Nonvalvular Cardiovascular Device–Related Infections Larry M. Baddour, Michael A. Bettmann, Ann F....

Nonvalvular Cardiovascular Nonvalvular Cardiovascular Device–Related InfectionsDevice–Related Infections

Larry M. Baddour, Michael A. Bettmann, Ann F. Larry M. Baddour, Michael A. Bettmann, Ann F. Bolger, Andrew E. Epstein, Patricia Ferrieri, Bolger, Andrew E. Epstein, Patricia Ferrieri, Michael A. Gerber, Michael H. Gewitz, Alice K. Michael A. Gerber, Michael H. Gewitz, Alice K. Jacobs, Matthew E. Levison, Jane W. Newburger, Jacobs, Matthew E. Levison, Jane W. Newburger, Thomas J. Pallasch, Walter R. Wilson, Robert S. Thomas J. Pallasch, Walter R. Wilson, Robert S. Baltimore, Donald A. Falace, Stanford T. Shulman, Baltimore, Donald A. Falace, Stanford T. Shulman, Lloyd Y. Tani, Kathryn A. TaubertLloyd Y. Tani, Kathryn A. Taubert

Circulation. 2003;108:2015-2031.

AHA Scientific Statement:AHA Scientific Statement:

From the Committee on Rheumatic Fever, From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, American Heart Endocarditis and Kawasaki Disease, American Heart

AssociationAssociation

Nonvalvular Cardiovascular Nonvalvular Cardiovascular Device-Related InfectionsDevice-Related Infections• AHA scientific statementAHA scientific statement– Circulation 2003;108:2015-2031Circulation 2003;108:2015-2031

First editionFirst edition ““Encyclopedic”Encyclopedic” Excludes intravascular cathetersExcludes intravascular catheters Full statement available on the web at Full statement available on the web at

http://circ.ahajournals.org/cgi/content/full/108/http://circ.ahajournals.org/cgi/content/full/108/16/2015 16/2015

Nonvalvular Cardiovascular Nonvalvular Cardiovascular Device-Related InfectionsDevice-Related Infections

Type of DevicesType of Devices Incidence of Infection %Incidence of Infection %

IntracardiacIntracardiacPacemakers…………………………………..Pacemakers………………………………….. 0.13-19.90.13-19.9Defibrillators………………………………….Defibrillators…………………………………. 0.00-3.20.00-3.2LVADs………………………………………….LVADs…………………………………………. 25-7025-70Total artificial hearts (TAH)…………….Total artificial hearts (TAH)……………. To be determinedTo be determinedVentriculoatrial shunts……………………..Ventriculoatrial shunts…………………….. 2.4-9.42.4-9.4Pledgets……………………………………….Pledgets………………………………………. RareRarePatent ductus arteriosus (PDA)Patent ductus arteriosus (PDA) occlusion devices…………………………. occlusion devices…………………………. RareRareAtrial septal defect (ASD) and ventricularAtrial septal defect (ASD) and ventricular septal defect (VSD) closure devices……. septal defect (VSD) closure devices……. RareRareConduits……………………………………….Conduits………………………………………. RareRarePatches…………………………………………Patches………………………………………… RareRare

Circulation 2003;108:2015-2031Circulation 2003;108:2015-2031

Type of DevicesType of Devices Incidence of Infection %Incidence of Infection %

Intra-arterialIntra-arterialPeripheral vascular stents……………………Peripheral vascular stents…………………… RareRareVascular grafts, including Vascular grafts, including hemodialysis………………………………….. hemodialysis………………………………….. 1.0-61.0-6Intra-aortic balloon pumps……………………Intra-aortic balloon pumps…………………… << 5-26 5-26Angioplasty/angiography-relatedAngioplasty/angiography-related bacteremias……………………………………. bacteremias……………………………………. < 1*< 1*Coronary artery stents…………………………Coronary artery stents………………………… RareRarePatches……………………………………………Patches…………………………………………… 1.81.8

IntravenousIntravenousVena caval filters………………………………..Vena caval filters……………………………….. RareRare

**Closure device use Closure device use << 1.9% 1.9%



Nonvalvular Cardiovascular Nonvalvular Cardiovascular Device-Related InfectionsDevice-Related InfectionsAHA Scientific StatementAHA Scientific Statement

-- -- Specific devicesSpecific devices IntracardiacIntracardiac Intra-arterialIntra-arterial IntravenousIntravenous


---- General principlesGeneral principles Clinical Clinical

manifestationsmanifestations MicrobiologyMicrobiology

PathogenesisPathogenesis DiagnosisDiagnosis Treatment Treatment PreventionPrevention

Two broad sections:Two broad sections:


PathogenesisPathogenesis• Pathogen virulence factorsPathogen virulence factors– Adhesions (MSCRAMM)Adhesions (MSCRAMM)– BiofilmBiofilm

• Host response to the artificial deviceHost response to the artificial device– Abnormal flowAbnormal flow– Immunologic effectsImmunologic effects

• Physical/chemical device characteristicsPhysical/chemical device characteristics– Platelet, fibrinogen attachmentPlatelet, fibrinogen attachment



Clinical Manifestations• Depend on location of infected portion of Depend on location of infected portion of

devicedevice

– LocalLocal

– SystemicSystemic



MicrobiologyMicrobiology• Staphylococcal species predominateStaphylococcal species predominate– Multidrug resistance, including oxacillin - Multidrug resistance, including oxacillin -

frequentfrequent• Aerobic gram-negative bacilliAerobic gram-negative bacilli– Pseudomonas, Acinetobacter, SerratiaPseudomonas, Acinetobacter, Serratia species species

• FungiFungi– Candida Candida species - most common among fungispecies - most common among fungi– AspergillusAspergillus species - reported


Vascular graft site infection in a hemodialysis patientdue to methicillin-resistant S aureus. The patient suffered bacteremiain addition to focal skin and soft tissue changes at thegraft site, including erythema, swelling, warmth, and pain.



DiagnosisDiagnosis

• LaboratoryLaboratory– Specimen (blood, drainage, device) Specimen (blood, drainage, device)

culturescultures• RadiologicRadiologic– EchocardiographicEchocardiographic


Transesophageal echocardiographic view of the leftatrium (LA) and right atrium (RA). A pacemaker lead (filled arrow)is seen as it crosses the tricuspid valve. The lead is thickenedby infective material, and there is a round mobile vegetation(open arrow) attached to its right atrial portion.



Manifestation of InfectionManifestation of Infection Initial Imaging Initial Imaging ModalityModality

EndocarditisEndocarditis TEETEEPacemakers (temporary and permanent)Pacemakers (temporary and permanent)DefibrillatorsDefibrillatorsLVADsLVADsVentriculoatrial shuntsVentriculoatrial shuntsPledgetsPledgetsASD closure devicesASD closure devicesPatchesPatchesConduitsConduits PDA occlusion devices PDA occlusion devices

PericarditisPericarditis TTE or TEE TTE or TEECoronary artery stentsCoronary artery stentsPledgetsPledgets


TTE or TEETTE or TEE


PerivasculitisPerivasculitis CT or MRICT or MRIPeripheral vascular stentsPeripheral vascular stentsVascular grafts, including hemodialysisVascular grafts, including hemodialysisAngioplasty/angiography-relatedAngioplasty/angiography-related bacteremias bacteremiasCoronary artery stentsCoronary artery stentsPatchesPatches

Aneurysm or pseudoaneurysmAneurysm or pseudoaneurysm AngiographyAngiographyPledgetsPledgetsCoronary artery stentsCoronary artery stentsPatchesPatchesAngioplasty/angiography-relatedAngioplasty/angiography-related bacteremias bacteremiasVascular grafts, including hemodialysisVascular grafts, including hemodialysis





Infected thrombosisInfected thrombosis UltrasoundUltrasoundVena caval filterVena caval filterVascular grafts, including hemodialysisVascular grafts, including hemodialysis

Pocket site infectionsPocket site infections UltrasoundUltrasoundPacemakers (permanent)Pacemakers (permanent)DefibrillatorsDefibrillatorsLVADsLVADsTotal artificial heartsTotal artificial hearts


Nonvalvular Cardiovascular Nonvalvular Cardiovascular Device-Related Infections Device-Related Infections

TreatmentTreatment• AntimicrobialAntimicrobial– Acute (induction)Acute (induction)– Long-term (lifelong) suppressiveLong-term (lifelong) suppressive– Device replacement impregnationDevice replacement impregnation

• Device removalDevice removal– ““Percutaneous”Percutaneous”– SurgicalSurgical



TreatmentTreatment• Acute (induction)Acute (induction)– Bactericidal/fungicidalBactericidal/fungicidal– ParenteralParenteral– SelectionSelection

Based on pathogen Based on pathogen identification/susceptibility testingidentification/susceptibility testing

Host factors Host factors – DurationDuration

Variable depending on type of device Variable depending on type of device and location of infectionand location of infection


Nonvalvular Cardiovascular Nonvalvular Cardiovascular Device-Related Infections Device-Related Infections

TreatmentTreatment• Long-term (lifelong) suppressive therapyLong-term (lifelong) suppressive therapy– Infected device removal - not an optionInfected device removal - not an option– Response to acute treatment - clinically and Response to acute treatment - clinically and

microbiologicallymicrobiologically– Cardiovascular status - stableCardiovascular status - stable


Nonvalvular Cardiovascular Nonvalvular Cardiovascular Device-Related InfectionsDevice-Related InfectionsPrimary prophylaxisPrimary prophylaxis• Modeled after surgical site infection Modeled after surgical site infection

prophylaxis.prophylaxis.• Because of the low incidence of infection for Because of the low incidence of infection for

many of the devices, without evidence-based many of the devices, without evidence-based data.data.

• Routinely used: electrophysiological cardiac Routinely used: electrophysiological cardiac devices, VAD, TAH, VA shunts, pledgets, devices, VAD, TAH, VA shunts, pledgets, vascular grafts, and arterial patches.vascular grafts, and arterial patches.


Nonvalvular Cardiovascular Nonvalvular Cardiovascular Device-Related InfectionsDevice-Related InfectionsSecondary prophylaxisSecondary prophylaxis• Antibiotic prophylaxis is not recommended for Antibiotic prophylaxis is not recommended for

patients who undergo dental, respiratory, patients who undergo dental, respiratory, gastrointestinal or genitourinary procedures.gastrointestinal or genitourinary procedures.

• It is recommended for patients if they undergo It is recommended for patients if they undergo incision and drainage of infection at other sites incision and drainage of infection at other sites (eg, abscess) or replacement of an infected (eg, abscess) or replacement of an infected device.device.

• It is recommended for patients with residual It is recommended for patients with residual leak after device placement for attempted leak after device placement for attempted closure of the leak associated with PDA, ASD, closure of the leak associated with PDA, ASD, or VSDor VSD


Electrophysiologic DevicesElectrophysiologic Devices

• PacemakersPacemakers– Incidence of infection, 0.13%-19.9%Incidence of infection, 0.13%-19.9%

• Implantable cardioverter-defibrillators Implantable cardioverter-defibrillators (ICDs)(ICDs)– Incidence of infection, 0%-0.8%Incidence of infection, 0%-0.8%


Electrophysiologic DevicesElectrophysiologic Devices• Generator pocket - most common Generator pocket - most common

infection siteinfection site

• Lead infection Lead infection – ““Pacemaker endocarditis” Pacemaker endocarditis” – ~10% of pacemaker infections~10% of pacemaker infections– Most often due to generator pocket Most often due to generator pocket

infectioninfection


Electrophysiologic Devices Electrophysiologic Devices • Infection sourcesInfection sources– Generator pocket contamination at Generator pocket contamination at

implantationimplantation– Cutaneous erosion of generatorCutaneous erosion of generator– Hematogenous seeding Hematogenous seeding

(“late - onset infection”)(“late - onset infection”)


Electrophysiologic DevicesElectrophysiologic Devices• TreatmentTreatment

– Duration of therapy Duration of therapy No evidence-based dataNo evidence-based data Limited to generator site - ~ 10 daysLimited to generator site - ~ 10 days Lead infection - 2 to 6 weeks Lead infection - 2 to 6 weeks

– Device removal Device removal Paramount Reduce risk of infection relapse and Paramount Reduce risk of infection relapse and

mortalitymortality– Device replacementDevice replacement

TimingTimingVaried recommendations - at least wait Varied recommendations - at least wait

until bacteremia/fungemia cleareduntil bacteremia/fungemia clearedSome may not require/want device Some may not require/want device

replacementreplacement


• Lead removalLead removal– Greater difficulty if prolonged Greater difficulty if prolonged

implantation timeimplantation time– Techniques (nonsurgical)Techniques (nonsurgical)

81%-93% successful81%-93% successful 0%-3.3% complications0%-3.3% complications 0%-0.8% mortality0%-0.8% mortality Locking styletLocking stylet Telescoping sheathTelescoping sheath Laser sheathLaser sheath


Electrophysiologic DevicesElectrophysiologic Devices

Left Ventricular Assist DevicesLeft Ventricular Assist Devices

• Incidence of infection; 13%-80%Incidence of infection; 13%-80%• 85% of infections occur > 2 weeks after 85% of infections occur > 2 weeks after

LVAD placementLVAD placement• Mean duration of LVAD use = 73 daysMean duration of LVAD use = 73 days– Statistical association - postoperative Statistical association - postoperative

hemodialysishemodialysis– Clin Infect Dis 2002;34:1295-1300Clin Infect Dis 2002;34:1295-1300



• Three infection syndromesThree infection syndromes– Driveline infection (most common)Driveline infection (most common)

– LVAD pocket site infectionLVAD pocket site infection

– LVAD endocarditis (least common)LVAD endocarditis (least common)

– Not mutually exclusiveNot mutually exclusive


• Immunologic effectsImmunologic effects– Aberrant state of CD4Aberrant state of CD4– T-cell activation - apoptosisT-cell activation - apoptosis– Cutaneous anergy - recall antigensCutaneous anergy - recall antigens– Lower T-cell proliferative responsesLower T-cell proliferative responses– Higher surface expression of CD95Higher surface expression of CD95– B-cell hyperactivity and dysregulated B-cell hyperactivity and dysregulated

immunoglobulin synthesisimmunoglobulin synthesis



• Persistent bacteremia/fungemia not a Persistent bacteremia/fungemia not a

contraindication to cardiac transplantationcontraindication to cardiac transplantation

• Transplantation is life-saving for some Transplantation is life-saving for some

patients with uncontrollable LVAD patients with uncontrollable LVAD

infectioninfection



Total Artificial HeartTotal Artificial Heart• 1980s - Jarvik-71980s - Jarvik-7– Infectious/noninfectious complicationsInfectious/noninfectious complications

• January 2001 - FDA (USA) approval - January 2001 - FDA (USA) approval - AbiomedAbiomed– Totally implantable except external Totally implantable except external

battery and lead to electrical inductor coilbattery and lead to electrical inductor coil– 10 patients (3/10/03)10 patients (3/10/03)– Blood clotting problems, CVAsBlood clotting problems, CVAs– No infectious complications, 7 patientsNo infectious complications, 7 patients– No data, 3 patientsNo data, 3 patients


Ventriculoatrial (VA) ShuntsVentriculoatrial (VA) Shunts

• VP > VA useVP > VA use• Incidence of infection < 10%Incidence of infection < 10%– Large majority within six months of Large majority within six months of

placementplacement– CONS > CONS > S. aureusS. aureus

• Clinical manifestationsClinical manifestations– Infection site dependent, virulence of Infection site dependent, virulence of

organism, +/- shunt malfunctionorganism, +/- shunt malfunction– Varied, though meningitis unusualVaried, though meningitis unusual

Remember immunologic sequelaeRemember immunologic sequelae


• Diagnosis of infectionDiagnosis of infection– Findings Findings

Presence of fever and > 10% PMNs in Presence of fever and > 10% PMNs in ventricular fluid ventricular fluid

– TreatmentTreatment Two-staged exchangeTwo-staged exchange


Ventriculoatrial (VA) ShuntsVentriculoatrial (VA) Shunts

Cardiac Suture Line PledgetsCardiac Suture Line Pledgets• Teflon pledgets commonly usedTeflon pledgets commonly used• Three infection syndromesThree infection syndromes– Chest wall or epigastric involvementChest wall or epigastric involvement

Draining sinuses, sub-q masses, painDraining sinuses, sub-q masses, pain– Bronchopulmonary infectionBronchopulmonary infection

Recurrent hemoptysis, Recurrent hemoptysis, bronchiectasis, pneumonia with bronchiectasis, pneumonia with empyemaempyema

– Endocardial infectionEndocardial infection Bacteremia or fungemiaBacteremia or fungemia


Occlusion DevicesOcclusion Devices

• Patent ductus arteriosus, atrial septal Patent ductus arteriosus, atrial septal defect, and ventricular septal defectdefect, and ventricular septal defect• Extremely rare infections (n=2)Extremely rare infections (n=2)• Left atrial appendage occludersLeft atrial appendage occluders– Pending more extensive evaluationPending more extensive evaluation


Prosthetic Vascular GraftsProsthetic Vascular Grafts• Incidence of infection 1%-6% (Incidence of infection 1%-6% (>> 5 yrs) 5 yrs)• Location - relatedLocation - related– Aortic Aortic << 1% 1%– Aortofemoral 1.5%-2%Aortofemoral 1.5%-2%– Infrainguinal Infrainguinal << 6% (originate in groin) 6% (originate in groin)

• Intraoperative or perioperative contaminationIntraoperative or perioperative contamination– Majority of casesMajority of cases– Incubation period - Incubation period - << 2 months 2 months– Longer for indolent (CONS) pathogensLonger for indolent (CONS) pathogens


Prosthetic Vascular GraftsProsthetic Vascular Grafts• Purported risk factorsPurported risk factors– Groin incisionsGroin incisions– Emergent surgeryEmergent surgery– Invasive intervention (local)Invasive intervention (local)

Before/after placementBefore/after placement– Contiguous infectionContiguous infection– Medical conditions (diabetes mellitus, Medical conditions (diabetes mellitus,

obesity, chronic renal disease, obesity, chronic renal disease, immunocompromised host)immunocompromised host)


Prosthetic Vascular GraftsProsthetic Vascular Grafts• Clinical presentationsClinical presentations– Distal (extremity) infectionsDistal (extremity) infections

Focal inflammatory changesFocal inflammatory changes– Intracavitary infectionsIntracavitary infections

Nonspecific, difficult to diagnoseNonspecific, difficult to diagnose

Magnified if years after Magnified if years after placementplacement

– GI bleedGI bleed


Prosthetic Vascular GraftsProsthetic Vascular Grafts• Diagnostic modalitiesDiagnostic modalities– Blood culturesBlood cultures– Radiologic/nuclear medicineRadiologic/nuclear medicine

CT scanning CT scanning Sensitivity/specificity - 94%/95%Sensitivity/specificity - 94%/95%

MRIMRISensitivity/specificity - Sensitivity/specificity -

85%/100%85%/100% Indium WBC, gallium - lower Indium WBC, gallium - lower

specificityspecificity


Prosthetic Vascular GraftsProsthetic Vascular Grafts• ManagementManagement– 4 tenets 4 tenets

Excision of graft (foreign body)Excision of graft (foreign body) Wide/complete debridement of Wide/complete debridement of

devitalized, infected tissuedevitalized, infected tissue Maintain or establish vascular flowMaintain or establish vascular flow Institute prolonged systemic Institute prolonged systemic

antimicrobial therapyantimicrobial therapy


Hemodialysis Prosthetic Hemodialysis Prosthetic Vascular Grafts Vascular Grafts• Epidemiologic factorsEpidemiologic factors– Immunocompromised stateImmunocompromised state– Repetitive needle puncture at graft siteRepetitive needle puncture at graft site– Increased carriage of Increased carriage of S. aureusS. aureus

• 3.2 infections/100 patient-months3.2 infections/100 patient-months– CDC national surveillance systemCDC national surveillance system– AV fistulas - 0.56AV fistulas - 0.56– Synthetic AV grafts - 1.36Synthetic AV grafts - 1.36– Cuffed catheters - 8.42Cuffed catheters - 8.42– Non-cuffed catheters - 11.98Non-cuffed catheters - 11.98


• MicrobiologyMicrobiology– Access-related bacteremia (fistulas or Access-related bacteremia (fistulas or

grafts)grafts) S. aureusS. aureus - 53% - 53% CONS - 20.3%CONS - 20.3%

– MDR commonplaceMDR commonplace MRSA (VISA, VRSA)MRSA (VISA, VRSA) MRSEMRSE VREVRE

Hemodialysis Prosthetic Hemodialysis Prosthetic Vascular Grafts Vascular Grafts


• ManagementManagement– Complex issues, including available vascular Complex issues, including available vascular

accessaccess– Old, nonfunctioning AV graftsOld, nonfunctioning AV grafts

Cause of “delayed” sepsisCause of “delayed” sepsis• PreventionPrevention– MupirocinMupirocin– Increased AV fistula useIncreased AV fistula use– Cryopreserved human femoral vein allograftCryopreserved human femoral vein allograft– VaccinesVaccines

Hemodialysis Prosthetic Hemodialysis Prosthetic Vascular Grafts Vascular Grafts


Endovascular Stents and Endovascular Stents and Stent-GraftsStent-Grafts

• >400,000 patients in US undergo stent >400,000 patients in US undergo stent placement annuallyplacement annually

• Incidence of infection <1/10,000Incidence of infection <1/10,000

• Early (<4 weeks) presentationEarly (<4 weeks) presentation

• Predominant pathogen Predominant pathogen – S. aureusS. aureus


Endovascular Stents and Endovascular Stents and Stent-Grafts Stent-Grafts • ComplicationsComplications– Pseudoaneurysms Pseudoaneurysms – Others (abscess formation, arterial necrosis, Others (abscess formation, arterial necrosis,

septic emboli, refractory sepsis, amputation septic emboli, refractory sepsis, amputation requirement, death)requirement, death)

• TreatmentTreatment– Excision with extra-anatomic revascularizationExcision with extra-anatomic revascularization

• PreventionPrevention– Primary prophylaxis - “selected” patientsPrimary prophylaxis - “selected” patients


Intra-aortic Balloon Intra-aortic Balloon Counterpulsation Catheters (IABP)Counterpulsation Catheters (IABP)• Incidence of infectionIncidence of infection– Wound infection Wound infection << 5% 5%– Bacteremia Bacteremia << 2.2% 2.2%

• Purported risksPurported risks– ObesityObesity– Emergent placementEmergent placement– Surgical insertionSurgical insertion– Longer duration of useLonger duration of use– Done in areas outside OR or cath labDone in areas outside OR or cath lab– Larger diameter catheters (used in past)Larger diameter catheters (used in past)


Coronary Angiography Coronary Angiography and PTCA and PTCA• ~900,000 annually worldwide~900,000 annually worldwide– Stents used in 80%-85%Stents used in 80%-85%

• Incidence of infection < 1%Incidence of infection < 1%• Multiple infectious complications are Multiple infectious complications are

describeddescribed– BacteremiaBacteremia– Mycotic aneurysm, septic arthritis, Mycotic aneurysm, septic arthritis,

endarteritisendarteritis


• Risk factorsRisk factors– Brachial artery accessBrachial artery access

Cutdown approachCutdown approach– Repeat puncture (ipsilateral)Repeat puncture (ipsilateral)– Prolonged indwelling FA sheathProlonged indwelling FA sheath

Pressurized heparin solutionPressurized heparin solution– Older ageOlder age– CHFCHF

Coronary Angiography Coronary Angiography and PTCA and PTCA


• MicrobiologyMicrobiology– Staphylococcus Staphylococcus species - Most common species - Most common

• DiagnosisDiagnosis– CT scan or angiographyCT scan or angiography

Persistent sepsis, septic emboli, and Persistent sepsis, septic emboli, and abdominal flank painabdominal flank pain

• TreatmentTreatment– Aneurysms require resection or ligationAneurysms require resection or ligation

Rupture propensityRupture propensity

Coronary Angiography Coronary Angiography and PTCA and PTCA


Coronary Artery StentsCoronary Artery Stents• Infection extremely rareInfection extremely rare– Only 5 cases described in English Only 5 cases described in English

literatureliterature– Acute infection Acute infection – PathogensPathogens

S. aureus - 3; P. aeruginosa - 2S. aureus - 3; P. aeruginosa - 2– 3/5 patients died 3/5 patients died


Vascular Closure DevicesVascular Closure Devices (VCD) (VCD)• FDA (USA) approval - 5 devicesFDA (USA) approval - 5 devices• Favored over manual compression or Favored over manual compression or

compression devicescompression devices– Decrease time to hemostasis, increased Decrease time to hemostasis, increased

patient comfortpatient comfort• Incidence of infection Incidence of infection << 1.9% 1.9%– Two concernsTwo concerns

VCD > manual compressionVCD > manual compression Infections more severe, more difficult to Infections more severe, more difficult to

treat (often surgical intervention)treat (often surgical intervention)


Vascular Closure DevicesVascular Closure Devices (VCD) (VCD)• MicrobiologyMicrobiology– S. aureusS. aureus

Methicillin-resistantMethicillin-resistant• RiskRisk– Diabetes mellitus?Diabetes mellitus?

Prophylaxis for this group and for Prophylaxis for this group and for vascular access per prosthetic graftvascular access per prosthetic graft


Dacron Carotid PatchesDacron Carotid Patches

• Incidence of infection = 0.33% - 1.8%Incidence of infection = 0.33% - 1.8%

• Local (cervical) findingsLocal (cervical) findings– Early (< 3 months)Early (< 3 months)

Cellulitis, abscess, sepsis, Cellulitis, abscess, sepsis, pseudoaneurysm, massive pseudoaneurysm, massive hemorrhage, patch dehiscencehemorrhage, patch dehiscence

– LateLate Sinus tracts with drainage, Sinus tracts with drainage,

pseudoaneurysmpseudoaneurysm


Dacron Carotid PatchesDacron Carotid Patches

• MicrobiologyMicrobiology– Both viridans group streptococci and Both viridans group streptococci and

S.aureus predominate early; late S.aureus predominate early; late infections - coagulase-negative infections - coagulase-negative staphylococci staphylococci

• TreatmentTreatment– Surgical Surgical

Usually patch removal Usually patch removal • OutcomeOutcome– Overall good Overall good


Vena Caval FiltersVena Caval Filters

• ~30 years in use, 10 filters available (USA)~30 years in use, 10 filters available (USA)• Infection extremely rareInfection extremely rare– 3 proven, 2 suspect3 proven, 2 suspect– Staphylococcal species - all 5 casesStaphylococcal species - all 5 cases– 4 with bacteremia, 2 with spondylodiscitis4 with bacteremia, 2 with spondylodiscitis– 3 cures with device removal3 cures with device removal– 1 sepsis death, 1 long-term suppressive 1 sepsis death, 1 long-term suppressive

therapytherapy


ConclusionsConclusions

• MMedical 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


Nonvalvular Cardiovascular Device–Related Infections Larry M. Baddour, Michael A. Bettmann, Ann F....

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