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:
- 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)
- Mechanical lead failure (leading to improper pacemaker function or inappropriate ICD shocks)
- 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.