A 64-year-old man comes to the office with pain and swelling over the left upper chest for 7 days. He also had an episode of fever, but no cough, sore throat, abdominal pain, diarrhea, or urinary symptoms. Five months ago, the patient had a single-lead implantable cardioverter-defibrillator placed due to a sudden cardiac arrest. His other medical problems include nonischemic cardiomyopathy (ejection fraction, 20%) and chronic kidney disease.
Temperature is 36.7 (98 F) , blood pressure is 109/70 mm Hg, pulse is 70/min, and respirations are 16/min. Pulse oximetry is 95% on room air. Examination shows clear lungs and normal S1 and S2. Swelling, erythema, and tenderness are present over the defibrillator generator. A small amount of discharge is seen through an erosion of the healed suture line.
Leukocytes are 11,200/mm³. Two sets of blood cultures are negative after 2 days.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Infection of a cardiovascular implantable electronic device (CIED) (ie, pacemaker, implantable cardioverter-defibrillator) has become common due to the increased frequency of device placement. Appropriate management of a known or suspected CIED infection involves removal of the entire device (generator and leads) if any of the following are present: Evidence of valve or lead vegetation on transesophageal echocardiogram (TEE)Positive blood cultures with an organism with high propensity for causing infective endocarditis (eg, Staphylococcus, Streptococcus, or Candida spp)Evidence of pocket infection, including localized pain/tenderness, erythema, swelling, purulent drainage, or skin erosion Evidence of valve or lead vegetation on transesophageal echocardiogram (TEE) Positive blood cultures with an organism with high propensity for causing infective endocarditis (eg, Staphylococcus, Streptococcus, or Candida spp) Evidence of pocket infection, including localized pain/tenderness, erythema, swelling, purulent drainage, or skin erosion In patients with suspected endocardial involvement (such as this patient with pain, swelling, and purulent drainage), device removal should be followed by appropriate antibiotic treatment for infective endocarditis (eg, 6 weeks of therapy). Patients with CIED pocket infection but no evidence of endocardial involvement (eg, those with negative blood cultures and unremarkable TEE) can receive 2 weeks of antibiotic therapy following device removal. When needed, reimplantation of a new CIED is performed on the contralateral side of the chest once appropriate source control of the infection is achieved. (Choice A) Incision and drainage followed by prolonged antibiotic treatment may be appropriate for patients with a short life expectancy or those in whom CIED removal is strongly contraindicated (eg, removal is likely to cause severe cardiac injury); however, it is not appropriate in most cases. (Choice C) Removal of the CIED generator without removing the leads is associated with treatment failure and increased mortality, likely due to frequent infection of the leads with microbial biofilm. (Choice D) Staphylococcus aureus and coagulase-negative Staphylococcus are the most common causes of CIED infection, and treatment with an anti-staphylococcal antibiotic (eg, vancomycin) is often appropriate. However, adequate treatment of the infection also requires CIED removal. Educational objective: In the case of known or suspected infection of a cardiovascular implantable electronic device, removal of the device (generator and leads) is indicated if there is echocardiographic evidence of valve or lead vegetation, blood cultures positive for a common infective endocarditis-causing organism, or evidence of pocket infection. Removal of the device should be accompanied by an appropriate course of antibiotic therapy. __________ References: AHA scientific statement. (http://www.ncbi.nlm.nih.gov/pubmed/15956145)

A 64-Year-Old Man Comes to the Office with Pain and Swelling