Pacemaker-related endocarditis. Report of 7 cases and review of the literature

Glomerulonephritis and Septic Pulmonary Embolism: A Rare but Life-Threatening Complication of Permanent Pacemaker Implantation

Infection-related glomerulonephritis (IRGN) is an immunologically mediated glomerular injury triggered by an extrarenal infection. Infective endocarditis-associated glomerular nephritis is an entity caused by infection of the cardiac valves. IRGN is most common in children, and post-streptococcal glomerulonephritis (PSGN) is commonest in the age group of 2-14 years. In contrast to childhood PSGN and epidemic PSGN, which usually resolve completely with antibiotics, IRGN in adults has a guarded prognosis. Cardiovascular implantable electronic device-associated infective endocarditis (CIED-IE) is a phenomenon for which the incidence is on the rise (0.1-5.1%). The most frequent CIED-IE pathogens were staphylococci or other Gram-positive bacteria. CIED-IE poses difficult management problems for the clinician. We present the case of a 50-year-old patient with a pacemaker who was found to have infective endocarditis and septic embolism.

Pseudomonas aeruginosa infective endocarditis in patients who do not use intravenous drugs: Analysis of risk factors and treatment outcomes

BACKGROUND

Infective endocarditis (IE) due to Pseudomonas aeruginosa is rare and accounts for only about 3% of all patients with this disease. Most infections are associated with the use of intravenous drugs. Patients with P. aeruginosa-related IE who do not use intravenous drugs are extremely rare. We carried out a review of the literature to identify the nature and risk factors of this disease.

METHODS

Patients with IE reported between 1993 and 2013 were reviewed by searching the Medline database using the keywords "endocarditis" and "Pseudomonas aeruginosa". All of the patients included met the definition of the modified Duke criteria.

RESULTS

Twenty-seven patients in 22 reports were reviewed. IE associated with health care accounted for 20 patients (74%). The mean age of the patients was 53.4 years and there was a predominance of men (81.5%). Native valve endocarditis was seen in 20 (74.1%) patients. Surgery for infection control was performed in 15 (55.6%) patients and the mortality rate in patients who underwent surgery was 33.3% (five patients). A relapse of IE after adequate treatment was seen in nine (33.3%) patients. The mortality rate in all 27 patients was 28.6% (2/7) for those with community-acquired IE and 40% (8/20) for those with IE associated with health care. Univariate analysis showed a higher mortality rate in patients aged >60 years and in those whose source of endocarditis was related to a prosthetic device.

CONCLUSION

P. aeruginosa endocarditis has substantial morbidity and mortality. It is characterized by easy relapse and is highly associated with prosthetic devices.

Cardiac device-related endocarditis: Epidemiology, pathogenesis, diagnosis and treatment - a review

Cardiac device-related endocarditis (CDE) is a phenomenon for which incidence is on the rise; it presents difficult management problems to the clinician. On one hand, there is the patient who needs the implanted device, and the potential morbidity and mortality associated with its removal. On the other hand, there is the problem of a persistent infection - usually acquired during insertion of an electrical device - that is resistant to many antibiotics, has a high recurrence rate, and necessitates an extensive operation to remove the device if removal is delayed. Most studies recommend device and metal lead replacement if CDE occurs. The aim of the present review is to raise awareness of CDE among clinicians, and to provide an appropriate approach to its management.

Characterization of Staphylococcus lugdunensis endocarditis in patients with cardiac implantable electronic devices

OBJECTIVES

Although the application of cardiac implantable electronic devices (CIED) has greatly increased over the past few decades, CIED endocarditis is becoming a challenging scenario in clinical practice. Recently, Staphylococcus lugdunensis has emerged as a pathogen in CIED endocarditis. However, a detailed phenotypic characterization has not been addressed.

METHODS

We conducted a systematic literature review covering the period between 1989 and 2011 using the PubMed, Medline, Cochrane, and Embase databases. All cases included had a CIED in use and met the modified Duke criteria for infective endocarditis, and all had isolates of S. lugdunensis. The clinical features, predisposing conditions, echocardiographic findings, and therapeutic strategies/outcomes were evaluated. Polymorphonuclear neutrophil functions were examined to test whether the defect of innate immunity may play a permissive role in host susceptibility to tissue destruction in S. lugdunensis endocarditis.

RESULTS

Eleven patients with CIED endocarditis caused by S. lugdunensis were identified. Their mean age was 61.7±11.2 years, and there was a male preponderance (72.7%). Six patients (54.5%) had undergone re-manipulation of the pacing system within a few months to years before the occurrence of clinical symptoms. The median time of symptoms before the diagnosis of CIED endocarditis was 60 days. On echocardiography, vegetations in the CIED were detected in nine cases (81.8%). Nine patients (81.8%) underwent surgical removal of the entire device, and one patient received medical treatment alone. The overall mortality rate was 18.2%. One patient had a septic perforation of the ventricular septum, with a high serum level of N-terminal prohormone of brain natriuretic peptide (NT-pro-BNP) in the absence of pump failure. The assessment of polymorphonuclear neutrophil (PMN) functions revealed normal PMN responses to the various stimuli and normal oxidative burst responses.

CONCLUSIONS

Identification and differentiation of staphylococcal species in a timely manner would allow us to intervene more aggressively at an earlier stage to prevent unfavorable outcomes. Clinicians should never consider the isolation of S. lugdunensis as contamination. In selected individuals, therapeutic abstention may be preferable to exposing patients to a high risk of S. lugdunensis CIED endocarditis due to re-manipulation of the pacing system. The prognostic value of NT-pro-BNP warrants further investigations.

Evidence of MexT-independent overexpression of MexEF-OprN multidrug efflux pump of Pseudomonas aeruginosa in presence of metabolic stress

BACKGROUND

The Pseudomonas aeruginosa MexEF-OprN efflux pump confers resistance to clinically significant antibiotics. Regulation of mexEF-oprN operon expression is multifaceted with the MexT activator being one of the most prominent regulatory proteins.

METHODOLOGY

We have exploited the impaired metabolic fitness of a P. aeruginosa mutant strain lacking several efflux pump of the resistance nodulation cell division superfamily and the TolC homolog OpmH, and isolated derivatives (large colony variants) that regained fitness by incubation on nutrient-rich medium in the absence of antibiotics. Although the mexEF-oprN operon is uninducible in this mutant due to a 8-bp mexT insertion present in some P. aeruginosa PAO1 strains, the large colony variants expressed high levels of MexEF-OprN. Unlike large colony variants obtained after plating on antibiotic containing medium which expressed mexEF-oprN in a MexT-dependent fashion as evidenced by clean excision of the 8-bp insertion from mexT, mexEF-oprN expression was MexT-independent in the large colony variants obtained by plating on LB alone since the mexT gene remained inactivated. A search for possible regulators of mexEF-oprN expression using transposon mutagenesis and genomic library expression approaches yielded several candidates but proved inconclusive.

SIGNIFICANCE

Our results show that antibiotic and metabolic stress lead to up-regulation of MexEF-OprN expression via different mechanisms and that MexEF-OprN does not only extrude antimicrobials but rather serves other important metabolic functions.

Intracardiac lead endocarditis due to Staphylococcus lugdunensis

Staphylococcus Lugdunensis is a rare but potentially aggressive pathogen in the family of coagulase negative staphylococcus (CoNS). It can cause a wide variety of infections ranging from superficial skin to fulminant infections like endocarditis. Both native and prosthetic valve endocarditis due to S. lugdunensis have been documented in the English literature. Eight cases of pacemaker lead endocarditis due to S. lugdunensis have been described so far. We present the ninth case of pacemaker lead and first case of automatic implantable cardioverter defibrillator (AICD) lead endocarditis due to S. lugdunensis.

Fulminant staphylococcus lugdunensis septicaemia following a pelvic varicella-zoster virus infection in an immune-deficient patient: a case report

INTRODUCTION

the deadly threat of systemic infections with coagulase negative Staphylococcus lugdunensis despite an appropriate antibiotic therapy has only recently been recognized. The predominant infectious focus observed so far is left-sided native heart valve endocarditis, but bone and soft tissue infections, septicaemia and vascular catheter-related bloodstream infections have also been reported. We present a patient with a fatal Staphylococcus lugdunensis septicaemia following zoster bacterial superinfection of the pelvic region. case presentation: a 71-year old male diagnosed with IgG kappa plasmocytoma presented with a conspicuous weight loss, a hypercalcaemic crisis and acute renal failure. After initiation of haemodialysis treatment his condition improved rapidly. However, he developed a varicella-zoster virus infection of the twelfth thoracic dermatome requiring intravenous acyclovir treatment. Four days later the patient presented with a fulminant septicaemia. Despite an early intravenous antibiotic therapy with ciprofloxacin, piperacillin/combactam and vancomycin the patient died within 48 hours, shortly before the infective isolate was identified as Staphylococcus lugdunensis by polymerase chain reaction.

CONCLUSION

despite S. lugdunensis belonging to the family of coagulase-negative staphylococci with an usually low virulence, infections with S. lugdunensis may be associated with an aggressive course and high mortality. This is the first report on a Staphylococcus lugdunensis septicaemia following a zoster bacterial superinfection of the pelvic region.

Cardiovascular implantable electronic device infection in patients with Staphylococcus aureus bacteremia

BACKGROUND

Staphylococcus aureus bacteremia (SAB) in patients with cardiovascular implantable electronic devices (CIED), including permanent pacemakers (PPMs) and implantable cardioverter-defibrillators (ICD), can be the sole manifestation of device infection.

METHODS

To assess clinical factors associated with CIED infection, we retrospectively reviewed all patients with both CIED and SAB seen at Mayo Clinic Rochester between 2001 through 2006. CIED infection was defined using microbiological and clinical criteria.

RESULTS

Of the 62 patients with SAB and a CIED, 22 patients (35.5%) had CIED infection. The generator pocket was identified as the source of bacteremia in seven (11%) patients. The majority of CIED infections were device-related infective endocarditis (12 of 22, 55%). Thirty percent of patients presenting with SAB greater than 1 year after device implantation had CIED infection; all but one had CIED-related infective endocarditis. Sixty percent of ICD patients (12 of 20) with SAB had CIED infection, compared with 24% of PPM patients (10 of 42, P = 0.01). On univariate analysis factors associated with CIED-related infective endocarditis included device type [odds ratio (OR) for ICD 13.3, 95% confidence interval [CI] 2.1, 84.9) and presence of a prosthetic heart valve (OR 6.8 95% CI 1.1, 43.4).

CONCLUSIONS

CIED infection is common in patients with SAB. The presence of an ICD and prosthetic heart valve were associated with CIED-related infective endocarditis. Subsequent work should focus on prospectively characterizing the subset of patients with CIED infection who present with SAB as the sole manifestation of their device infection. (PACE 2010; 407-413).

Successful management of multiple permanent pacemaker complications--infection, 13 year old silent lead perforation and exteriorisation following failed percutaneous extraction, superior vena cava obstruction, tricuspid valve endocarditis, pulmonary embolism and prosthetic tricuspid valve thrombosis

A 59 year old man underwent mechanical tricuspid valve replacement and removal of pacemaker generator along with 4 pacemaker leads for pacemaker endocarditis and superior vena cava obstruction after an earlier percutaneous extraction had to be abandoned, 13 years ago, due to cardiac arrest, accompanied by silent, unsuspected right atrial perforation and exteriorisation of lead. Postoperative course was complicated by tricuspid valve thrombosis and secondary pulmonary embolism requiring TPA thrombolysis which was instantly successful. A review of literature of pacemaker endocarditis and tricuspid thrombosis along with the relevant management strategies is presented. We believe this case report is unusual on account of non operative management of right atrial lead perforation following an unsuccessful attempt at percutaneous removal of right sided infected pacemaker leads and the incidental discovery of the perforated lead 13 years later at sternotomy, presentation of pacemaker endocarditis with a massive load of vegetations along the entire pacemaker lead tract in superior vena cava, right atrial endocardium, tricuspid valve and right ventricular endocardium, leading to a functional and structural SVC obstruction, requirement of an unusually large dose of warfarin postoperatively occasioned, in all probability, by antibiotic drug interactions, presentation of tricuspid prosthetic valve thrombosis uniquely as vasovagal syncope and isolated hypoxia and near instantaneous resolution of tricuspid prosthetic valve thrombosis with Alteplase thrombolysis.

From clinical microbiology to infection pathogenesis: how daring to be different works for Staphylococcus lugdunensis

Staphylococcus lugdunensis has gained recognition as an atypically virulent pathogen with a unique microbiological and clinical profile. S. lugdunensis is coagulase negative due to the lack of production of secreted coagulase, but a membrane-bound form of the enzyme present in some isolates can result in misidentification of the organism as Staphylococcus aureus in the clinical microbiology laboratory. S. lugdunensis is a skin commensal and an infrequent pathogen compared to S. aureus and S. epidermidis, but clinically, infections caused by this organism resemble those caused by S. aureus rather than those caused by other coagulase-negative staphylococci. S. lugdunensis can cause acute and highly destructive cases of native valve endocarditis that often require surgical treatment in addition to antimicrobial therapy. Other types of S. lugdunensis infections include abscess and wound infection, urinary tract infection, and infection of intravascular catheters and other implanted medical devices. S. lugdunensis is generally susceptible to antimicrobial agents and shares CLSI antimicrobial susceptibility breakpoints with S. aureus. Virulence factors contributing to this organism's heightened pathogenicity remain largely unknown. Those characterized to date suggest that the organism has the ability to bind to and interact with host cells and to form biofilms on host tissues or prosthetic surfaces.

Pacemaker Endocarditis in Patients with Prosthetic Valve Replacements: Case Trilogy and Literature Review

Infective endocarditis is not uncommon in patients with both a permanent pacemaker system and a prosthetic valve. No guidelines exist to aid management. The recommendations for pacemaker infective endocarditis alone are limited and contradictory. We present a case trilogy and literature review that highlights these shortcomings and the challenges facing physicians. Complete extraction of the infected pacemaker system is essential. The timing of extraction, duration of antibiotic therapy, and timing of reimplantation are all controversial. The presence of a concomitant prosthetic valve exacerbates these dilemmas further.

Outcome after complete percutaneous removal of infected pacemaker systems and implantable cardiac defibrillators

The mortality of retained, infected pacemaker systems is high. We assessed the safety and rate of relapse of infection after complete percutaneous removal of leads of infected pacemaker systems. None of the 40 subjects experienced procedure-related mortality and there were no cases of relapse after a median duration of follow up of 8 years (range, 3 months to 12 years). Procedure-related complications and other adverse events during therapy are reported. Percutaneous removal of infected pacemakers in conjunction with appropriate antibiotic therapy is safe and effective.

Septicemia in a young dog following treatment of patent ductus arteriosus via coil occlusion

CASE DESCRIPTION-A 12-week-old female English Springer Spaniel was evaluated for lethargy, vomiting, and pyrexia 1 week after treatment of patent ductus arteriosus (PDA) via coil occlusion. CLINICAL FINDINGS-Test results were consistent with septicemia, and the assumption was made that the PDA occlusion coils were infected. Radiography revealed partial migration of the coil mass into the pulmonary artery and signs of congestive heart failure. TREATMENT AND OUTCOME-After successful treatment of the septicemia and heart failure, surgical removal of the coils and resection of the PDA were undertaken. Although the coil that embolized to the pulmonary vasculature was left in place, the dog's clinical signs resolved. CLINICAL RELEVANCE-This case highlights the fact that as PDA coil occlusion devices become more widely used in dogs, practitioners must be prepared to treat implant infections aggressively, with both medical and surgical interventions if necessary.

Aspergillus pacemaker endocarditis presenting as pulmonary embolism

Pacemaker endocarditis (PME) is a rare but severe complication of endocardial pacemaker implantation. Fungal PME is extremely uncommon. The case of a 66-year-old female patient who was diagnosed as having a pulmonary embolus based upon the patient's clinical presentation and computed tomography angiography findings is presented. Transthoracic echocardiography demonstrated a huge vegetation attached to the pacemaker wire. The pacemaker system was removed surgically during cardiovascular bypass. The vegetation was cultured, the results of which were positive for Aspergillus spp. No risk factors for Aspergillus infection were found in the patient. She was treated with liposomal amphotericin B for 3 weeks, followed by itraconazole for 40 weeks. At 1 year later, the patient remains asymptomatic.

Staphylococcus lugdunensis infective endocarditis: description of 10 cases and analysis of native valve, prosthetic valve, and pacemaker lead endocarditis clinical profiles

OBJECTIVE

To evaluate the incidence and the clinical and echocardiographic features of infective endocarditis (IE) caused by Staphylococcus lugdunensis and to identify the prognostic factors of surgery and mortality in this disease.

DESIGN

Prospective cohort study.

SETTING

Study at two centres (a tertiary care centre and a community hospital).

PATIENTS

10 patients with IE caused by S lugdunensis in 912 consecutive patients with IE between 1990 and 2003.

METHODS

Prospective study of consecutive patients carried out by the multidisciplinary team for diagnosis and treatment of IE from the study institutions. English, French, and Spanish literature was searched by computer under the terms "endocarditis" and "Staphylococcus lugdunensis" published between 1989 and December 2003.

MAIN OUTCOME MEASURES

Patient characteristics, echocardiographic findings, required surgery, and prognostic factors of mortality in left sided cases of IE.

RESULTS

10 cases of IE caused by S lugdunensis were identified at our institutions, representing 0.8% (four of 467), 1.5% (two of 135), and 7.8% (four of 51) of cases of native valve, prosthetic valve, and pacemaker lead endocarditis in the non-drug misusers. Native valve IE was present in four patients (two aortic, one mitral, and one pulmonary), prosthetic valve aortic IE in two patients, and pacemaker lead IE in the other four patients. All patients with left sided IE had serious complications (heart failure, periannular abscess formation, or shock) requiring surgery in 60% (three of five patients) of cases with an overall mortality rate of 80% (four of five patients). All patients with pacemaker IE underwent combined medical treatment and surgery, and mortality was 25% (one patient). In total 59 cases of IE caused by S lugdunensis were identified in a review of the literature. The combined analysis of these 69 cases showed that native valve IE (53 patients, 77%) is characterised by mitral valve involvement and frequent complications such as heart failure, abscess formation, and embolism. Surgery was needed in 51% of cases and mortality was 42%. Prosthetic valve endocarditis (nine of 60, 13%) predominated in the aortic position and was associated with abscess formation, required surgery, and high mortality (78%). Pacemaker lead IE (seven of 69, 10%) is associated with a better prognosis when antibiotic treatment is combined with surgery.

CONCLUSIONS

S lugdunensis IE is an uncommon cause of IE, involving mainly native left sided valves, and it is characterised by an aggressive clinical course. Mortality in left sided native valve IE is high but the prognosis has improved in recent years. Surgery has improved survival in left sided IE and, therefore, early surgery should always be considered. Prosthetic valve S lugdunensis IE carries an ominous prognosis.

Causative organisms of infective endocarditis according to host status

A prospective study of infective endocarditis (IE) was conducted between 1994 and 2000 in Marseilles, France, and included 170 definite cases diagnosed with the use of modified Duke criteria. Classification of IE based on the aetiological agent was related to epidemiological characteristics, including age, gender and the nature of the injured valve. Enterococci and Streptococcus bovis were identified more frequently in older subjects (p 0.02), and S. bovis was also associated with mitral valve infection (p 0.03). Streptococcus spp. were found to be associated with native valves (p < 10(-3)), whereas coagulase-negative staphylococci and Coxiella burnetii were associated with intracardiac prosthetic material (p < 0.05). S. bovis and Staphylococcus aureus were the predominant species associated with presumably healthy valves (p < 0.05), whereas oral streptococci caused IE exclusively in patients with previous valve damage. The basic host status of IE patients has been linked to specific microorganisms, and this may be of value when empirical treatment is needed in patients who have received previous antibiotic therapy and whose blood cultures are negative.

Successful treatment of pacemaker related endocarditis with acute embolic stroke without device removal

Pacemaker related endocarditis is a rare potentially fatal condition, most commonly acquired during manipulation of the pacemaker system. Most patients have involvement of the right heart. Only rarely has involvement of the left-heart been documented. In the absence of controlled studies regarding management of such cases, many recommend complete removal of the pacing system along with intravenous antibiotics. We present a patient with documented pacemaker related left-sided endocarditis associated with an acute embolic stroke who was treated with antibiotics with complete recovery and its two-year follow up.

Staphylococcus lugdunensis infections: high frequency of inguinal area carriage

Following a change in surgical practice, we noted that the rate at which Staphylococcus lugdunensis was isolated from samples from the plastic surgery unit of our hospital increased considerably. We investigated the sources of these S. lugdunensis strains, and we found that in the case of drain colonization or surgical site infection, the strain was more likely to have come from the patient's skin bacteria when the pubic site had been shaved preoperatively. To test the hypothesis of pubic site colonization, we evaluated the prevalence of S. lugdunensis carriage among the cutaneous flora of the inguinal area. We found that 22% of 140 incoming patients carried S. lugdunensis in this area and that carriage at both inguinal folds was frequent (68% of carriers). A study of the genetic structure of the total population, including the clinical (n = 18) and the commensal (n = 53) strains, revealed that the diversity of the species was low and that the population was composed of two major groups that diverged at a distance of 35%. No particular characteristics made it possible to distinguish between clinical and commensal strains. Only isolates producing beta-lactamase were homogeneous; six of the eight beta-lactamase-positive strains displayed the same pulsed-field gel electrophoresis pattern.

Acp. Best practice no 155. Pathological investigation of deaths following surgery, anaesthesia, and medical procedures

The pathological investigation of deaths following surgery, anaesthesia, and medical procedures is discussed. The definition of "postoperative death" is examined and the classification of deaths following procedures detailed. The review of individual cases is described and the overall approach to necropsy and interpretation considered. There are specific sections dealing with the cardiovascular system (including air embolism, perioperative myocardial infarction, cardiac pacemakers, central venous catheters, cardiac surgery, heart valve replacement, angioplasty, and vascular surgery); respiratory system (postoperative pneumonia, pulmonary embolism, pneumothorax); central nervous system (dissection of cervical spinal cord), hepatobiliary and gastrointestinal system; musculoskeletal system; and head and neck region. Deaths associated with anaesthesia are classified and the specific problems of epidural anaesthesia and malignant hyperthermia discussed. The article concludes with a section on the recording of necropsy findings and their communication to clinicians and medicolegal authorities.