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Arrhythmias and sudden death
Original research article
Clinical presentation of CIED infection following initial implant versus reoperation for generator change or lead addition
  1. Mariko W Harper1,
  2. Daniel Z Uslan2,
  3. Arnold J Greenspon3,
  4. Larry M Baddour4,
  5. Roger G Carrillo5,
  6. Stephan B Danik6,
  7. Jose M Tolosana7,
  8. Katherine Le4,
  9. Jose M Miro7,
  10. Christoph K Naber8,
  11. James Peacock Jr.9,
  12. Muhammad Rizwan Sohail4,
  13. Holenarasipur R Vikram10 and
  14. Jordan M Prutkin1
  15. for the MEDIC Investigators
    1. 1 Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
    2. 2 Division of Infectious Diseases, Department of Medicine, UCLA, Los Angeles, California, USA
    3. 3 Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
    4. 4 Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
    5. 5 Division of Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
    6. 6 Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
    7. 7 Infectious Diseases Service, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
    8. 8 Klinik für Kardiologie und Angiologie, Elisabeth Krankenhaus, Essen, Germany
    9. 9 Section on Infectious Diseases, Department of Medicin, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
    10. 10 Division of Infectious Diseases, Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
    1. Correspondence to Dr Jordan M Prutkin; jprutkin{at}cardiology.washington.edu

    Abstract

    Objective To explore differences in clinical manifestations and outcomes in those patients who develop infection after undergoing initial implantation versus reoperation.

    Methods We compared cases of cardiac implantable electronic device (CIED) infection based on initial implantation versus reoperation from 11 centres.

    Results There were 432 patients with CIED infection, 178 occurring after initial device placement and 254 after repeat reoperation. No differences were seen in age, sex or device type. Those with infection after initial implant had a higher Charlson Comorbidity Score (median 3 (IQR 2–6) vs 2 (IQR 1–4), p<0.001), shorter time since last procedure (median 8.9 months (IQR 0.9–33.3) vs 19.5 months (IQR 1.1–62.9), p<0.0001) and fewer leads (2.0±0.6vs 2.5±0.9, p<0.001). Pocket infections were more likely to occur after a reoperation (70.1%vs48.9%, p<0.001) and coagulase negative staphylococci (CoNS) was the most frequently isolated organism in this group (p=0.029). In contrast, initial implant infections were more likely to present with higher white cell count (10.5±5.1 g/dL vs 9.5±5.4 g/dL, p=0.025), metastatic foci of infection (16.9%vs8.7%, p=0.016) and sepsis (30.9%vs19.3%, p=0.006). There were no differences in in-hospital (7.9%vs5.2%, p=0.31) or 6-month mortality (21.9%vs14.0%, p=0.056).

    Conclusions CIED infections after initial device implant occur earlier, more aggressively, and often due to Staphylococcus aureus. In contrast, CIED infections after reoperation occur later, are due to CoNS, and have more indolent manifestations with primary localisation to the pocket.

    • permanent pacemaker
    • implantable cardioverter-defibrillator
    • endocarditis

    This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

    https://doi.org/10.1136/openhrt-2017-000681

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      Footnotes

      • Contributors All the authors were actively involved in the planning, conduct and reporting of this original work.

      • Funding This study was funded, in part, by a grant from the American Heart Association (DZU, Primary Investigator). Data from the Hospital Clinic of Barcelona (Spain) were supported in part by a grant from the ‘Ministerio de Sanidad y Consumo’, the ‘Instituto de Salud Carlos III’ and the Spanish Network for the Research in Infectious Diseases (REIPI RD06/0008), Madrid (Spain).

      • Competing interests None declared.

      • Patient consent Obtained.

      • Ethics approval The local Institutional Review Board at each site approved the study protocol.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Collaborators JMP (University of Washington, Seattle, WA, USA), DZU (UCLA, Los Angeles, CA, USA), AJG (Thomas Jefferson University Hospital, Philadelphia, PA), MRS, LMB, KL (Mayo Clinic College of Medicine, Rochester, MN, USA), RGC (University of Miami, Miami, FL, USA), SBD (Massachusetts General Hospital, Boston, MA, USA), JMT, JMM, S Ninot, A del Rio X Castañeda, F Marco, C García de la María, C Cervera, Y Armero, M Almela, C Paré, A Moreno, L Mont and C Mestres (Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain). Elisabeth Blank, CKN (Elisabeth Krankenhaus, Essen, Germany), JP (Wake Forest School of Medicine, Winston-Salem, NC, USA), HRV (Mayo Clinic, Phoenix, AZ, USA).