Device-related infections

Last updated: September 8, 2022

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Device-related infections are associated with surgical implants, e.g., pacemakers or joint prostheses. Clinical presentation ranges from asymptomatic infections resulting from device erosion, to severe systemic illness, sepsis, and septic shock. Diagnosis is generally clinical, supported by laboratory and imaging studies and intraoperative evidence of infection. Diagnosis is confirmed by microorganism growth in cultures taken from or near the device, or by evidence of infection on biopsy samples. Management is multidisciplinary, with assistance from surgical teams and infectious disease services, and it includes antibiotic therapy and invasive treatment of the device (usually removal).

This article provides an overview of the diagnosis and management of common device-related infections. See also “Intravascular catheter-related bloodstream infections” and “Hospital-acquired infections.”

Epidemiological data refers to the US, unless otherwise specified.

  • Most often due to bacteria
  • Infections can result from:
    • Contamination of the device (e.g., during surgery, trauma)
    • Seeding of the device from bacteremia
    • Spread from a contiguous infection (e.g., deep tissue infection)
Etiology of device-related infections [3][4][5][6][7][8][9]
Device Common causative pathogens
Cardiac
Neurosurgical
Orthopedic
Vascular
Reproductive
  • Penile implant
Urological

Patients may present with symptoms localized to the site of the device, systemic symptoms (e.g., fever, chills), and/or bacteremia; see also “Fever” and “Sepsis.”

Cardiac devices [10][11]

Neurosurgical devices [6]

Orthopedic hardware [6]

  • Early onset (< 4 weeks)
  • Late onset (> 10 weeks)
    • Persistent pain
    • Wound drainage or sinus tract
    • Loosening of the implant

Vascular devices [9]

Symptoms depend on the location of the vascular graft infection.

Reproductive and genitourinary devices [6]

Breast implants [7]

Infections involving breast implants are typically unilateral.

Sepsis rarely occurs in breast implant infections. [6]

Penile implants [6][8][12]

  • Acute (< 6 weeks)
    • Erythema
    • Systemic symptoms (e.g., fever)
    • Pain over the area of the prosthesis
    • Induration
    • Drainage
    • Device exposure
  • Chronic (≥ 6 weeks)
    • Pain over the area of the prosthesis
    • Device migration

The approach to management varies based on the site of infection. Management should be specialist-guided.

  • Order initial diagnostics.
    • General diagnostics:
      • Inflammatory markers including CBC: elevations are nonspecific but may be useful for monitoring infection
      • BMP: Patients with impaired renal function require adjustments to renally dosed antibiotics.
    • Microbiological studies (obtained before initiation of antibiotics if possible)
      • Blood cultures (2 sets) [13]
      • Wound or device cultures (preferably from deep tissue or surgical procedure)
    • Imaging studies: often necessary to support the diagnosis and for surgical planning
  • Start antibiotics.
  • Provide supportive care, e.g.:
  • Consider the need for device removal: Consult appropriate services (e.g., neurosurgery, vascular surgery).
  • Choose an appropriate care setting: e.g., ICU care for patients with severe sepsis or septic shock

If present, start immediate management of sepsis or septic shock (e.g., immediate hemodynamic support with IV fluids and/or vasopressors) and empiric antibiotics.

Management of all device-related infections requires a multidisciplinary approach.

This section covers infections related to cardiac implantable electronic devices (CIEDs), e.g., pacemakers, and ventricular assist devices (VADs). For prosthetic heart valve infections, see “Infective endocarditis.”

Diagnostics [3][10][11]

Duke criteria can be used for suspected cardiac device-associated endocarditis. [3]

Diagnostic device pocket needle aspiration should be avoided because of the risk of introducing bacteria. [10]

Treatment [3][4][10]

Antibiotic therapy [3][10]

Invasive therapy [4][14]

CIED removal is usually not needed in superficial or incisional infections. [14]

This section covers infections related to CSF shunts and drains , neurostimulators, and intraspinal pumps.

Diagnostics [15][16]

All patients require general blood tests, CSF studies, and neuroimaging.

Laboratory studies

Negative CSF cultures in patients who have previously received antimicrobial therapy do not rule out health care-associated meningitis or ventriculitis.

An elevated serum procalcitonin may help distinguish bacterial infections from intracranial hemorrhage or surgery as the cause of abnormal CSF studies in patients with negative cultures.

Imaging studies

Treatment [15][16]

This section covers infection after fracture fixation (IAFF); for prosthetic joint infection (PJI), see “Septic arthritis.”

Diagnostics [17][18]

General principles

  • A diagnosis can be made in patients with either: [17]
    • Characteristic clinical features like presence of wound breakdown, sinus tract, or purulent drainage
    • Confirmatory microbiological study results
  • Additional studies (e.g., imaging, WBC, ESR, CRP) further support the diagnosis.

Microbiological studies [17]

  • Intraoperative samples: for diagnostic confirmation
    • Specimen collection (ideally, no antibiotics should be given for 2 weeks prior to collection)
      • ≥ 5 separate samples from near the fracture or implant for culture
      • Additional samples for histopathology and staining
    • Diagnostic criteria
      • Growth of the same pathogen on ≥ 2 separate culture samples
      • OR microorganisms seen on staining of deep tissue samples
  • Cultures from fluid aspirate: may further support the diagnosis [19]

Swab cultures or cultures of sinus tracts should be avoided because of low sensitivity and the risk of contamination by skin flora. [18]

Imaging studies [20]

  • Indications
    • Evaluation of fracture healing and device stability
    • Surgical planning
    • To further support a diagnosis of IAFF
  • Modalities: The choice of imaging modality depends on its availability and the clinical concern.
    • X-ray of the extremity [20][21]
      • Initial screening study in suspected infection
      • May show widening of the fracture gap or loosening of the implant, bone lysis, nonunion, periosteal bone formation, and sequestration
    • CT of the extremity: used for better visualization or if chronic infection is suspected [19][20]
    • MRI of the extremity: for the assessment of soft tissue and intramedullary infection [20]
      • Findings are similar to CT.
      • Additional findings: better definition of bone and soft tissue involvement
    • Nuclear imaging (e.g., WBC scintigraphy, FDG-PET): used to precisely localize infection

Treatment [18][19]

The goal of treatment is to promote fracture and soft tissue healing, restore limb function, eradicate the infection, and prevent chronic osteomyelitis. [19]

Antibiotic therapy [18]

Start antibiotic therapy after microbiological studies (including intraoperative samples) have been collected.

Invasive treatment [18][19]

Surgical debridement with or without device removal is recommended for all infections.

This section covers vascular graft infections. For infections related to intravascular catheters (e.g., central venous lines, arterial lines), see “Intravascular catheter-related bloodstream infections.”

Diagnostics [9][24]

Obtain diagnostics early and consult a multidisciplinary specialist team.

  • Laboratory studies: nonspecific but useful for monitoring response to therapy
  • Microbiological studies [9][24]
  • Initial imaging studies: based on the location of the graft [9][24]
    • Extracavitary infections
    • Intracavitary infections:
      • CT chest or abdomen
      • Supportive findings include fluid collection or gas around the graft, tissue plane destruction and perigraft stranding, focal thickening of bowel wall in intraabdominal grafts, and pseudoaneurysms.
  • Additional imaging studies
    • MRI: Consider as an alternative to CT or if CT results are indeterminate.
    • Echocardiography: Consider for intrathoracic infections to evaluate for complications.
    • Nuclear imaging (e.g., WBC scintigraphy, FDG-PET): Consider if results from other studies are indeterminate.
  • EGD: Obtain for patients with GI bleed; may reveal graft-enteric fistula or erosion

CT is the preferred initial imaging for intracavitary infections; ultrasound is preferred for extracavitary infections.

Treatment [9][24]

Lifelong suppressive antibiotics may be considered in patients with retained endovascular devices. [9]

This section covers infection of breast and penile implants. For information on infections related to indwelling urinary tract devices (e.g., urinary catheters, ureteral stents, nephrostomy tubes), see “Catheter-associated UTI (CAUTI),” and “Complicated pyelonephritis.”

Breast implants

Diagnostics [6][7][25]

Breast implant-related infection is primarily a clinical diagnosis (see “Clinical features”).

Treatment [7][25]

There is limited evidence regarding the most effective antibiotic therapy for breast and penile implant infections. Decisions should be specialist-guided.

Penile implants [6][12][26]

If there is concern for Fournier gangrene, see “Necrotizing soft tissue infections.”

Diagnostics

Penile implant-related infection is primarily a clinical diagnosis (see “Clinical features”).

  • Microbiological studies
    • May further support the diagnosis and guide therapy
    • Obtained from intraoperative tissue or implant or from periprosthetic fluid
  • Imaging studies: to support the diagnosis and for surgical planning [12][27][28]
    • MRI pelvis (preferred modality): Supportive findings include hyperintensity near the device, fluid collection with surrounding rim enhancement, and gas in severe infections.
    • Ultrasound of prosthesis: to assess for fluid collections and edema surrounding the prosthesis
    • CT pelvis: usually reserved for severe infection if MRI might be delayed

An exposed device is always considered infected.

Cultures may be negative, even in patients with clinical signs of infection.

Treatment [28]

There is limited evidence regarding the most effective antibiotic therapy for breast or penile implant infections. Decisions should be specialist-guided.

Device removal is especially important in patients with systemic illness, immunocompromise, and severe infections. [6][27]

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