Cardiac Implantable Electronic Device Infection in Patients at Risk

Abstract

Device TherapyOver the last few decades an increasing body of evidence has supported the role of cardiovascular implantable electronic devices However, the cost and complications of device implantation, including infection or hardware malfunction in patients receiving CIEDs, have led to the concern that negative outcomes may partially counteract the expected benefits. The rate of CIED infection has been estimated at 0.5 % with primary implants and 1-7 % with secondary interventions.3,5-8 It is difficult to give accurate estimates of infection rates, given the fact that figures are partly based on retrospective series of varying duration, and that different definitions of infection exist. However, the incidence of CIED infection is increasing out of proportion to CIED implantation. 3,5,9 A US study reported a 12 % increase in the number of CIED implantations from 2004 to 2006, with a 57 % increment in CIED infections during the same period. 9Reasons for this rise in CIED infections include the fact that younger patients are receiving CIEDs, and therefore surviving long enough to require more pulse generator changes and lead revisions, which are associated with a higher infection rate. 7,10 In addition, there has been an increase in comorbidities, such as diabetes and kidney disease, resulting in poor wound healing and diminished immune responses. 3,9,11,12 Expanding indications for CIED use, coupled with an ageing population with more comorbidities, mean this trend is likely to increase.2 Better awareness and improved reporting of CIED infections may, however, help to decrease the higher complication rates noted in recent years.CIED infections also impose a substantial financial burden resulting from prolonged hospital stays, long duration of antibiotic therapy, management of sepsis and complications, device extraction and reimplantation.3 These infections typically cost at least $52,000 13 and may exceed $100,000. 14 This article will review strategies for management and prevention of CIED infections, including lead extraction and the use of an absorbable antibacterial envelope. Risk Factors for Cardiac Implantable Electronic Device Infections

Prevention of Cardiac Implantable Electronic Device Infections: Single Operator Technique with Use of Povidone‐Iodine, Double Gloving, Meticulous Aseptic/Antiseptic Measures and Antibiotic Prophylaxis

“…In the present series we employed a combination of alcohol and povidone‐iodine for skin cleansing, but subsequently used only aqueous povidone‐iodine to maintain wound sterility and rinse the pocket during the remainder of the procedure. Concerns about povidone‐iodine adversely affecting wound healing have not panned out in more recent studies . Others have used antibiotic solution or have even suggested the alternative use of mere saline solution for CIED pocket irrigation periprocedurally .…”

“…Concerns about povidone-iodine adversely affecting wound healing 15 have not panned out in more recent studies. 13,14,16,17 Others have used antibiotic solution or have even suggested the alternative use of mere saline solution for CIED pocket irrigation periprocedurally. 2,18 Our choice of povidone-iodine was based on its strong and broad spectrum bactericidal properties, without the emergence of resistance with its long-term use conferring lower infection rates compared to placebo.…”

Microflora of Retained Intracochlear Electrodes from Infected Cochlear Implants

“…Refractory infections of deep brain stimulation (DBS) hardware, vagal nerve stimulators, and cardiac pacemakers/defibrillators may also be cleared with partial explantation in an attempt to salvage the electrodes. [17][18][19][20] Lead salvage is attempted prior to removing hardware in localized wound infections for vagal nerve stimulators and DBS hardware. 17,18 Sillay et al reported a DBS hardware infection cure rate of 64% with lead-sparing partial explantation.…”

“…Vagal nerve stimulators 18 Partial or complete explantation Delayed reimplantation Cerebrospinal shunts 29,30 Complete explantation Immediate or delayed reimplantation Orthopedic fracture hardware 31,32 Complete explantation Immediate or no reimplantation Prosthetic joint hardware 15,[33][34][35] Complete explantation Immediate or delayed reimplantation Craniomaxillofacial fracture hardware 36 Complete explantation Immediate or no reimplantation Vascular prosthetic grafts 37,38 Complete explantation Immediate replacement or extra-anatomic bypass Cardiac implantable electronic devices 20,24,28 Partial or complete explantation Immediate or delayed reimplantation design of the work as well as the acquisition, analysis, and interpretation of data for the work. She also participated in drafting and revising it critically for important intellectual content.…”

Implantable Cardiac Device Infection - A Clinical Audit

“…In literature risk factors which have been considered to predispose patients to infection include presence of other comorbidities like coexisting organs malfunction, number of implanted leads, female group and use of steroids. Multiple leads and device revision or replacement are also identified as independent markers of device infection 6 .…”