James E Peacock1, Jeanette M Stafford2, Katherine Le3, Muhammad Rizwan Sohail3, Larry M Baddour3, Jordan M Prutkin4, Stephan B Danik5, Holenarasipur R Vikram6, Marta Hernandez-Meneses7, José M Miró7, Elisabeth Blank8, Christoph K Naber9, Roger G Carrillo10, Arnold J Greenspon11, Chi-Hong Tseng12, Daniel Z Uslan13. 1. Section on Infectious Diseases, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA. 2. Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA. 3. Division of Infectious Diseases, Department of Medicine, and the Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA. 4. Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA. 5. Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. 6. Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA. 7. Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain. 8. Ärztin im Studienzentrum Kardiologie, Contilia Heart and Vascular Center, Essen, Germany. 9. Klinik für Kardiologie und Angiologie, Contilia Heart- and Vascular Center, Elisabeth-Krankenhaus, Essen, Germany. 10. Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA. 11. Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA. 12. Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, CA, USA. 13. Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, CA, USA.
Abstract
BACKGROUND: Published guidelines mandate complete device removal in cases of cardiovascular implantable electronic device (CIED) infection. Clinical predictors of successful salvage of infected CIEDs have not been defined. METHODS: Data from the Multicenter Electrophysiologic Device Infection Collaboration, a prospective, observational, multinational cohort study of CIED infection, were used to investigate whether clinical predictors of successful salvage of infected devices could be identified. RESULTS: Of 433 adult patients with CIED infections, 306 (71%) underwent immediate device explantation. Medical management with device retention and antimicrobial therapy was initially attempted in 127 patients (29%). "Early failure" of attempted salvage occurred in 74 patients (58%) who subsequently underwent device explantation during the index hospitalization. The remaining 53 patients (42%) in the attempted salvage group retained their CIED. Twenty-six (49%) had resolution of CIED infection (successful salvage group) whereas 27 patients (51%) experienced "late" salvage failure. Upon comparing the salvage failure group, early and late (N = 101), to the group experiencing successful salvage of an infected CIED (N = 26), no clinical or laboratory predictors of successful salvage were identified. However, by univariate analysis, coagulase-negative staphylococci as infecting pathogens (P = 0.0439) and the presence of a lead vegetation (P = 0.024) were associated with overall failed salvage. CONCLUSIONS: In patients with definite CIED infections, clinical and laboratory variables cannot predict successful device salvage. Until new data are forthcoming, device explantation should remain a mandatory and early management intervention in patients with CIED infection in keeping with existing expert guidelines unless medical contraindications exist or patients refuse device removal.
BACKGROUND: Published guidelines mandate complete device removal in cases of cardiovascular implantable electronic device (CIED) infection. Clinical predictors of successful salvage of infected CIEDs have not been defined. METHODS: Data from the Multicenter Electrophysiologic Device Infection Collaboration, a prospective, observational, multinational cohort study of CIED infection, were used to investigate whether clinical predictors of successful salvage of infected devices could be identified. RESULTS: Of 433 adult patients with CIED infections, 306 (71%) underwent immediate device explantation. Medical management with device retention and antimicrobial therapy was initially attempted in 127 patients (29%). "Early failure" of attempted salvage occurred in 74 patients (58%) who subsequently underwent device explantation during the index hospitalization. The remaining 53 patients (42%) in the attempted salvage group retained their CIED. Twenty-six (49%) had resolution of CIED infection (successful salvage group) whereas 27 patients (51%) experienced "late" salvage failure. Upon comparing the salvage failure group, early and late (N = 101), to the group experiencing successful salvage of an infected CIED (N = 26), no clinical or laboratory predictors of successful salvage were identified. However, by univariate analysis, coagulase-negative staphylococci as infecting pathogens (P = 0.0439) and the presence of a lead vegetation (P = 0.024) were associated with overall failed salvage. CONCLUSIONS: In patients with definite CIED infections, clinical and laboratory variables cannot predict successful device salvage. Until new data are forthcoming, device explantation should remain a mandatory and early management intervention in patients with CIED infection in keeping with existing expert guidelines unless medical contraindications exist or patients refuse device removal.