Local device infection successfully treated without pacemaker removal in a neonate: a case report

Aims: Local device infection is a serious complication, especially in neonates. Complete device removal is the gold standard treatment for cardiac device infection; however, in selected cases alternative strategies could be adopted. We describe a case of a 14-day-old neonate, weighing 2.5kg, who had undergone epicardial double chamber pacemaker implantation for a congenital complete atrioventricular block. The generator pocket was created in the epigastric area below the rectus abdominis. At six days after implantation, pocket infection was found; blood cultures and the transoesophageal echocardiogram were normal. Due to the low weight of the neonate, and the limited possibility of finding a new comfortable site for housing the generator far from the infected area, we opted for a conservative strategy. We successfully applied a combination of antibiotic therapy, a vacuum-assisted wound closure system (KCI, Germany) for 40 days, and then skin transfer flap from the right flank without device removal. At one-year follow-up there were no local or systemic signs of infection.

814. Successful Treatment of Cutibacterium acnes (CA) Prosthetic Device Infection (PDI) with Oral Linezolid and Rifampin (LR)

Background CA PDI is increasingly recognized. CA is felt to create a slime layer that makes infection more likely and treatment more difficult in this setting. Traditional management has included prosthetic device explantation (PDE), prolonged antibiotic treatment, and delayed reimplantation. Recent interest in the use of oral treatment regimens and single stage procedures with long duration antibiotic therapy led us to treat a series of patients with oral treatment and retained prosthesis after debridement. We report those results. Methods Sequential patients with CA PDI treated with oral therapy were identified. All patients underwent debridement of the tissue, exchange of components and/or reimplantation of the prosthetic device. Only patients with exchanges were included. PDE was excluded. MIC testing for CA isolates was obtained when possible. Initial treatment was recorded at time of surgery. LR was the treatment of choice unless toxicity developed. A minimum of a 3-month follow-up post treatment was required to be included. 6 and 12 month follow up were obtained for all patients but 1 at this time. Results 10 patients were treated (Table 1). Shoulder joint infections were most common. All patients were treated with LR. All completed a minimum of 42 days of treatment (Table 2). The medication was well tolerated. The most common adverse events were nausea. 9/10 patients with 12 month follow up had no evidence of relapse. 1/10 had no relapse at 3 months. Typical for CA infection laboratory markers for infection were not markedly elevated. Notably thrombocytopenia did not occur (Table 3). Table 1. Distribution of Prosthetic Device Infections Table 2. Duration of Treatment Table 3. Selected Laboratory Results Conclusion We demonstrated the ability to successfully treat 10/10 patients with CA PDI without explantation using prolonged oral treatment with LR after debridement. This combination should be considered a treatment option and explored further as a low cost, well tolerated, high value treatment approach to this difficult infection. Disclosures Ronald G. Nahass, MD, Abbvie (Grant/Research Support, Speaker’s Bureau)Alkermes (Grant/Research Support)Gilead (Grant/Research Support, Speaker’s Bureau)Merck (Grant/Research Support, Speaker’s Bureau) Kathleen H. Seneca, MSN, Abbvie (Research Grant or Support)Alkermes (Research Grant or Support)Gilead (Speaker’s Bureau)

57. Evaluation of the 2019 European Heart Rhythm Association International Consensus Document in Patients with Cardiovascular Implantable Electronic Devices Who Develop Staphylococcus aureus Bacteremia

Background Cardiovascular implantable electronic device (CIED) implantation has markedly increased over the past two decades. Staphylococcus aureus bacteremia (SAB) occurs in patients with CIED and determination of device infection among patients without clinical findings of pocket site infection is often difficult. Our study examines the characteristics, management, and outcomes of SAB in patients living with CIED using 2019 international criteria to define CIED infection. Methods We conducted a retrospective study of patients with CIED who were hospitalized at Mayo Clinic, Rochester, with SAB from January 1, 2012 to December 31, 2019. Patients who met CIED infection criteria following SAB based on the 2019 European Heart Rhythm Association International Concensus Document were identified. A time-to-event analysis was used to determine the impact, if any, of complete device extraction on outcomes. Results Overall, 110 patients with CIED developed SAB and 92 (83.6%) of them underwent transesophageal echocardiogram (TEE). Eighty-eight (80%) had CIED infection with 57 (51.8%) and 31 (28.2%) patients meeeting criteria for definite and possible CIED infections, respectively. Forty-three (75.4%) patients with definite CIED infection underwent complete device extraction. For possible and rejected CIED infection, the rates of complete device extraction were 35.5% and 27.3%, respectively (p< .001 for each). The primary endpoint of a composite of one-year mortality and SAB relapse had a rate that was significantly lower in patients with CIED infection who underwent complete device extraction as compared to that of patients who did not undergo device extraction (25.9% vs. 76.5%, p< .001). No significant difference in outcomes was seen in the rejected CIED infection group (33.3% vs. 62.5%, p =.27). Conclusion The rate of CIED infections following SAB was higher than that reported previously. Increased use of TEE and a novel case definition with broader diagnostic criteria were likely operative, in part, in accounting for the the higher rate of CIED infections complicating SAB. Complete device removal is critical in patients with either definite or possible CIED infection as defined by the 2019 consensus document to improve one-year mortality and SAB relapse rates. Disclosures Larry M. Baddour, MD, Boston Scientific (Individual(s) Involved: Self): Consultant; Botanix Pharmaceuticals (Individual(s) Involved: Self): Consultant; Roivant Sciences (Individual(s) Involved: Self): Consultant Muhammad R. Sohail, MD, Medtronic (Consultant)Philips (Consultant)

The Additive Value of Semi-Quantitative Analysis of 18F-FDG PET/CT For The Diagnosis of Device Related Infections In Patients With A Left Ventricular Assist Device.

Background: Left ventricular assist devices (LVADs) improve quality of life and long-term survival in advanced heart failure, but device related infections (DRI) remain cumbersome. We evaluated the diagnostic capability of FDG-PET/CT and the additive value of semi-quantitative analysis for the diagnosis of DRI. Methods: LVAD recipients undergoing FDG-PET/CT between December 2012 and August 2020 for suspected DRI were retrospectively included. FDG-PET/CT was performed and evaluated according to EANM guidelines and assessors were blinded to the clinical context of included patients. Final clinical diagnosis of driveline infection and/or central device infection, based on multidisciplinary consensus and findings during surgery whenever performed, was used as the reference for the diagnosis. Results: 44 patients were evaluated for 62 episodes of suspected DRI. Clinical evaluation established driveline infection in 33 (54%) episodes, central device infection in 8 (14%) and combined infection in 2 (4%). Visual analysis of FDG-PET/CT achieved a sensitivity and specificity of 0.83 and 0.73, respectively, for driveline infections, while semi-quantitative analysis found comparable results (p=0.77). For central device component infections, visual analysis of FDG-PET/CT achieved a sensitivity and specificity of 1.0 and 0.26, respectively, while semi-quantitative analysis using SUVratio (background liver) achieved a sensitivity and specificity of 1.0 and 0.8, respectively. Both SUVmax and SUVratio outperformed visual analysis (p<0.001). Conclusions: FDG-PET/CT is a valuable tool for the assessment of DRI in LVAD recipients. Semiquantitative analysis significantly increases specificity of FDG-PET/CT for the analysis of central device components and should be considered in equivocal cases after visual analysis.

Impact of Choice of Prophylaxis on the Microbiology of Cardiac Implantable Electronic Device Infections: Insights from the Prevention of Arrhythmia Device infection Trial (PADIT)

Background The Prevention of Arrhythmia Device Infection Trial (PADIT) investigated whether intensification of perioperative prophylaxis could prevent cardiac implantable electronic device (CIED) infections. Compared with a single dose of cefazolin, the peri-operative administration of cefazolin, vancomycin, bacitracin and cephalexin did not significantly decrease the risk of infection. Our objective is to compare the microbiology of infections between study arms in PADIT. Methods Post-hoc analysis. Differences between study arms in the microbiology of infections were assessed at the level of individual patients and at the level of microorganisms using the Fisher’s exact test. Results Overall, 209 microorganisms were reported from 177 patients. The most common microorganisms were coagulase-negative staphylococci (CoNS, 82/209; 39.2%) and S. aureus (75/209; 35.9%). There was a significantly lower proportion of CoNS in the incremental arm compared with the standard arm (30.1% vs. 46.6%, p=0.04). However, there was no significant difference between study arms in the frequency of recovery of other microorganisms. In terms of antimicrobial susceptibility, 26.5% of microorganisms were resistant to cefazolin. CoNS were more likely to be cefazolin-resistant in the incremental arm (52.2% vs. 26.8%, respectively; p=0.05). However, there was no difference between study arms in terms of infections in which the main pathogen was sensitive to cefazolin (77.8% vs. 64.3%; p=0.10) or vancomycin (90.8% vs. 90.2%; p=0.90). Conclusions Intensification of the prophylaxis led to significant changes in the microbiology of infections, despite the absence of a decrease in the overall risk of infections. These findings provide important insight on the physiopathology of CIED infections.

Predictors of cardiac implantable electronic device infection in the United States

Background Cardiac implantable electronic devices (CIED) are important tools for managing arrhythmias, improving hemodynamics, and preventing sudden cardiac death. Device infection (DI) remains a significant complication of CIED and is associated with high morbidity, mortality, and healthcare cost. Purpose To analyze predictors of DI and its in-hospital outcomes. Methods National Inpatient Sample 2011–2018 database was analyzed for admissions for CIED implantation or DI. Baseline and hospital level characteristics were derived. The Chi-square test and student t-test were used for comparison of categorical and continuous variables respectively. Variables with p&lt;0.20 from univariate analysis were included in the multivariate logistic regression to identify independent predictors of DI. Results A total of 1,604,173 admissions for CIED implantations and 71,007 (4.4%) admissions for DI were reported during 2011–2018. There was no significant change in annual admissions for DI (range 8550 to 9307, p for trend=0.98). Those with DI were more likely to be male (69.3 vs 57%, p&lt;0.001) and had higher Charlson comorbidity index score ≥3 (46.6%-vs-36.8%, p&lt;0.001). Multivariate analysis identified post-procedural hematoma (odds ratio (OR)=3.96; 95% Confidence Interval (CI)=3.46–4.54), congestive heart failure (CHF; OR=2.80, 95% CI=2.66–2.96), age group 45–60 years (OR=2.46, 95% CI=2.30–2.63), malnutrition (OR=1.99, 95% CI=1.85–2.15), coagulopathy (OR=1.75, 95% CI=1.64–1.86), end-stage renal disease (OR=1.65, 95% CI=1.53–1.78), atrial fibrillation (OR=1.42; 95% CI=1.35–1.49), non-Hispanic race (OR=1.25; 95% CI=1.16–1.36), coronary artery disease (OR=1.21; 95% CI=1.15–1.26), and thyroid disease (OR=1.15; 95% CI=1.09–1.12) [all p&lt;0.001] as independent predictors of DI. Prevalence of CHF, malnutrition, and atrial fibrillation increased in those admitted with DI over the observation period as shown in Figure 1 (p for trend &lt;0.001). Prevalence of diabetes mellitus also increased during the observation period although it was not an independent predictor of DI (p for trend &lt;0.001). Pulmonary embolism and deep vein thrombosis were most common complications in those with DI (4.1 and 3.6% respectively). Annual in-hospital mortality ranged from 3.9 to 5.7% (mean 4.4%, p for trend=0.07). Conclusion DI is relatively common and continues to be associated with high morbidity and mortality. Prevalence of DI has not changed significantly despite technical and technological advances in device implantation. Evaluation of risk factors for DI and management of modifiable comorbidities may be needed to reduce the incidence of this important complication of CIED implantation. FUNDunding Acknowledgement Type of funding sources: None.