Moffitt <3 AM report PEARLS 11/3: AICD removal

Take-home point: when a patient with an AICD has bacteremia, think about whether device removal is indicated (more on indications below!). If it is, think about whether the patient is pacer-dependent or not and consider placing epicardial leads if so. You don’t want to replace the device for at least 4-6 weeks (after complete treatment and ensuring no complications).

4 major indications for lead removal:

  1. Infection
  2. Venous occlusion (i.e. anytime you are needing to place a stent for stenosis/occlusion, lead should be removed to avoid lead being trapped between stent and vessel wall)
  3. Mechanical lead failure (leading to improper pacemaker function or inappropriate ICD shocks)
  4. Advisory or recall by the company

Infectious indications for lead removal:

  • Valvular or lead-associated endocarditis
  • Pocket infection (i.e. abscess)
  • Device erosion through the skin
  • Chronically draining sinus tract/fistula from pocket to skin
  • *NOT necessary for incisional infection without involvement of device or leads


How about bacteremia without obvious device infection?

  • Staph bacteremia without alternative source
  • Any bacteremia that persists or recurs without alternative source despite appropriate abx
  • Whenever patient undergoes valve replacement or repair for infective endocarditis


Complications of lead extraction:

  • Perforation (esp if lead has been in for a long time, there is much more fibrosis around the lead so it is harder to extract)
    • –> pericardial effusion (tamponade)
    • *If there is a microperforation, effusion/tamponade may not manifest until days/weeks out

A few bonus points from the hour:

Indications for early surgery for endocarditis: valvular heart failure, highly resistant organism, prosthetic valves, abscess/fistula/heart block, persistent infection on appropriate abx. For more, check out SFGH AM report PEARLS from 10/5 and 10/27!

Daptomycin for pulmonary septic emboli from MRSA endocarditis: from an HH pearl at 8/26 AM report: “The classic teaching is that daptomycin should not be used for MRSA pneumonia because dapto is inactivated by pulmonary surfactant. However, in a patient with pulmonary septic emboli, this is due to hematogenous spread and is not primary an airspace disease, so you can consider dapto in this case.”

Lastly, a plug for treating Staph aureus bacteremia: always treat a positive blood culture as a TRUE infection! ID consults have been shown to improve mortality because of aggressive w/u for source of infection and metastatic foci of infection; aggressive removal of prosthetic devices, and improved antibiotic choice and duration.



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