Long-Term Suppressive Antimicrobial Therapy for Intravascular Device-Related Infections

doi:10.1097/00000441-200110000-00011

The American Journal of the Medical Sciences

Volume 322, Issue 4, October 2001, Pages 209-212

https://doi.org/10.1097/00000441-200110000-00011 Get rights and content

ABSTRACT

Background

Long-term suppressive antimicrobial therapy is an alternative treatment choice in patients with medical device-related infection who are not eligible for surgical device removal for attempted cure. There is a paucity of data published that examines this treatment option.

Methods

Members of the Infectious Diseases Society of America’s Emerging Infections Network were polled to identify patients with intravascular device-related infections who were not candidates for surgery and were given long-term antimicrobial therapy to suppress clinical manifestations of infection.

Results

Clinical and microbiologic data were collected retrospectively for 51 patients. Sixty-nine percent of patients were men; vascular grafts were the most common type of medical device infected [30 (58.8%) patients]. Sixty-three percent (32 of 51) of cases involved Gram-positive cocci. A variety of antimicrobials were administered as chronic suppressive therapy, with β-lactams used most frequently (39.2%). Therapy ranged from 3 months to 10 years. Three (7.32%) of 41 patients in whom follow-up data were available developed relapsing infection while on long-term suppressive therapy. Three other patients suffered drug adverse events.

Conclusions

Overall, long-term suppressive therapy was well-tolerated and efficacious in preventing signs of infection relapse.

Section snippets

Materials and Methods

An initial query form was mailed to approximately 790 EIN members in January 2000 to obtain clinical data of patients administered long-term suppressive therapy for intravascular infection. The EIN is a sentinel network of infectious diseases consultants who report on unusual cases or phenomena seen in their respective clinical practices that might have broad epidemiologic or public health significance. It is sponsored by the Infectious Diseases Society of America and funded by a Cooperative

Results

Sixty-five EIN members responded to the initial query. Thirteen (20.0%) of them indicated that they had not given patients long-term suppressive therapy for intravascular device-related infections. Patient data from 6 of the remaining 52 members were excluded for the following reasons: the primary site of infection was bone and not intravascular (n = 1); no member name was included on the query form (n = 1); the patient had been managed before 1990 (n = 1); and no patient-specific information was

Discussion

The risk of intravascular device-related infection has increased⁸ because of at least 3 factors: (1) an ever-enlarging pool of patients has had indwelling medical devices implanted for sustaining or improving life; (2) an increasing number of novel medical devices have become available; and (3) nosocomial infections have increased, which has resulted in contamination of indwelling medical devices.

A survey of the IDSA’s EIN membership was conducted to retrospectively collect clinical data for 51

Acknowledgments

We thank Laura Liedtke and Larry J. Strausbaugh for their generous assistance in polling the EIN membership for case data, Mandana Mobasseri for a superb effort in data analysis, and Sandra R. Tallant for excellent manuscript preparation. We would also like to thank Darilyn H. Dealy, Mary Ramundo, Daniel J. Sexton, and Janara Younger for providing case data.

Infectious Diseases Society of America’s Emerging Infections Network

Additional case data for this series were provided by the following members: John M. Boggs, Palo Alto Medical Foundation, Palo Alto, CA; Jane L. Burns, University of Washington Children’s Hospital and Regional Medical Center, Seattle, WA; Kenneth C. Earhart, Naval Medical Center, San Diego, CA; Sylvia A. Firary, Gundersen Lutheran, La Crosse, WI: Michael W. Fitzgibbons, UC Irvine Medical Center, Orange, CA; E. Patricia Gill, Longmont Clinic, PC, Longmont, CO; Daniel P. Gluckstein, Inland Valley

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Treatment and Prevention of Cardiovascular Implantable Electronic Device (CIED) Infections
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Citation Excerpt :
Long-term suppressive therapy should be considered for only those patients who have CIED infection and are not candidates for complete device removal. Such patients may have unacceptable risk of device removal, inability to reimplant, loss of CRT, high risk of reinfection related to inadequate source control of infections at other sites, or life expectancy of less than 1 year.28,66 For this approach to be viable, an initial 4-6-week course of intravenous antibiotic therapy should be given, as for prosthetic valve endocarditis associated with clinical improvement and clearance of bacteremia (if present), followed by long-term suppressive oral antimicrobial therapy.3
An expanded role for cardiac implantable electronic devices (CIEDs) in recent decades reflects an aging population and broader indications for devices, including both primary prevention and management of dysrhythmias. CIED infection is one of the most important device-related complications and has a major impact on mortality, quality of life, healthcare utilization, and cost. Unfortunately, the investigation and management of CIED infection remain complex, often necessitating complete and timely removal of the device and leads in order to eradicate the infection. In addition, the translation of knowledge from an extensive literature to a disparate group of medical practitioners has often been inadequate. This review of CIED infection management highlights the significant advances made during the past decade, including diagnostic criteria, advanced imaging, and next-generation sequencing for culture-negative cases or those in which uncertainty remains. We also outline the role and indication for powered lead extraction, the process of antibiotic choice and treatment duration, considerations related to the timing and location for reimplantation, and preimplantation risk stratification and associated interventions to reduce the risk of CIED infection.
L’élargissement du rôle des dispositifs électroniques cardiaques implantables (DECI) au cours des dernières décennies reflète le vieillissement de la population et les indications plus vastes des dispositifs, notamment dans la prévention primaire et la prise en charge des dysrythmies. Les infections liées aux DECI sont l’une des plus importantes complications liées aux dispositifs et ont des conséquences majeures sur la mortalité, la qualité de vie, l’utilisation et les coûts des soins de santé. Malheureusement, le dépistage et la prise en charge des infections liées aux DECI demeurent complexes et nécessitent souvent le retrait complet et rapide du dispositif et des sondes en vue d’éradiquer l’infection. De plus, l’application des connaissances issues d’une vaste littérature à un groupe disparate de médecins praticiens a souvent été inadéquate. La présente revue sur la prise en charge des infections liées aux DECI illustre les avancées importantes réalisées au cours de la dernière décennie, notamment les critères diagnostiques, l’imagerie avancée et le séquençage de prochaine génération des cas à culture négative ou de ceux pour lesquels des incertitudes demeurent. Nous avons aussi décrit le rôle et les indications d’extraction des sondes fonctionnelles, le processus du choix des antibiotiques et de la durée du traitement, les considérations relatives au moment et au lieu de la réimplantation, et la stratification du risque en préimplantation et les interventions associées afin de réduire le risque d’infections liées aux DECI.
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The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF.
A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed.
During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality.
These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.
2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction
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Chronic Infections of the Heart
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Successful management of vascular graft infection: The role of 18fluorodeoxyglucose positron emission tomography/computed tomography
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La opción de un injerto vascular es una medida correctiva para pacientes con enfermedad arterial periférica o aneurismas y para acceso arteriovenoso en pacientes con hemodiálisis crónica. A partir de la colocación de una prótesis de injerto vascular se puede desarrollar infección asociada en el 1-6% de los pacientes, con una alta incidencia de mortalidad del 13 al 58%. El diagnóstico de una infección asociada a injerto vascular se realiza a partir de hallazgos clínicos, microbiológicos e imagenológicos, para así definir, además de su presencia, su compromiso y extensión. El manejo ideal requiere de tratamiento quirúrgico y antibioticoterapia; sin embargo, el tratamiento quirúrgico no siempre es posible. Reportamos este caso de manejo médico exitoso de una infección de injerto vascular de aorta en la cual el 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) presentó utilidad como método diagnóstico y de seguimiento.
The option of a vascular graft is a corrective intervention for patients with peripheral artery disease, aneurisms, and to achieve arterio-venous access in patients on chronic hemodialysis. Infections from a prosthetic vascular graft occurs in 1 to 6% of patients, and this development is related to the incidence of mortality of 13 to 58%. The diagnosis of a vascular graft infection is made via the combination of clinical, microbiologic and imaging findings that allow a definition of not only the presence of infection but also its severity and spread. The ideal approach requires both surgical and antimicrobial therapy; however, the former is not always possible. We report a case of successful medical management of an aortic vascular graft infection and the usefulness of a 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) scan as a tool for diagnosis and follow-up.
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Along with the increased frequency of implantation, the incidence of cardiac implantable electronic device (CIED) infection, which can have serious or fatal complications, has also increased. Although several successful conservative therapies for CIED infection have been reported, retained infected devices remain a source of relapse, which is closely related to a higher mortality rate. Presently, complete hardware removal is initially recommended for infected CIED patients, and indications for conservative therapy, including continuous administration of antibiotics, require careful consideration.
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: The Infectious Diseases Society of America Emerging Infections Network is supported by Cooperative Agreement U50/CCU112346 from the Centers for Disease Control and Prevention.

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Original ArticlesLong-Term Suppressive Antimicrobial Therapy for Intravascular Device-Related Infections

ABSTRACT

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Infectious Diseases Society of America’s Emerging Infections Network

Long-term suppressive therapy for fungal endocarditis

Clin Infect Dis

Surgical and long-term antifungal therapy for fungal prosthetic valve endocarditis

Ann Thorac Surg

Successful treatment of fungal prosthetic valve endocarditis: case report and review

Clin Infect Dis

Role of fluconazole in the long-term suppressive therapy of fungal infections in patients with artificial implants

Mycoses

Original Articles
Long-Term Suppressive Antimicrobial Therapy for Intravascular Device-Related Infections