitary graft infections, in contrast, may present with nonspecific findings, including gastrointestinal bleed if aortoenteric fistula is present. Circulation 2003;108:

39 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 Blood cultures and radiologic procedures are both used as diagnostic modalities for prosthetic graft infection. CT scanning is a premier tool because of its high sensitivity and specificity in demonstrating graft infection. Circulation 2003;108:

40 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 The four tenets of prosthetic vascular graft infection management are listed on this slide. The techniques and grafts used for each strategy varies within each institution and by individual vascular surgeon. Circulation 2003;108:

41 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 Synthetic AV grafts Cuffed catheters Non-cuffed catheters Hemodialysis patients are at increased risk of prosthetic vascular graft infection. Several epidemiologic factors increase the infection risk. Synthetic AV grafts are intermediate in their infection risk as compared to AV fistula and catheters for use in hemodialysis. Circulation 2003;108:

42 Hemodialysis Prosthetic Vascular Grafts
Microbiology Access-related bacteremia (fistulas or grafts) S. aureus - 53% CONS % MDR commonplace MRSA (VISA, VRSA) MRSE VRE Bacteremia is a frequent complication of prosthetic vascular graft infection in hemodialysis patients. Often, infection is due to multi-drug resistant gram-positive cocci. Circulation 2003;108:

43 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 The management of hemodialysis prosthetic vascular graft infection is complex in many cases due to the limited number of active antimicrobials available, the paucity of remaining vascular access sites, and the need to continue hemodialysis to sustain life. Infection prevention, therefore, is key. Currently, there is a movement in this country to increase the use of AV fistulae and diminish the use of prosthetic vascular grafts and catheters for chronic hemodialysis use due to increased infection risks with the latter two devices. Circulation 2003;108:

44 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 The incidence of peripheral vascular stent or stent-graft infection is extremely low, but because so many are placed in patients in this country annually at an increasing rate, the number of stent infections is increasing. Most infections become apparent within 4 weeks of placement and likely reflects the aggressive nature of the predominant pathogen, S. aureus. Circulation 2003;108:

45 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 Serious complications are seen with peripheral vascular stent and stent-graft infections. Aggressive surgical treatment is required for cure and includes stent resection and often extra-anatomic revascularization. Because of the extremely low incidence of infection, primary prophylaxis is not routinely recommended, but has been used in certain patients who are considered high-risk for infection, including those with diabetes mellitus. Circulation 2003;108:

46 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) Wound infection at the insertion site and device infection can complicate intra-aortic balloon counterpulsation catheter use. Bacteremia is seen and several purported risk factors for infection have been theorized. Circulation 2003;108:

47 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 Coronary angiography with percutaneous transluminal coronary angiography (PTCA) is done appropriately 900,000 times annually worldwide. The incidence of procedure-related infection, which can include bacteremia, is <1%. Circulation 2003;108:

48 Coronary Angiography and PTCA
Risk factors Brachial artery access Cutdown approach Repeat puncture (ipsilateral) Prolonged indwelling FA sheath Pressurized heparin solution Older age CHF There are several risk factors for the development of infection complicating PTCA and are listed on this slide. Circulation 2003;108:

49 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 Staphylococcal species account for most of these infections. CT scanning or angiography is used to evaluate for vascular infectious complications. Aneurysms usually require surgical resection or ligation. Circulation 2003;108:

50 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 Coronary artery stent infection is extremely rare and to date only 5 cases have been described. In all cases, the “incubation period” was short (< 4 weeks). Three stent infections were due to S. aureus and 2 were due to P. aeruginosa. Three of the 5 patients died. Circulation 2003;108:

51 Vascular Closure Devices (VCD)
FDA (USA) approval - 5 devices Favored over manual compression or compression devices Decrease time to hemostasis, increased patient comfort Incidence of infection < 1.9% Two concerns VCD > manual compression Infections more severe, more difficult to treat (often surgical intervention) Five different vascular closure devices have been approved by the FDA presently and the incidence of infection is 1.9% or less. When compared to infection risks following use of manual compression to achieve hemostasis, vascular closure devices increase both the infection risk and the severity of infection at the artery access site. Circulation 2003;108:

52 Vascular Closure Devices (VCD)
Microbiology S. aureus Methicillin-resistant Risk Diabetes mellitus? Prophylaxis for this group and for vascular access per prosthetic graft S. aureus accounts for the large majority of closure device infections. No risk factor analysis has been conducted probably due the infrequency of infection and the relatively recent adoption of use of this device. Circulation 2003;108:

53 Dacron Carotid Patches
Incidence of infection = 0.33% - 1.8% Local (cervical) findings Early (< 3 months) Cellulitis, abscess, sepsis, pseudoaneurysm, massive hemorrhage, patch dehiscence Late Sinus tracts with drainage, pseudoaneurysm The incidence of Dacron carotid patch infection ranges from 0.33% to 1.8% and local (cervical) findings predominant. Clinical onset of infection occurs “early” or “late” and the presentations can differ. Circulation 2003;108:

54 Dacron Carotid Patches
Microbiology Both viridans group streptococci and S.aureus predominate early; late infections - coagulase-negative staphylococci Treatment Surgical Usually patch removal Outcome Overall good Both viridans group streptococci and S. aureus are commonly identified as pathogens in “early” infection. Coagulase-negative staphylococci predominate (~80%) in “late” patch infections. Surgical removal of the infected patch is usually done and outcomes have been good. Circulation 2003;108:

55 Vena Caval Filters ~30 years in use, 10 filters available (USA)
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 Despite 30 years of use, vena caval filter infection is extremely rare. Only 3 proven and 2 suspect cases have been reported. All 5 cases were due to staphylococcal species and 3 patients were cured with device removal and antibiotic treatment. Circulation 2003;108:

56 Conclusions 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 Development of medical devices has greatly enhanced our ability to care for patients with CV diseases. These devices have not only extended the life span of patients, but also have improved quality of life. For some patients, the benefits of device availability are not fully realized because of complicating device infection. These infections are often severe and, in some cases, life threatening. Cure of infection may be difficult to achieve if removal of the infected device is not a treatment option. Thus, future developments should be directed at designing devices that are more resistant to infection and identifying antimicrobial agents that have enhanced activity in clearing infection from these indwelling medical devices. Methyl-silicone surface layers under development may minimize the accumulation of platelets, fibrinogen, and white blood cells, thus reducing the mass of debris that is an excellent substrate for growth of microorganisms on biomaterials. Also, there is the expected future availability of staphylococcal vaccines, which would make preoperative use of active or passive immunization feasible. CV device infections will continue to present critical clinical challenges that demand vigilance and attention to changing materials, design, and patient characteristics for best outcomes. Circulation 2003;108:


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