M Rizwan Sohail1, Bharath Raj Palraj2, Sana Khalid2, Daniel Z Uslan2, Farah Al-Saffar2, Paul A Friedman2, David L Hayes2, Christine M Lohse2, Walter R Wilson2, James M Steckelberg2, Larry M Baddour2. 1. From the Division of Infectious Diseases, Department of Medicine (M.R.S., B.R.P., S.K.,W.R.W., J.M.S, L.M.B.), Division of Cardiovascular Diseases, Department of Medicine (M.R.S., P.A.F., D.L.H., L.M.B.), Department of Biostatistics and Informatics (C.M.L.), Mayo Clinic College of Medicine, Rochester, MN; Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); and Department of Medicine, University of Florida Health Science Center, Jacksonville (F.A.-S.). sohail.muhammad@mayo.edu. 2. From the Division of Infectious Diseases, Department of Medicine (M.R.S., B.R.P., S.K.,W.R.W., J.M.S, L.M.B.), Division of Cardiovascular Diseases, Department of Medicine (M.R.S., P.A.F., D.L.H., L.M.B.), Department of Biostatistics and Informatics (C.M.L.), Mayo Clinic College of Medicine, Rochester, MN; Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); and Department of Medicine, University of Florida Health Science Center, Jacksonville (F.A.-S.).
Abstract
BACKGROUND: Prompt recognition of underlying cardiovascular implantable electronic device (CIED) infection in patients presenting with Staphylococcus aureus bacteremia (SAB) is critical for optimal management of these cases. The goal of this study was to identify clinical predictors of CIED infection in patients presenting with SAB and no signs of pocket infection. METHODS AND RESULTS: All cases of SAB in CIED recipients at Mayo Clinic from 2001 to 2011 were retrospectively reviewed. We identified 131 patients with CIED who presented with SAB and had no clinical signs of device pocket infection. Forty-five (34%) of these patients had underlying CIED infection based on clinical or echocardiographic criteria. The presence of a permanent pacemaker rather than an implantable cardioverter-defibrillator (odds ratio, 3.90; 95% confidence interval, 1.65-9.23; P=0.002), >1 device-related procedure (odds ratio, 3.30; 95% confidence interval, 1.23-8.86; P=0.018), and duration of SAB ≥4 days (odds ratio, 5.54; 95% confidence interval, 3.32-13.23; P<0.001) were independently associated with an increased risk of CIED infection in a multivariable model. The area under the receiver operating characteristics curve for the multivariable model was 0.79, indicating a good discriminatory capacity to distinguish SAB patients with and without CIED infection. CONCLUSIONS: Among patients presenting with SAB and no signs of pocket infection, the risk of underlying CIED infection can be calculated based on the type of device, number of device-related procedures, and duration of SAB. We propose that patients without any of these high-risk features have a low risk of underlying CIED infection and may be monitored closely without immediate device extraction. Prospective studies are needed to validate this risk prediction model.
BACKGROUND: Prompt recognition of underlying cardiovascular implantable electronic device (CIED) infection in patients presenting with Staphylococcus aureus bacteremia (SAB) is critical for optimal management of these cases. The goal of this study was to identify clinical predictors of CIED infection in patients presenting with SAB and no signs of pocket infection. METHODS AND RESULTS: All cases of SAB in CIED recipients at Mayo Clinic from 2001 to 2011 were retrospectively reviewed. We identified 131 patients with CIED who presented with SAB and had no clinical signs of device pocket infection. Forty-five (34%) of these patients had underlying CIED infection based on clinical or echocardiographic criteria. The presence of a permanent pacemaker rather than an implantable cardioverter-defibrillator (odds ratio, 3.90; 95% confidence interval, 1.65-9.23; P=0.002), >1 device-related procedure (odds ratio, 3.30; 95% confidence interval, 1.23-8.86; P=0.018), and duration of SAB ≥4 days (odds ratio, 5.54; 95% confidence interval, 3.32-13.23; P<0.001) were independently associated with an increased risk of CIED infection in a multivariable model. The area under the receiver operating characteristics curve for the multivariable model was 0.79, indicating a good discriminatory capacity to distinguish SABpatients with and without CIED infection. CONCLUSIONS: Among patients presenting with SAB and no signs of pocket infection, the risk of underlying CIED infection can be calculated based on the type of device, number of device-related procedures, and duration of SAB. We propose that patients without any of these high-risk features have a low risk of underlying CIED infection and may be monitored closely without immediate device extraction. Prospective studies are needed to validate this risk prediction model.
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