Cured infection or not?

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Frank Bracke's picture
Frank Bracke
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Joined: 2015-05-15 05:29
Cured infection or not?

A 73-year-old female patient is known with an mechanical aortic valve replacement in 2007 followed by a DDD pacemaker because of sick sinus syndrome. Last box replacement in 2015

She was admitted in the referring hospital with fever, chills and one day later back pain diagnosed as spondylodiscitis. Blood cultures were positive for streptococcus infantarius. TEE showed a small mobile structure on the pacing lead. PET scan was negative (3 weeks after start of treatment with antibiotics). The referral hospital decided for treatment with iv antibiotics during 6 weeks. She recovered, CRP from 132 at the start returned to normal.

She was discharged, but did not feel completely well afterwards. She was readmitted two weeks later with a one time fever of 38.1 C, but negative blood cultures and normal CRP. A new TEE showed the possible small vegetation (see movie). She was discharged without treatment but referred for lead extraction. When she was admitted in our hospital she felt well, no fever, normal CRP 25 days after the last gift of antibiotics.

My question: proceed with lead extraction or wait and see? She is not pacemaker dependent, possibly can live without a device.

Frank Bracke's picture
Frank Bracke
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Comment: 

An update about this patient.

There was a lot to say in favour of abstaining from lead extraction: the patient is free of complaints, and there are no signs of infection 25 days after the last gift of antibiotics. Lead extraction of 10-year-old leads is not without any risk.

Further, it remains dubious if the attachment seen on the lead is indeed a vegetation: often, fibrous strands can be seen on leads outside the setting of (possible) infection (1).

Streptococcus infantarius is known to be related to colonic cancer, and this might have been the source of infection (however screening of the digestive tract did not indicate it as a source). Lead did not need to be involved as spondylodiscitis has also been described as a complication of streptococcus infantarius bacteraemia, thus this could be the sole focus of the infection.

Some of these arguments may also be used in favour of lead extraction. We have seen patients with intermittent (short) self-limiting bouts of septicaemia, with silent periods of weeks to months in between without any symptoms or signs of infection. Therefore with such a short follow-up a simmering infection cannot be ruled out yet. And Streptococcus infantarius is a known cause of endocarditis. Further, spondylodiscitis is also known to be associated with lead endocarditis (2).

However, the main argument in favour of extraction was the presence of a mechanical valve. There were no signs of involvement of the valve at that time, but in case of a recurrence, this would be a major risk for the patient. In the absence of a mechanical valve we would have refrained from extraction and followed the patient.

Finally, we extracted the leads (it was helpful that the patient also insisted on extraction, even after discussing all arguments against it). The extraction went uneventful.

As we were still ambivalent about the presence of infection, we only administered a single dose of antibiotics before the procedure and none afterwards waiting for a rise in CRP after infection, which normally happens with infected leads in our experience, and for positive cultures. But there was no rise in CRP after the procedure, no fever and negative cultures of the leads. Now about 6 weeks after the procedure, she is still free of complaints.

So finally, I think there has been no device or lead related infection, but the decision to extract the leads remains valid with the available evidence at the time.

 

1.     Downey BC, Juselius WE, Pandian NG, Estes NAM, Link MS. Incidence and significance of pacemaker and implantable cardioverter-defibrillator lead masses discovered during transesophageal echocardiography. Pacing Clin Electrophysiol. 2011 Jun;34(6):679–83.

2.     Klug D, Lacroix D, Savoye C, Goullard L, Grandmougin D, Hennequin J, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation. 1997;95(8):2098–107. 

 

Bruce Wilkoff's picture
Bruce Wilkoff
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Comment: 

Nicely summarized Frank.  The good news is this isn't as bad of a bacteria as we often see and is generally more sensitive to antibiotics. I think I would have given antibiotics post extraction, which I support because you are still not out of the woods.  (Does that translate around the world?)  Particularly the question is about reimplantation.and the risk of residual infection of the mechanical valve, more indolent and later to crop up.  If it is possible to not reimplant that is good, sometimes possible with sinus node dysfunction.  Now you are faced with possible reimplantation, possible future recurrence and you didn't give it your best shot, reducing the infection burden and using antibiotics.  Hope it works out, but I have seen these come back late, even more than a year later.

Just another point. It isn't rare that a surgeon takes an infected valve to surgery for replacement and fails to remove the pacemaker system also likely colonized/infected. Make sure every case is evaluated from diagnosis to final therapy and not focus just on the first problem.

Frank Bracke's picture
Frank Bracke
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Joined: 2015-05-15 05:29
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Thank you for the comments.

Luckily, there was no need for reimplantation in this patient.

I must admit that my approach was somewhat ambivalent. My estimation was that the odds of a device related infection was quite low and I was quite hesitant to proceed with the extraction. In the end, it came down to comparing the risk of extraction and that of a recurrent infection with possible mechanical valve endocarditis. Lead extraction has a mortality of around 0.25% in our hospital over the last 10 years. I presumed that even if the risk of an artificial valve endocarditis was maybe only 10%, with the high mortality of prosthetic valve endocarditis, lead extraction would still be favourable regarding outcome, even it proves to be unnecessary in most patients.

It should indeed have been more consequential if we had extracted the leads followed by a course of antibiotic treatment. However, this would have had the consequence of a prolonged hospital stay, and possibly no good endpoint as cultures were negative and CRP was normal before the procedure.  I therefore used a possible infectious response after lead extraction as a diagnostic indicator to determine if the leads were contaminated:  in our experience, there is almost always a clear rise in CRP after lead extraction for documented CIED infection with either a femoral approach or sheaths that have to go down to the myocardium, even if the patient has clinically responded well to antibiotic therapy. As there was no rise in CRP, and later no positive cultures, I presumed there had been no infection of the leads from the start and we refrained from antibiotics.

I understand that this is a weird form of diagnostics, but I wonder if anyone agrees that this can be a valid observation.