Elsevier

Heart Rhythm

Volume 18, Issue 5, May 2021, Pages 752-759
Heart Rhythm

Clinical
Devices
Staphylococcus bacteremia without evidence of cardiac implantable electronic device infection

https://doi.org/10.1016/j.hrthm.2020.12.011Get rights and content

Background

Staphylococcus bacteremia (SB) in the presence of a cardiac implantable electronic device (CIED) is frequently associated with CIED infection. In patients without clear CIED infection but SB, the role of empirical CIED removal is unclear.

Objective

The purpose of this study was to describe the natural history of SB in the setting of a CIED and the effect of CIED removal on mortality in patients with concurrent SB without evidence of CIED infection.

Methods

Three hundred sixty consecutive patients (mean age 61 ± 17 years; 255 (71%) men; 329 (92%) Staphylococcus aureus) with a CIED and concurrent SB were reviewed.

Results

At the initial presentation with SB, 178 patients had no evidence of CIED infection. Of these, 132 (74%) had another identified source of infection. Among the 178 patients without CIED infection, 18 (10%) had empirical CIED removal during the initial bacteremia. Among those who did not undergo CIED removal, SB subsequently relapsed in 19% and relapse rates were not different for those with or without another identifiable source at the initial presentation. Relapse was strongly associated with the duration of SB >1 day (odds ratio 9.99; 95% confidence interval 3.24–30.86). Despite the absence of CIED infection, 1-year mortality was 35% and empirical device removal during the initial presentation was associated with survival benefit (hazard ratio 0.28; 95% confidence interval 0.08–0.95).

Conclusion

For patients with SB without evidence of CIED infection, relapse is predicted by the duration of bacteremia. Empirical CIED removal appears to be associated with a survival benefit, although there are likely clinical situations in which this could be deferred.

Introduction

Staphylococcus aureus and coagulase-negative Staphylococcus (CoNS) are among the most common and virulent causes of cardiac implantable electronic device (CIED) infections.1,2 Staphylococcal pathogens have a high affinity for polymer surfaces, and their ability to form a protective biofilm can lead to treatment failure in CIED infections when antibiotics alone are used without device removal.3,4 Consequently, the American Heart Association and Heart Rhythm Society statements recommend complete device removal in all patients with established staphylococcal CIED infections.5,6 Importantly, the diagnosis of CIED infection is difficult to make in the absence of local signs and symptoms or visible lead/valvular vegetations on echocardiography, which may explain the focus of prior studies on patients who prove to have CIED infections compared with those without.1,7,8 Because of the high virulence, high likelihood of CIED involvement, and presumed difficulty clearing the infection, the current Heart Rhythm Society consensus statement and a systematic review also recommend complete CIED removal even in patients with occult Staphylococcus bacteremia (SB) (no identifiable source) without definite CIED infection.6,9 However, this recommendation is based on limited evidence.

In this study we sought to assess the rate and outcomes in patients with SB and no evidence of CIED infection at the initial presentation. Furthermore, we sought to assess the effect of empirical device removal at the initial presentation on mortality in the hope of providing an insight into appropriate clinical management.

Section snippets

Study population

All consecutive patients with a CIED and SB who presented to Vanderbilt University Medical Center between 2000 and 2018 were identified retrospectively using the Vanderbilt Research Derivative data repository screening for patient records using “PheWAS” phenotypic code groups for the presence of pacemakers or defibrillators, bacteremia, and sepsis as well as all International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes for SB.10

Study population

During the 216-month study period, a total of 360 patients with a CIED and concurrent SB (mean age 61 ± 17 years; 255 (71%) men) were eligible for inclusion. The baseline clinical characteristics of the study patients are summarized in Table 1. At the initial presentation, 178 of the 360 patients (49.4%) with SB and a CIED had no evidence of CIED infection. Those included 132 (74%) with an identified non-CIED source of infection and 46 (26%) with an unknown primary focus of the infection.

Discussion

The main findings of our study on the clinical significance of SB in patients with a CIED can be summarized as follows: (1) 49% of patients with SB demonstrated no evidence of CIED infection at the time of initial presentation, and these patients had a 35% 1-year mortality; (2) bacteremia relapsed in ∼20% of patients without initial evidence of CIED infection who survived to discharge and did not undergo empirical CIED removal, of whom 48% (13 of 27) developed definite CIED infection at the

Conclusion

Among patients with a CIED and SB, approximately half lack the clinical evidence of CIED infection. In the absence of detected CIED infection, the duration of bacteremia is strongly predictive of relapse if the CIED is not removed, with 1 day of bacteremia having only a 5% chance of relapse. Empirical CIED removal was associated with decreased mortality, though given the low risk of relapse, there are likely clinical situations (high procedural risk due to old leads and patient dependence on

References (15)

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Funding sources: This project was supported by Clinical Translation Science Award no. UL1TR000445 from the National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health. Drs Nakajima and Narui have received a scholarship from the Japanese Heart Rhythm Society.

Disclosures: Dr Stevenson has received speaking honoraria from Abbott Medical, Boston Scientific, and Medtronic. Dr Ellis has received research funding from Medtronic, AtriCure, Thoratec, and Boston Scientific and consulting fees from Medtronic, Sentre Heart, Spectranetics, Biosense Webster, Boston Scientific, and AtriCure. Dr Crossley has served as a consultant for Medtronic and Boston Scientific and as a speaker for Medtronic. Dr Montgomery has served as a consultant for Medtronic. The rest of the authors report no conflicts of interest.

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