March 26, 2019
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Certain symptoms indicate bloodstream infection in patients with cardiac device pocket infections

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Patients with cardiovascular implantable electronic device pocket infections who meet criteria for systemic inflammatory response syndrome or are hypotensive at admission — or both — are more likely to have underlying bloodstream infections and should immediately be started on empiric antibiotics after blood cultures are obtained, researchers suggested.

“Cardiovascular implantable electronic device (CIED) infections have been recognized as a growing problem, with [a] reported incidence of 1% for initial placement and up to 7% for device re-intervention,” Zerelda Esquer Garrigos, MD, from the division of infectious diseases at the Mayo Clinic College of Medicine and Science, and colleagues wrote.

“At present, there are no established criteria to differentiate patients with CIED pocket infection who may have underlying [bloodstream infections (BSI)], and therefore should be immediately started on empiric antibiotic therapy, from cases where underlying BSI is unlikely and therefore reasonable to withhold empiric antibiotic therapy to optimize the yield of intraoperative cultures and avoid unnecessary antibiotic exposure.”

At their institution, Garrigos and colleagues conducted a retrospective review of all adult patients aged 18 years or older with CIED pocket infections from January 2005 through January 2016.

Of the 429 CIED infection cases screened, 95 met inclusion criteria. According to the study, 71.6% of the included cases were categorized as non-BSI and 28.4% were categorized as having a BSI. The researchers said they did not observe any statistically significant differences in patient comorbidities or device characteristics between the two groups.

In a multivariable analysis, they found that independent predictors of underlying BSI in patients presenting with a CIED pocket infection included the presence of systemic inflammatory response syndrome (SIRS) criteria — such as tachycardia, tachypnea, fever or hypothermia and leukocytosis or leukopenia — and hypotension.

Compared with patients in the non-BSI cohort who received pre-extraction antibiotics, Garrigos and colleagues highlighted a higher frequency of positive intraoperative pocket/device cultures among those who did not receive pre-extraction antibiotics. Specifically, 79.4% of non-BSI patients who did not receive pre-extraction antibiotics had positive cultures compared with 58.6% among non-BSI patients who received the antibiotics.

The researchers suggested that patients with a CIED pocket infection may not require empiric antibiotics during device extraction if they are not hypotensive upon admission and if they do not meet SIRS criteria.

“Based on our study findings and review of the published literature, we recommend obtaining two sets of blood cultures in all patients regardless of clinical presentation,” Garrigos and colleagues wrote. “Patients who exhibit one or more predictors of underlying BSI, should be started on empiric antibiotic therapy directed against staphylococci.” – by Marley Ghizzone

Disclosures: Garrigos report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.