ClinicalDevicesStaphylococcus bacteremia without evidence of cardiac implantable electronic device infection
Graphical abstract
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
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Cited by (10)
Risk of cardiac device-related infection in patients with late-onset bloodstream infection. Analysis on a National Cohort
2022, Journal of InfectionCitation Excerpt :Up to now, S. aureus had been identified as risk factor for CDRI in a cohort of S. aureus and Gram-negative bacteraemia [8] and as one of the most frequent causative species of CDRI, both in generator pocket and endovascular infections [19]. In contrast, we observed a very low incidence of CDRI in patients with Gram-negative-BSI suggesting that haematogenous seeding produced by Gram-negative strains in late-onset-BSI is rare [20]. Some prior studies had described also low incidence of CDRI in Gram-negative bacteraemia; however, they reported mainly generator pocket infections and, when described, almost half of the patients presented early-onset-BSI [8,10].
Evaluation of European Heart Rhythm Association consensus in patients with cardiovascular implantable electronic devices and Staphylococcus aureus bacteremia
2022, Heart RhythmCitation Excerpt :Apart from an adequate antimicrobial therapy, complete CIED extraction has been a standard of care and critical management for CIED infection as recommended by multiple guidelines. Surprisingly, CIED extraction may even provide a survival benefit regardless of CIED infection status.27 Our study reiterated the survival benefit of CIED extraction in the definite infection group, which was associated with an 83% reduction in the risk of 1-year mortality.
Rate of permanent cardiac implantable electronic device infections after active fixation temporary transvenous pacing: A nationwide Danish cohort study
2022, Heart Rhythm O2Citation Excerpt :However, abandonment of extraction owing to frailty is less likely in our patients, as follow-up was restricted to 1 year. Secondly, CIED infections remain a challenging diagnosis, as clinical evidence of CIED involvement may be absent.21 The evidence base for management of occult septicemia with pathogens associated with CIED infections is sparse, and choice of treatment may have relied on institutional guidelines or physician preference.
Fighting the invisible enemy
2021, Heart RhythmInfective Endocarditis Involving Implanted Cardiac Electronic Devices: JACC Focus Seminar 1/4
2024, Journal of the American College of CardiologyFactors associated with foreign body infection in methicillin-resistant Staphylococcus aureus bacteremia
2024, Frontiers in Immunology
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.