Long-Term Outcomes of Cardiovascular Implantable Electronic Devices in Patients with Staphylococcus aureus Bacteremia

Background: The use of cardiovascular implantable electronic devices (CIEDs) is increasing. Staphylococcus aureus bacteremia (SAB) poses a risk for hematogenous seeding of the device. Our aim is to identify risk factors associated with secondary CIED infection, due to hematogenous seeding, during SAB from an unrelated primary focus. Methods: All patients with SAB and CIED were screened. Patients with SAB due to a primary source unrelated to the CIED were included. Patients were classified into cases if CIED infection was documented and controls without CIED infection during a minimum of 12 weeks follow-up. A retrospective review of patients' charts was done. Results: Thirty patients with CIED and SAB from an unrelated focus were identified. CIED infection developed in 11 patients (36.7%). No significant differences were noted between cases and controls in the source, time-to-therapy, and time-to-intervene but infected devices were more likely to be implantable cardioverter-defibrillators (ICD) versus permanent pacemakers (PPMs) (9/11 [81.8%] vs 2/11 [18.2%] respectively, crude odds ratio 12.6, 95% confidence interval 10.8-14.4; P = 0.003). Conclusion: Hematogenous seeding of a CIED during SAB from an unrelated focus is not uncommon. The risk factors for CIED seeding are unknown but ICD devices seem to be at greater risk when compared to PPM. The reasons are not yet clear. Larger studies are needed to better define risk factors and design preventive measures. (PACE 2012; 35:961-965).     

Clinical predictors of cardiovascular implantable electronic device-related infective endocarditis

Background: Cardiovascular implantable electronic device (CIED)‐related infective endocarditis (CIED‐IE) is a serious complication of cardiac device infection and is associated with increased mortality. At present, there exist no criteria to predict CIED‐IE in patients who present with CIED infection. Methods: We retrospectively reviewed all cases of CIED infection seen at Mayo Clinic Rochester between 1991 and 2008. CIED‐IE was classified using pathologic and clinical criteria. Clinical predictors of CIED‐IE were identified using logistic regression, and quantified using a summary score and plotted against the distribution of CIED‐IE. Results: Ninety‐three (22.4%) of the 416 patients with CIED infection had CIED‐IE. Host factors including chronic immunomodulator therapy exclusive of corticosteroid (odds ratio [OR], 3.79 [confidence interval (CI) 1.10, 13.04]), chronic corticosteroid therapy (OR, 2.15 [CI 0.93, 5.00]), hemodialysis (OR, 3.24 [CI 1.39, 7.55]), or remote infection (OR, 1.77 [CI 0.99, 3.14]) were associated with increased odds of CIED‐IE. Patients with CIED‐IE were at increased odds of presenting with fever (OR, 3.78 [CI 1.93, 7.40]), or malaise (OR, 1.87 [CI 1.02, 3.41]), and have findings of leukocytosis (OR, 3.61 [CI 1.51, 8.62]). In marked contrast, they were at decreased odds of exhibiting signs/symptoms of infection at the generator pocket site (OR, 0.19 [CI 0.10, 0.36]). Summary scores of 6 and 11 predicted CIED‐IE in approximately 50% and 90% of cases, respectively. Conclusions: Certain comorbid conditions and systemic manifestations of infection were associated with CIED‐IE. In contrast, pocket site infection was negatively associated with CIED‐IE. These findings should assist clinicians in identifying patients who would more likely benefit from further investigation of CIED‐IE with transesophageal echocardiography. (PACE 2011; 34:450–459)     

Implantation success and infection in cardiovascular implantable electronic device procedures utilizing an antibacterial envelope

Background: Cardiovascular implantable electronic device (CIED) infection rates are increasing faster than implantation rates. More effective antimicrobial prophylaxis may help reduce CIED infections and improve clinical outcomes. The AIGIS_Rx^® antibacterial envelope is a polymer mesh implanted in the generator pocket with the CIED. After implantation it releases two antibiotics, minocycline and rifampin, that have been shown to reduce infections associated with other medical devices. The purpose of this retrospective cohort study is to determine the rate of CIED implantation success and CIED infection in procedures utilizing the antibacterial envelope. Methods: This study enrolled consecutive CIED procedures utilizing the antibacterial envelope at 10 US academic, community, and Veterans Affairs medical centers. Procedures following an explantation for a prior CIED infection or off‐label use of the antibacterial envelope were excluded. Results: The 624 eligible procedures (age 70 ± 13 years, 68.1% men, 27.2% renal insufficiency, 35.4% oral anticoagulant use, 67.8% replacement/revision procedures) utilized pacemakers (35%), implantable cardioverter‐defibrillators (ICD)(29%), and cardiac resynchronization therapy with defibrillator devices (CRT‐D)(36%). Nearly half of the patients (49%) had at least three predefined risk factors for CIED infection. CIED implantation was successful in 621 procedures (99.5%[95% confidence interval (CI) 98.8–99.9]). There were three major infections (0.48%[95%CI 0.17–1.40]) after 1.9 ± 2.4 months follow‐up. The infections followed one ICD revision and two CRT‐D replacements. There were seven deaths; none was a result of the antibacterial envelope or the CIED procedure. Conclusions: CIED procedures that utilized an antibacterial envelope had a high rate of CIED implantation success (>99%). Although the follow‐up to date is short, there was also a low rate of infection (<0.50%) in this population at high risk for CIED infection. (PACE 2011; 34:133–142)     

Management of systemic fungal infections in the presence of a cardiac implantable electronic device: A systematic review

Evidence to inform the management of systemic fungal infections in the setting of a cardiac implantable electronic devices (CIED), such as a permanent pacemaker or implantable cardioverter‐defibrillator, is scant and limited to case reports and series. The available literature suggests high morbidity and mortality. To better characterize the shared experience of these cases and their outcomes, we performed a systematic review. We investigated all published reports of systemic fungal infections—fungemia and fungal vegetative disease—in the context of CIED, drawing from PubMed, EMBASE, and the Cochrane database of systematic reviews, inclusive of patients who received treatment between January 2000 and May 2020. Exclusion criteria included presence of ventricular assist device and concurrent bacteremia, bacterial endocarditis, bacterial vegetative infection, or viremia. Among 6261 screened articles, 48 cases from 41 individual studies were identified. Candida and Aspergillus species were the most commonly isolated fungi. There was significant heterogeneity in antifungal medication selection and duration. CIED extraction—either transvenous or surgical—was associated with increased survival to hospital discharge (92%) and clinical recovery at latest follow‐up (81%), compared to cases where CIED extraction was deferred (56% and 40%, respectively). Importantly, there were no prospective data, and the data were limited to individual case reports and one small case series. In summary, CIED extraction is associated with improved fungal clearance and patient survival. Reported antifungal regimens are heterogeneous and nonuniform. Prospective studies are needed to verify these results and define optimal antifungal regimens.     

Contemporary management of cardiovascular implantable electronic device infections

Cardiovascular implantable electronic device (CIED) implantation rate has substantially risen in the foregoing decades. Unfortunately, this upsurge in CIED implantation rate has been accompanied by a disproportionate rise in the rate of CIED infections. Device infection is a major complication of CIED implantation, necessitating removal of an infected device followed by systemic antimicrobial therapy and reimplantation of a new system. In this article, we review the current epidemiology, risk factors, diagnostic strategy and contemporary management of CIED infection. In addition, we address the vexing question of how to best manage patients with Staphylococcus aureus bacteremia, in the setting of an implanted device, but no overt clinical signs of CIED infection. Lastly, we discuss the preventive strategies to minimize risk of CIED infection.     

Appropriate use of echocardiography in managing Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is increasing, both in the community and in healthcare settings. Accurate and timely diagnosis of underlying infective endocarditis (IE) is critical for optimal management of SAB cases as it has significant management and prognostic implications. Reported prevalence of IE in patients with SAB varies depending on the study population, and ranges from 10 to 30%. As clinical presentation of IE can be nonspecific, echocardiography is usually recommended in SAB cases to ‘rule out’ IE. Due to its poor sensitivity (<50%), especially for diagnosing prosthetic valve IE, transthoracic echocardiography is considered inadequate in this setting and clinicians have to rely on transesophageal echocardiography (TEE) to confirm or exclude endocarditis in SAB cases. Although some experts recommend TEE in all patients presenting with SAB, it is believed that the use of TEE could be guided by individual patient risk factors, mode of acquisition of SAB and clinical presentation. In this article, published data regarding the use of TEE in the SAB population are reviewed and a simplified algorithm to guide use of TEE in SAB cases is proposed.     

Treatment patterns,costs, and mortality among Medicare beneficiaries with CIED infection

1 Background

Cardiac implantable electronic device (CIED) infection is a serious adverse event, but there are limited contemporary real‐world data on treatment pathways and associated costs in the Medicare population following diagnosis of CIED infection. Hence, this study evaluates postinfection treatment pathways and associated healthcare expenditures and mortality among Medicare fee‐for‐service beneficiaries with CIED infection.

2 Methods

Retrospective cohort analysis of 5,401 beneficiaries who developed a device‐related infection in the year following implantation/upgraded CIED (1/1/2010–12/31/2012). Patients were followed‐up to 12 months/death following diagnosis of infection and were divided into mutually exclusive groups based on whether they underwent CIED system removal (Group I), or no CIED system intervention (Group II; IIA with or IIB without infection hospitalization). All‐cause healthcare resource utilization/expenditures were also measured.

3 Results

In the year following infection, 64.1% of patients underwent device extraction, of who 2,109 (39.0%) had their device replaced (Group IA) and 1,355 (25.1%) had their device extracted without replacement (Group IB); 62.2% of patients were hospitalized and 25.3% of patients died. Mean Medicare payments‐per‐patient for facility‐based services by group were: IA = $62,638 (standard deviation [SD]: $46,830), IB = $50,079 (SD: $45,006), IIA = $77,397 (SD: $79,130), and IIB = $22,856 (SD: $31,167).

4 Conclusions

Hospitalizations were the largest cost driver; infection‐related costs, including cost of extraction/replacement, accounted for >50% of expenditures for patients with surgical/hospital intervention. Management of CIED infection in Medicare beneficiaries is associated with high healthcare expenditures in the year following infection. Additional measures to prevent device infection are needed to improve the outcomes and reduce costs in these patients.     

Incidence and Risk Factors of Ocular Infection Caused by Staphylococcus aureus Bacteremia

Staphylococcus aureus bacteremia (SAB) often leads to ocular infections, including endophthalmitis and chorioretinitis. However, the incidence, risk factors, and outcomes of ocular infections complicated by SAB are largely unknown. We retrospectively analyzed the incidence and risk factors of ocular involvement in a prospective cohort of patients with SAB at a tertiary-care hospital. Ophthalmologists reviewed the fundoscopic findings and classified the ocular infections as endophthalmitis or chorioretinitis. During the 5-year study period, 1,109 patients had SAB, and data for 612 (55%) who underwent ophthalmic examinations within 14 days after SAB onset were analyzed. Of those 612 patients, 56 (9% [95% confidence interval [CI], 7 to 12%]) had ocular involvement, including 15 (2.5%) with endophthalmitis and 41 (6.7%) with chorioretinitis. In a multivariate analysis, infective endocarditis (adjusted odds ratio [aOR], 5.74 [95% CI, 2.25 to 14.64]) and metastatic infection (aOR, 2.38 [95% CI, 1.29 to 4.39]) were independent risk factors for ocular involvement. Of the 47 patients with ocular involvement who could communicate, only 17 (36%) had visual disturbances. Two-thirds of the patients with endophthalmitis (10/15 patients) were treated with intravitreal antibiotics combined with parenteral antibiotics, whereas all of the patients with chorioretinitis were treated only with systemic antibiotics. No patients became blind. Among 42 patients for whom follow-up assessments were available, the ocular lesions improved in 29 (69%) but remained the same in the others. Ocular involvement was independently associated with death within 30 days after SAB onset. Ocular involvement is not uncommon among patients with SAB. Routine ophthalmic examinations should be considered for patients with infective endocarditis or metastatic infections caused by SAB.     

Cardiovascular implantable electronic device replacement infections and prevention: results from the REPLACE Registry

Background: Infection following cardiovascular implantable electronic device (CIED) replacement is a serious complication, and rates of infection have increased. Analysis of procedural and clinical data from device replacement procedures collected by the REPLACE Registry may provide insights into infection prevention strategies and outcomes. Methods: We prospectively evaluated procedural complications in patients undergoing CIED replacement over 6 months from 72 U.S. sites. Major and minor infections were predefined and adjudicated by an independent blinded clinical events committee. Data regarding infection prevention strategies and infectious outcomes were analyzed for their potential relationships. Results: A total of 1,744 patients were included in REPLACE. All patients received preoperative intravenous antibiotics and 68.7% received postoperative systemic antibiotic therapy. CIED infection developed in 22 patients (1.3%), of which 14 cases were major (0.8%, 95% confidence interval [CI] 0.4%–1.3%) and eight were minor (0.5%, 95% CI 0.2%–0.9%). Patients with infections were more likely to have had postoperative hematomas (five of 22 [22.7%] vs 17 of 1,722 [0.98%], P = 0.002). Participating sites experiencing infection rates >5% were more likely to use povidone‐iodine for topical antisepsis, had lower implantation volume, and had patients with higher Charlson Comorbidity Index (2.79 vs 2.32, 95% CI for difference 0.08–0.86, P = 0.019). Conclusions: In this multicenter prospective study with 6 months of follow‐up, infections associated with CIED replacements were surprisingly infrequent, possibly due to the use of preoperative antibiotics. Patients with infections were more likely to have had a postoperative hematoma, and sites with higher infection rates had sicker patients and lower overall procedural volume. (PACE 2012; 35:81–87)     

Appropriate use of echocardiography in managing Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is increasing, both in the community and in healthcare settings. Accurate and timely diagnosis of underlying infective endocarditis (IE) is critical for optimal management of SAB cases as it has significant management and prognostic implications. Reported prevalence of IE in patients with SAB varies depending on the study population, and ranges from 10 to 30%. As clinical presentation of IE can be nonspecific, echocardiography is usually recommended in SAB cases to 'rule out' IE. Due to its poor sensitivity (<50%), especially for diagnosing prosthetic valve IE, transthoracic echocardiography is considered inadequate in this setting and clinicians have to rely on transesophageal echocardiography (TEE) to confirm or exclude endocarditis in SAB cases. Although some experts recommend TEE in all patients presenting with SAB, it is believed that the use of TEE could be guided by individual patient risk factors, mode of acquisition of SAB and clinical presentation. In this article, published data regarding the use of TEE in the SAB population are reviewed and a simplified algorithm to guide use of TEE in SAB cases is proposed.     

Clinical Presentation,Management, and Outcomes of Cardiovascular Implantable Electronic Device Infections Due to Gram-Negative Versus Gram-Positive Bacteria

ObjectiveTo describe and compare the clinical presentation, management, and outcomes of cardiovascular implantable electronic device (CIED) infections due to gram-negative bacteria (GNB) and CIED infections due to gram-positive bacteria (GPB).Patients and MethodsWe retrospectively reviewed all CIED infection cases at Mayo Clinic from January 1, 1992, through December 31, 2015. Cases were classified based on positive microbiology data from extracted devices or blood cultures.ResultsOf the 623 CIED infections during the study period, 31 (5.0%) were caused by GNB and 323 (51.8%) by GPB. Patients in the GNB group were more likely to present with local inflammatory findings at the pocket site (90.3% vs 72.4%; P=.03). All patients with bacteremia due to GNB had concomitant pocket infection compared with those with GPB (100% vs 33.9%; P=.002). After extraction, 41.9% of patients in the GNB group were managed with oral antibiotics vs 2.4% in the GPB group (P<.001). There were no statistically significant differences in infection relapse/recurrence or 1-year survival rates between the 2 groups.ConclusionCompared with CIED infections caused by GPB, those due to GNB are more likely to present with pocket infection. Device-related GNB bacteremia almost always originates from the generator pocket. After extraction, oral antibiotic drug therapy may be a reasonable option in select cases of pocket infections due to GNB. No difference in outcomes was observed between the 2 groups.     

Risk factors for infective endocarditis and outcome of patients with Staphylococcus aureus bacteremia

OBJECTIVE: To investigate the risk factors for Staphylococcus aureus infective endocarditis (SAIE) and 6-month mortality in patients with S aureus bacteremia (SAB). PATIENTS AND METHODS: This study consisted of patients who were diagnosed as having nosocomial or community-acquired SAB or SAIE between June 1, 2000, and December 31, 2005. Clinical characteristics of patients with SAB were compared with those of patients with SAIE, and predictors of mortality in patients with SAB were analyzed. RESULTS: The median age of the 132 randomly selected patients with SAB and the 66 patients with SAIE was 66 and 68 years, respectively. Univariable analysis showed that unknown origin of SAB, a valvular prosthesis, a pacemaker, persistent fever, and persistent bacteremia were significantly associated with SAIE. In multivariable analysis, unknown origin of SAB (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.9-9.3; P=.001), a valvular prosthesis (OR, 9.2; 95% CI, 3.2-26.2; P<.001), persistent fever (OR, 3.1; 95% CI, 1.0-9.0; P=.04), and persistent bacteremia (OR, 6.8; 95% CI, 2.3-20.2- P=.001) were independently associated with SAIE. Six- month mortality was 8% in patients with SAB vs 35% in patients with SAIE (OR, 6.5; 95% CI, 2.9- 14.8; P<.001). In univariable analysis, methicillin- resistant S aureus (OR, 7.2; 95% CI, 1.7 - 29.4; P=.005) was significantly associated with 6-month mortality in patients with SAB. CONCLUSION: Unknown origin of SAB, a valvular prosthesis, persistent fever, and persistent bacteremia were independently associated with SAIE in patients with SAB. In univariable analysis, methicillin-resistant S aureus was associated with 6-month mortality in patients with SAB. S aureus infective endocarditis had a significantly higher mortality than SAB. The optimal management of SAB and SAIE deserves further study.     

A surveillance of high-level gentamicin-resistant enterococcal bacteremia

Enterococci have recently been recognized as a causative organism of intractable infections, including severe sepsis and infective endocarditis, in immunocompromised patients. This study investigated the epidemiological, microbiological, and prognostic characteristics of high-level gentamicin-resistant (HLGR) enterococcal bacteremia, including severe cases of infective endocarditis, in Japan. A total of 155 enterococcal bacteremia episodes were identified between July 2007 and December 2009. HLGR strains accounted for 28% of all enterococcal strains: HLGR Enterococcus faecalis/Enterococcus faecium strains accounted for 32%/24%. The 30-day mortality rate was 31%. There was no significant difference in the 30-day mortality rates between HLGR and non-HLGR enterococcal bacteremia. There were two cases of HLGR enterococcal endocarditis, which were successfully treated with ampicillin plus ceftriaxone. We consider it important to examine the presence or absence of HLGR strains in all cases of intractable enterococcal infection, especially infective endocarditis.     

Cardiac device-related endocarditis complicated by spinal abscess

Background: Infective endocarditis is the most serious manifestation of cardiac device infection and metastatic seeding of distant sites has been reported. However, the association between device‐related endocarditis and spinal abscess has not been fully described. Methods: We reviewed hospital records at three high‐volume cardiovascular referral centers from January 2005 to October 2010. Device‐related endocarditis was confirmed in all cases with positive blood cultures and transesophageal echocardiogram revealing lead and/or valvular vegetations. Six patients with spinal abscesses in association with device‐related endocarditis were identified. Results: A total of 384 patients met the clinical criteria for device‐related endocarditis. Among these, infection was complicated by spinal abscess formation in six (1.5%) cases. The mean age of patients was 69.3 ± 11.8 years (47–82 years). The predominant clinical manifestations in these six patients included a recent history of fever (six), malaise (four), and neurological or meningeal signs (five). Spinal abscesses were diagnosed by magnetic resonance imaging in two and computed tomography scans in four of the cases. The causative pathogens were methicillin‐resistant Staphylococcus aureus (three), methicillin‐sensitive S. aureus (one), coagulase‐negative Staphylococci (two), and Enterococcus fecalis (one). All patients underwent complete device removal with no procedure‐related complications. Two patients died in the hospital, two were discharged with permanent neurological deficits, and the remaining two recovered with no permanent neurologic sequelae. Conclusion: Device‐related endocarditis must be considered in patients who present with a spinal abscess and bacteremia. Early recognition of this scenario is imperative in order to avoid permanent neurological sequelae and patient mortality. Early imaging, appropriate parenteral antimicrobial therapy, and expedited removal of all cardiac hardware are pivotal for optimal management. (PACE 2011;1–7)     

Continued Rise in Rates of Cardiovascular Implantable Electronic Device Infections in the United States: Temporal Trends and Causative Insights

Background: Cardiovascular implantable electronic device (CIED) infections have been increasing out of proportion to the number of devices implanted, based on data available through 2003. We investigated recent trends and possible causes of the increasing numbers of CIED infections. Methods: We analyzed the occurrence of CIED infections and the associated changes in characteristics of CIED recipients, using the National Hospital Discharge Survey database from 1996 through 2006. Results: The number of CIED implantations continued to increase after 2003 from 199,516 in 2004 to 222,940 in 2006, representing a 12% increment. In the same period, the number of CIED infections increased from 8,273 in 2004 to 12,979 in 2006, representing a 57% increment. From 1996 to 2006, comorbid illnesses in recipients of new CIED devices became more prevalent with an increasing percentage of patients with end‐organ failures (6.5% in 1996 vs 8.0% in 2006, P < 0.001) and diabetes mellitus (14.5% in 1996 vs 16.5% in 2006, P = 0.005). The proportion of Caucasian recipients also decreased (65.6% in 1996 vs 57.6% in 2006, P < 0.001). During that same period, the number of implanted cardiac resynchronization devices increased dramatically while the age of CIED recipients did not change. Conclusion: The number of patients with CIED‐related infections in the United States continues to increase out of proportion to the increase in implantation rates. Possible causes for this on‐going epidemic include sicker patients with varying racial backgrounds, and more complex procedures. These insights may help improve our ability to best select patients for CIED implantation in "real‐life" settings. (PACE 2010; 414–419)     

Impact of ICD Battery Longevity on Need for Device Replacements—Insights from a Veterans Affairs Database

Background: The number of implantable cardioverter defibrillator (ICD) replacements is increasing, which adds to patient risk and costs. Objectives: To understand the impact of increasing ICD longevity on need for replacements, costs, and some of the risks. Methods: Using the Veterans Affairs records, veterans with ICD implants between June 1992 and April 2007 and dead as of April 2009 were identified. Data were obtained by retrospective records review. The longevity of each ICD was the duration from implant to explant. For each ICD, the longevity needed to avoid one replacement was defined as longevity of that ICD plus the longevity of the subsequent ICD. Results: The study cohort had 164 patients with 301 ICD implants. Ninety‐two patients had at least one ICD replacement. Two patients were excluded for missing data. Twenty‐seven patients had an ICD explanted for reasons other than battery depletion. Sixty‐three patients received 83 ICDs for battery depletion alone. Among 27 patients who had ICD replacements for other reasons, four patients may have avoided a device infection related to ICD replacement if the initial ICD had lasted 7 years. If all ICDs had lasted 5, 7, or 9 years, then 26%, 58%, and 84% of patients, respectively, would not have needed an ICD replacement. Also 17, 37, and 53 ICD replacements, respectively, would have been avoided, saving US$314,500–US$980,500 over 15 years at 2005 Medicare re‐imbursement rates. Conclusions: Prolongation of battery life to 7 or 9 years is important to reduce patient risks and decrease costs. (PACE 2010; 33:314–319)     

Incidence and significance of pacemaker and implantable cardioverter-defibrillator lead masses discovered during transesophageal echocardiography

Background: Pacemaker and implantable cardioverter‐defibrillator device infections are feared complications. The finding of a lead‐associated mass on transesophageal echocardiogram (TEE) raises concern for endocarditis. However, the incidence and clinical importance of lead masses is not currently known. Methods: Consecutive patients with transvenous leads undergoing TEE from July 1, 2003, to June 30, 2005, were identified and assessed for a clinical diagnosis of endocarditis. An echocardiographer blinded to clinical information reviewed all TEEs. Results: Of 177 TEEs performed on 153 patients, a visible mass on a device lead was observed in 25 (14%), including 11 TEEs showing a lead vegetation, 13 TEEs showing lead strands, and one study showing both. Seventeen patients were adjudicated to have endocarditis, of which eight had a mass seen on a lead during TEE. Thus, 72% of patients (18 of 25) with a lead‐associated mass did not have evidence of an infection. In TEEs performed for indications other than to rule out endocarditis, lead masses were seen in 13 of 136 studies (10%), with only one patient adjudicated to clinically have an infected device. Conclusion: During this 2‐year study of consecutive patients with a tranvenous lead undergoing TEE, lead‐associated masses were found in 14% of patients. In 72% of patients, the mass did not prove to be secondary to infectious causes. Thus, masses attached to a device lead should be interpreted in the overall clinical context and, in the absence of concomitant evidence of endocarditis, should not mandate device and lead removal. (PACE 2011; 679–683)     

Transthoracic Echocardiography Is Still Useful in the Initial Evaluation of Patients With Suspected Infective Endocarditis: Evaluation of a Large Cohort at a Tertiary Referral Center

ObjectivesTo examine the sensitivity of contemporary transthoracic echocardiography (TTE) for the detection of vegetation, abscess cavity, or prosthetic valve dehiscence (Vg) in patients with suspected infective endocarditis (IE) and to identify whether a relatively normal initial TTE finding can be effectively used as a rule out test, obviating the need for transesophageal echocardiography (TEE).Patients and MethodsWe evaluated clinical, microbiological, and echocardiographic data for all patients with suspected IE referred for both TTE and TEE between January 1, 2005, and December 31, 2010. Patients were stratified into 3 groups by baseline TTE findings: negative TTE (native valves with less than or equal to mild regurgitation and no Vg), equivocal TTE (no Vg but prosthetic valve or greater than mild native valvular regurgitation), and positive TTE (Vg detected).ResultsWe studied 622 consecutive patients (68% male; mean ± SD age, 62±17 years), including 256 with Staphylococcus aureus bacteremia (SAB). The presence of Vg was confirmed by TEE in 141 patients (23%). The TTE had low sensitivity for the detection of Vg (58%). A total of 271 patients (44%) had an initial negative TTE. Of these, TEE demonstrated Vg in only 8 patients (negative predictive value [NPV] of negative TTE, 97%). The negative TTE group included 132 patients with SAB, only 6 of whom had Vg (NPV, 95%). Of 265 patients with equivocal TTE, Vg was demonstrated in 51 (19%).ConclusionIn a hospital population with clinically suspected IE, TTE had low sensitivity for the detection of Vg; however, a negative initial TTE was a common finding, with a high NPV, even in the setting of SAB. A TEE may be avoided in many patients with suspected IE.     

Treatment Duration for Uncomplicated Staphylococcus aureus Bacteremia To Prevent Relapse: Analysis of a Prospective Observational Cohort Study

Practice guidelines recommend at least 14 days of antibiotic therapy for uncomplicated Staphylococcus aureus bacteremia (SAB). However, these recommendations have not been formally evaluated in clinical studies. To evaluate the duration of therapy for uncomplicated SAB, we analyzed data from our prospective cohort of patients with SAB. A prospective observational cohort study was performed in patients with SAB at a tertiary-care hospital in Korea between August 2008 and September 2010. All adult patients with SAB were prospectively enrolled and observed over a 12-week period. Uncomplicated SAB was defined as follows: negative results of follow-up blood cultures at 2 to 4 days, defervescence within 72 h of therapy, no evidence of metastatic infection, and catheter-related bloodstream infection or primary bacteremia without evidence of endocarditis on echocardiography. Of 483 patients with SAB, 111 met the study criteria for uncomplicated SAB. Fifty-three (47.7%) had methicillin-resistant SAB. When short-course therapy (<14 days) and intermediate-course therapy (≥14 days) were compared, the treatment failure rates (10/38 [26.3%] versus 16/73 [21.9%]) and crude mortality (7/38 [18.4%] versus 16/73 [21.9%]) did not differ significantly between the two groups. However, short-course therapy was significantly associated with relapse (3/38 [7.9%] versus 0/73; P = 0.036). In multivariate analysis, primary bacteremia was associated with a trend toward increased treatment failure (P = 0.06). Therefore, in the treatment of uncomplicated SAB, it seems reasonable to consider at least 14 days of antibiotic therapy to prevent relapse, as practice guidelines recommend. Because of its poor prognosis, primary bacteremia, even with a low risk of complication, should not be treated with short-course therapy.     

ICD and Neuromodulation Devices: Is Peaceful Coexistence Possible?

Aim: The aim of this study was to investigate the potential cross‐talk between implantable cardioverter defibrillator device (ICD) and implantable neuromodulation device (IND) during the implantation procedure and the ventricular fibrillation induction test and in daily life. Methods: We present two cases of patients with an IND who underwent ICD implantation and one case of a patient implanted with a biventricular ICD who received an IND 6 months later. Two of these patients had a spinal cord stimulator (SCS), while the other had a sacral neuromodulator. Results: No cross‐talk was recorded in the patient with the sacral neuromodulator and the ICD. Temporary damage to one of the SCSs was observed after multiple ICD shocks. Conclusions: When implanted contemporarily with sacral or spinal neurostimulators, cardiac devices appear to be safe, as confirmed by the appropriate detection and interruption of arrhythmic episodes. On the other hand, neuromodulation devices could be temporarily or permanently damaged by multiple ICD discharges. It is recommended that the neurostimulator be interrogated after an ICD shock, in order to check the state of the device. (PACE 2011; 690–693)