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• W2113990419 abstract "HomeCirculationVol. 121, No. 15Cardiac Device Infection—or Not Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBCardiac Device Infection—or Not Larry M. Baddour Larry M. BaddourLarry M. Baddour From the Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minn. Search for more papers by this author Originally published5 Apr 2010https://doi.org/10.1161/CIR.0b013e3181de0334Circulation. 2010;121:1686–1687Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 5, 2010: Previous Version 1 Tremendous gains in our understanding of cardiovascular implantable electronic device (CIED) infection were achieved over the past decade. The investigative efforts that led to these achievements were prompted largely by an increasing rate of device infection, which has been considerably higher than expected on the basis of the increasing rate of device placement.1–3 This observation was somewhat unanticipated in view of the generalized incorporation of strict infection control and prevention practices during the perioperative period of device placement and the routine use of preoperative antibiotic administration as surgical site prophylaxis that characterize the current practice. From data generated from epidemiological and case-control analyses,3–5 we now recognize that much of the increasing rate of CIED infection is likely multifactorial in cause and involves both host- and device-related factors. These include device placement in older and sicker patients and the implantation of more “hardware” (leads), which can require a longer intervention time.Article see p 1691The increasing rate of CIED infection over the past decade prompted the American Heart Association (AHA) to develop a scientific statement4 that was published earlier this year that specifically addresses CIED infection and provides recommendations for its management. This, coupled with an updated version of the American College of Cardiology/AHA/Heart Rhythm Society document,6 was drafted to assist clinicians who care for patients with these devices.Of note, the AHA’s CIED infection document4 included a Class III recommendation to avoid microbiological studies in cases of CIED removal for noninfectious reasons. Previous work7 has demonstrated the common (≈25%) occurrence of positive pocket tissue and swab cultures from patients who undergo CIED revision and have no other evidence of device infection. These culture results have the potential for prompting unnecessary diagnostic and therapeutic interventions, including device removal. In general, it has been the assumption that contamination during device extraction and/or during the processing of a specimen for culture likely has resulted in “false-positive” results.But are there cases in which microorganisms colonize a device and cause no evidence of infection? In other words, are positive cultures obtained in some of the “noninfected” cases actually “true” positives rather than the result of exogenous contamination?Rohacek and colleagues8 provide a detailed examination of the hypothesis of device colonization and its clinical implications in this issue of the journal. The investigators used a sonication technique to increase the sensitivity of device culture results. Consecutive adult patients who underwent removal of a CIED were included in their prospective observational investigation conducted in a single tertiary care medical center in Switzerland. Overall, 68 permanent pacemakers and 53 implantable cardioverter-defibrillators were evaluated in the microbiology laboratory. The bulk of them (84%) were removed for insufficient battery charge, and 115 (95%) were removed in noninfected cases. In 44 (38%) of the 115 explanted devices, sonication fluid grew bacteria. Interestingly, the positive culture yield was more than twice that for implantable cardioverter-defibrillators (56%) compared with that of permanent pacemakers (25%). Propionibacterium acnes and coagulase-negative staphylococci predominated among the culture isolates. During follow-up, the incidence of subsequent device infection among those with the 44 sonicate fluid culture–positive devices was 4.5% (95% confidence interval, 0.6 to 15.5).The topic of CIED colonization in asymptomatic patients has received recent attention by 2 additional groups of investigators. Pichlmaier and coworkers9 used a bacterial DNA detection technique and identified DNA in 30% of biofilm samples that were collected from the surface of devices extracted from patients with no other evidence of infection. Kleeman and colleagues,10 in a separate study, examined patients with extracted implantable cardioverter-defibrillators who had no clinical evidence of infection and demonstrated bacterial growth from cultures of the generator pocket and leads in one third of cases. During a median follow-up time of 203 days after device revision, 7.5% of patients with a previous positive culture subsequently developed device infection.Our past clinical experience with CIED infection supports the notion that asymptomatic colonization actually does occur, at least in some cases, for an extended period of time. We know from surgical site prophylaxis studies11,12 and case-control analyses13,14 that contamination of a device occurs in the perioperative setting and that administering preoperative antibiotic prophylaxis reduces infection risk. Despite presumed device contamination at the time of implantation, clinical signs and symptoms of infection may not appear for weeks to months later in a small portion of patients who undergo device placement.A second, but possibly related, phenomenon is the observation that generator pocket cultures can be positive despite the lack of inflammatory changes on the skin surface of the pocket site on physical examination in a minority of patients with other evidence, including bacteremia, of CIED infection.15,16What are the interactions among host, device, and microbe that permit a colonization phase? What are the pathogenesis factors that are operative in prompting a transition from colonization to infection? Clearly, not all devices that are colonized become infected. The colonization rate of ≈33% demonstrated in the 3 investigations published to date8–10 is >10-fold greater than the expected rate of device infection. Klug et al,17 in an editorial accompanying the Kleemann et al10 article, reviewed the theory of achieving a balance between host immunity and microorganism that permits a sustained state of colonization. They raised as an example the possibility that small colony variation among staphylococcal species could be operative in securing a colonization phase. Concerns regarding phenotypic variation with small colony formation among coagulase-negative staphylococci and pathogenic mechanisms involved in the production of CIED infection were highlighted 2 decades ago.18What are the clinical implications of CIED colonization? Currently, a “formal” acknowledgment of the fact that device colonization occurs is reasonable. This does not, however, dictate a change in our current patient management schemes. Moreover, our support for the CIED guidelines published by the AHA this year4 should not waver despite this formal acknowledgment; routine cultures should not be obtained in noninfected cases in which device removal or exchange is done. It is our expectation that more investigation will yield a better understanding of the pathogenic mechanisms involved in the development of device infection and elucidation of factors that are operative in prompting a switch from mere colonization to active infection. In addition, work should proceed to define the subset of patients with colonized devices who are at increased risk of subsequent CIED infection.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to Larry M. Baddour, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail [email protected] References 1 Cabell CH, Heidenreich PA, Chu VH, Moore CM, Stryjewski ME, Corey GR, Fowler VG Jr. Increasing rates of cardiac device infections among Medicare beneficiaries: 1990–1999. Am Heart J. 2004; 147: 582–586.CrossrefMedlineGoogle Scholar2 Voight A, Shalaby A, Saba S. Rising rates of cardiac rhythm management device infections in the United States: 1996–2003. J Am Coll Cardiol. 2006; 48: 590–591.CrossrefMedlineGoogle Scholar3 Voight A, Shalaby A, Saba S. Continued rise in the rates of cardiovascular implantable electronic device infections in the United States: temporal trends and causative insights. Pacing Clin Electrophysiol. September 30, 2009. DOI: 10.1111/j.1540-8159.2009.02569.x. Accessed March 23, 2010.Google Scholar4 Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB, Masoudi FA, Okum EJ, Wilson WR, Beerman LB, Bolger AF, Estes M III, Gewitz M, Newburger JW, Schron EB, Taubert KA. Update on cardiovascular implantable electronic device infections and their management: a Scientific Statement from the American Heart Association. Circulation. 2010; 121: 458–477.LinkGoogle Scholar5 Uslan DZ, Tleyjeh IM, Baddour LM, Friedman PA, Jenkins SM, St Sauver JL, Hayes DL. Temporal trends in permanent pacemaker implantation: a population-based study. Am Heart J. 2008; 155: 896–903.CrossrefMedlineGoogle Scholar6 Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH III, Epstein LM, Friedman RA, Kennergren CE, Mitkowski P, Schaerf RH, Wazni OM. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management. Heart Rhythm. 2009; 6: 1085–1104.CrossrefMedlineGoogle Scholar7 Chua JD, Abdul-Karim A, Mawhorter S, Procop GW, Tchou P, Niebauer M, Saliba W, Schweikert R, Wilkoff BL. The role of swab and tissue culture in the diagnosis of implantable cardiac device infection. Pacing Clin Electrophysiol. 2005; 28: 1276–1281.CrossrefMedlineGoogle Scholar8 Rohacek M, Weisser M, Kobza R, Schoenenberger AW, Pfyffer GE, Frei R, Erne P, Trampuz A. Bacterial colonization and infection of electrophysiological cardiac devices detected with sonication and swab culture. Circulation. 2010; 121: 1691–1697.LinkGoogle Scholar9 Pichlmaier M, Marwitz V, Kuhn C, Niehaus M, Klein G, Bara C, Haverich A, Abraham WR. High prevalence of asymptomatic bacterial colonization of rhythm management devices. Europace. 2008; 10: 1067–1072.CrossrefMedlineGoogle Scholar10 Kleemann T, Becker T, Strauss M, Dyck N, Weisse U, Saggau W, Burkhardt U, Seidl K. Prevalence of bacterial colonization of generator pockets in implantable cardioverter defibrillator patients without signs of infection undergoing generator replacement or lead revision. Europace. 2010; 12: 58–63.CrossrefMedlineGoogle Scholar11 Da Costa A, Kirkorian G, Cucherat M, Delahaye F, Chevalier P, Cerisier A, Isaaz K, Touboul P. Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis. Circulation. 1998; 97: 1798–1801.Google Scholar12 de Oliveira JC, Martinelli M, D'Orio Nishioka SA, Varejão T, Uipe D, Pedrosa AA, Costa R, D'Avila A, Danik SB. Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter-defibrillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial. Circ Arrhythm Electrophysiol. 2009; 2: 29–34.LinkGoogle Scholar13 Sohail MR, Uslan DZ, Khan AH, Friedman PA, Hayes DL, Wilson WR, Steckelberg JM, Stoner SM, Baddour LM. Risk factor analysis of permanent pacemaker infection. Clin Infect Dis. 2007; 45: 166–173.CrossrefMedlineGoogle Scholar14 Klug D, Balde M, Pavin D, Hidden-Lucet F, Clementy J, Sadoul N, Rey JL, Lande G, Lazarus A, Victor J, Barnay C, Grandbastien B, Kacet S. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study. Circulation. 2007; 116: 1349–1355.LinkGoogle Scholar15 Chamis AL, Peterson GE, Cabell CH, Corey GR, Sorrentino RA, Greenfield RA, Ryan T, Reller LB, Fowler VG Jr. Staphylococcus aureus bacteremia in patients with permanent pacemakers or implantable cardioverter-defibrillators. Circulation. 2001; 104: 1029–1033.CrossrefMedlineGoogle Scholar16 Sohail MR, Uslan DZ, Khan AH, Friedman PA, Hayes DL, Wilson WR, Steckelberg JM, Stoner S, Baddour LM. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol. 2007; 49: 1851–1859.CrossrefMedlineGoogle Scholar17 Klug D, Wallet F, Kacet S, Courcol R. Positive cultures in asymptomatic patients during elective device replacement: a murderer hides in the darkness or an innocent person on the crime scene? Europace. 2010; 12: 5–6.CrossrefMedlineGoogle Scholar18 Baddour LM, Barker LP, Christensen GD, Parisi JT, Simpson WA. Phenotypic variation of Staphylococcus epidermidis in infection of transvenous endocardial pacemaker electrodes. J Clin Microbiol. 1990; 28: 676–679.CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Khubrani R, Alghamdi A, Alsubaie A, Alenazi T, Almutairi A and Alsunaydi F Rate of Cardiovascular Implantable Electronic Device-Related Infection at a Tertiary Hospital in Saudi Arabia: A Retrospective Cohort Study, Cureus, 10.7759/cureus.27078 Okuda K, Nagahori R, Yamada S, Sugimoto S, Sato C, Sato M, Iwase T, Hashimoto K and Mizunoe Y (2018) The Composition and Structure of Biofilms Developed by Propionibacterium acnes Isolated from Cardiac Pacemaker Devices, Frontiers in Microbiology, 10.3389/fmicb.2018.00182, 9 Nagpal A, Patel R, Greenwood-Quaintance K, Baddour L, Lynch D, Lahr B, Maleszewski J, Friedman P, Hayes D and Sohail M (2015) Usefulness of Sonication of Cardiovascular Implantable Electronic Devices to Enhance Microbial Detection, The American Journal of Cardiology, 10.1016/j.amjcard.2015.01.017, 115:7, (912-917), Online publication date: 1-Apr-2015. Graziosi M, Nanni C, Lorenzini M, Diemberger I, Bonfiglioli R, Pasquale F, Ziacchi M, Biffi M, Martignani C, Bartoletti M, Tumietto F, Boriani G, Viale P, Fanti S and Rapezzi C (2014) Role of 18F-FDG PET/CT in the diagnosis of infective endocarditis in patients with an implanted cardiac device: a prospective study, European Journal of Nuclear Medicine and Molecular Imaging, 10.1007/s00259-014-2773-z, 41:8, (1617-1623), Online publication date: 1-Aug-2014. De Maria E, Diemberger I, Vassallo P, Pastore M, Giannotti F, Ronconi C, Romandini A, Biffi M, Martignani C, Ziacchi M, Bonfatti F, Tumietto F, Viale P and Boriani G (2014) Prevention of infections in cardiovascular implantable electronic devices beyond the antibiotic agent, Journal of Cardiovascular Medicine, 10.2459/JCM.0000000000000008, 15:7, (554-564), Online publication date: 1-Jul-2014. Alagna L, Park L, Nicholson B, Keiger A, Strahilevitz J, Morris A, Wray D, Gordon D, Delahaye F, Edathodu J, Miró J, Fernández-Hidalgo N, Nacinovich F, Shahid R, Woods C, Joyce M, Sexton D and Chu V (2014) Repeat endocarditis: analysis of risk factors based on the International Collaboration on Endocarditis – Prospective Cohort Study, Clinical Microbiology and Infection, 10.1111/1469-0691.12395, 20:6, (566-575), Online publication date: 1-Jun-2014. Werdan K, Dietz S, Löffler B, Niemann S, Bushnaq H, Silber R, Peters G and Müller-Werdan U (2013) Mechanisms of infective endocarditis: pathogen–host interaction and risk states, Nature Reviews Cardiology, 10.1038/nrcardio.2013.174, 11:1, (35-50), Online publication date: 1-Jan-2014. Oliva A, Nguyen B, Mascellino M, D'Abramo A, Iannetta M, Ciccaglioni A, Vullo V and Mastroianni C (2013) Sonication of Explanted Cardiac Implants Improves Microbial Detection in Cardiac Device Infections, Journal of Clinical Microbiology, 10.1128/JCM.02230-12, 51:2, (496-502), Online publication date: 1-Feb-2013. Nagpal A, Baddour L and Sohail M (2012) Microbiology and Pathogenesis of Cardiovascular Implantable Electronic Device Infections, Circulation: Arrhythmia and Electrophysiology, 5:2, (433-441), Online publication date: 1-Apr-2012. Deharo J, Bongiorni M, Rozkovec A, Bracke F, Defaye P, Fernandez-Lozano I, Golzio P, Hansky B, Kennergren C, Manolis A, Mitkowski P, Platou E, Love C and Wilkoff B (2011) Pathways for training and accreditation for transvenous lead extraction: a European Heart Rhythm Association position paper, Europace, 10.1093/europace/eur338, 14:1, (124-134), Online publication date: 1-Jan-2012. (2011) Current World Literature, Current Opinion in Cardiology, 10.1097/HCO.0b013e32834294db, 26:1, (71-78), Online publication date: 1-Jan-2011. Oliva A, Belvisi V, Iannetta M, Andreoni C, Mascellino M, Lichtner M, Vullo V and Mastroianni C (2010) Pacemaker Lead Endocarditis Due to Multidrug-Resistant Corynebacterium striatum Detected with Sonication of the Device , Journal of Clinical Microbiology, 10.1128/JCM.01532-10, 48:12, (4669-4671), Online publication date: 1-Dec-2010. Deresinski S (2010) Bacterial Colonization of Implantable Cardiovascular Electronic Devices, Clinical Infectious Diseases, 10.1093/cid/51.3.iii, 51:4, (iii-iv), Online publication date: 15-Aug-2010. April 20, 2010Vol 121, Issue 15 Advertisement Article InformationMetrics https://doi.org/10.1161/CIR.0b013e3181de0334PMID: 20368526 Originally publishedApril 5, 2010 KeywordsEditorialsdefibrillationpacemakersinfectionPDF download Advertisement SubjectsEtiologyPacemaker" @default.
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