Device-related infections

Last updated: September 18, 2023

CME information and disclosurestoggle arrow icon

To see contributor disclosures related to this article, hover over this reference: [1]

Physicians may earn CME/MOC credit by reading information in this article to address a clinical question, and then completing a brief evaluation, in which they will identify their question and report the impact of any information learned on their clinical practice.

AMBOSS designates this Internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see “Tips and Links” at the bottom of this article.

Summarytoggle arrow icon

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.”

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

  • 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 [4][5][6][7][8][9][10]
Device Common causative pathogens
  • Penile implant

Clinical featurestoggle arrow icon

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 [11][12]

Neurosurgical devices [7]

Orthopedic hardware [7]

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

Vascular devices [10]

Symptoms depend on the location of the vascular graft infection.

Reproductive and genitourinary devices [7]

Breast implants [8]

Infections involving breast implants are typically unilateral.

Sepsis rarely occurs in breast implant infections. [7]

Penile implants [7][9][13]

  • 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

Management approachtoggle arrow icon

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

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.

Cardiac devicestoggle arrow icon

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 [4][11][12]

Duke criteria can be used for suspected cardiac device-associated endocarditis. [4]

Diagnostic device pocket needle aspiration should be avoided because of the risk of introducing bacteria. [11]

Treatment [4][5][11]

Antibiotic therapy [4][11]

Invasive therapy [5][15]

CIED removal is usually not needed in superficial or incisional infections. [15]

Neurosurgical devicestoggle arrow icon

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

Diagnostics [16][17]

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 [16][17]

Orthopedic hardwaretoggle arrow icon

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

Diagnostics [18][19]

General principles

  • A diagnosis can be made in patients with either: [18]
    • 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 [18]

  • 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 [20]

Swab cultures or cultures of sinus tracts should be avoided because of low sensitivity and the risk of contamination by skin flora. [19]

Imaging studies [21]

  • 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 [21][22]
      • 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 [20][21]
    • MRI of the extremity: for the assessment of soft tissue and intramedullary infection [21]
      • 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 [19][20]

The goal of treatment is to promote fracture and soft tissue healing, restore limb function, eradicate the infection, and prevent chronic osteomyelitis. [20]

Antibiotic therapy [19]

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

Invasive treatment [19][20]

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

Vascular devicestoggle arrow icon

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 [10][25]

Obtain diagnostics early and consult a multidisciplinary specialist team.

  • Laboratory studies: nonspecific but useful for monitoring response to therapy
  • Microbiological studies [10][25]
  • Initial imaging studies: based on the location of the graft [10][25]
    • 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 [10][25]

Lifelong suppressive antibiotics may be considered in patients with retained endovascular devices. [10]

Reproductive and genitourinary devicestoggle arrow icon

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 [7][8][26]

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

Treatment [8][26]

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

Penile implants [7][13][27]

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


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 [13][28][29]
    • 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 [29]

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. [7][28]

Referencestoggle arrow icon

  1. Baddour LM, Bettmann MA, Bolger AF, et al. Nonvalvular Cardiovascular Device–Related Infections. Circulation. 2003; 108 (16): p.2015-2031.doi: 10.1161/01.cir.0000093201.57771.47 . | Open in Read by QxMD
  2. Zinoviev R, Lippincott CK, Keller SC, Gilotra NA. In Full Flow: Left Ventricular Assist Device Infections in the Modern Era. Open Forum Infect Dis. 2020; 7 (5).doi: 10.1093/ofid/ofaa124 . | Open in Read by QxMD
  3. Sandoe JAT, Barlow G, Chambers JB, et al. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE). J Antimicrob Chemother. 2014; 70 (2): p.325-359.doi: 10.1093/jac/dku383 . | Open in Read by QxMD
  4. Vinh DC, Embil JM. Device-Related Infections: A Review. J Long Term Eff Med Implants. 2005; 15 (5): p.467-488.doi: 10.1615/jlongtermeffmedimplants.v15.i5.20 . | Open in Read by QxMD
  5. Lalani T. Breast Implant Infections. Infect Dis Clin North Am. 2018; 32 (4): p.877-884.doi: 10.1016/j.idc.2018.06.007 . | Open in Read by QxMD
  6. Carson CC. Diagnosis, treatment and prevention of penile prosthesis infection. Int J Impot Res. 2003; 15 (S5): p.S139-S146.doi: 10.1038/sj.ijir.3901091 . | Open in Read by QxMD
  7. Wilson WR, Bower TC, Creager MA, et al. Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association. Circulation. 2016; 134 (20).doi: 10.1161/cir.0000000000000457 . | Open in Read by QxMD
  8. $Contributor Disclosures - Device-related infections. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  9. Arciola CR, Campoccia D, Montanaro L. Implant infections: adhesion, biofilm formation and immune evasion. Nat Rev Microbiol. 2018; 16 (7): p.397-409.doi: 10.1038/s41579-018-0019-y . | Open in Read by QxMD
  10. Darouiche RO. Device‐Associated Infections: A Macroproblem that Starts with Microadherence. Clin Infect Dis. 2001; 33 (9): p.1567-1572.doi: 10.1086/323130 . | Open in Read by QxMD
  11. Palmeri NO, Kramer DB, Karchmer AW, Zimetbaum PJ. A Review of Cardiac Implantable Electronic Device Infections for the Practicing Electrophysiologist. JACC Clin Electrophysiol. 2021; 7 (6): p.811-824.doi: 10.1016/j.jacep.2021.03.021 . | Open in Read by QxMD
  12. Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al. 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017; 14 (12): p.e503-e551.doi: 10.1016/j.hrthm.2017.09.001 . | Open in Read by QxMD
  13. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association.. Circulation. 2010; 121 (3): p.458-77.doi: 10.1161/CIRCULATIONAHA.109.192665 . | Open in Read by QxMD
  14. Darouiche RO. Treatment of Infections Associated with Surgical Implants. N Engl J Med. 2004; 350 (14): p.1422-1429.doi: 10.1056/nejmra035415 . | Open in Read by QxMD
  15. Tunkel et al. 2017 Infectious Diseases Society of America’s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017; 64 (6): p.e34-e65.doi: 10.1093/cid/ciw861 . | Open in Read by QxMD
  16. Seidelman J, Lewis SS. Neurosurgical Device-Related Infections. Infect Dis Clin North Am. 2018; 32 (4): p.861-876.doi: 10.1016/j.idc.2018.06.006 . | Open in Read by QxMD
  17. Metsemakers WJ, Morgenstern M, McNally MA, et al. Fracture-related infection: A consensus on definition from an international expert group. Injury. 2018; 49 (3): p.505-510.doi: 10.1016/j.injury.2017.08.040 . | Open in Read by QxMD
  18. Depypere M, Morgenstern M, Kuehl R, et al. Pathogenesis and management of fracture-related infection. Clin Microbiol Infect. 2020; 26 (5): p.572-578.doi: 10.1016/j.cmi.2019.08.006 . | Open in Read by QxMD
  19. Metsemakers WJ, Kuehl R, Moriarty TF, et al. Infection after fracture fixation: Current surgical and microbiological concepts. Injury. 2018; 49 (3): p.511-522.doi: 10.1016/j.injury.2016.09.019 . | Open in Read by QxMD
  20. Govaert GAM, Kuehl R, Atkins BL, et al. Diagnosing Fracture-Related Infection: Current Concepts and Recommendations. J Orthop Trauma. 2020; 34 (1): p.8-17.doi: 10.1097/bot.0000000000001614 . | Open in Read by QxMD
  21. Trampuz A, Zimmerli W. Diagnosis and treatment of infections associated with fracture-fixation devices. Injury. 2006; 37 (2): p.S59-S66.doi: 10.1016/j.injury.2006.04.010 . | Open in Read by QxMD
  22. Depypere M, Kuehl R, Metsemakers WJ, et al. Recommendations for Systemic Antimicrobial Therapy in Fracture-Related Infection: A Consensus From an International Expert Group. J Orthop Trauma. 2020; 34 (1): p.30-41.doi: 10.1097/bot.0000000000001626 . | Open in Read by QxMD
  23. Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Elsevier ; 2019
  24. PIttet B, Moontandon D, Pittet D. Infection in breast implants. Lancet Infect Dis. 2005; 5 (2): p.94-106.doi: 10.1016/s1473-3099(05)70084-0 . | Open in Read by QxMD
  25. Ramanathan S, Bertolotto M, Shamsodini A, et al. Comprehensive Multimodality Imaging Review of Complications of Penile Prostheses. AJR Am J Roentgenol. 2018; 210 (6): p.1200-1207.doi: 10.2214/ajr.17.18943 . | Open in Read by QxMD
  26. Ramanathan S, Raghu V, Ramchandani P. Imaging of the adult male urethra, penile prostheses and artificial urinary sphincters. Abdom Radiol. 2019; 45 (7): p.2018-2035.doi: 10.1007/s00261-019-02356-x . | Open in Read by QxMD
  27. Al-Shaiji TF, Yaiesh SM, Al-Terki AE, Alhajeri FM. Infected penile prosthesis: literature review highlighting the status quo of prevention and management. Aging Male. 2018; 23 (5): p.447-456.doi: 10.1080/13685538.2018.1519786 . | Open in Read by QxMD
  28. Cosentino M, Bianco M, Ruiz-Castañé E, Iafrate M. Treatment of Penile Prosthesis Implant’s Infection. Urol Int. 2020; 104 (7-8): p.542-545.doi: 10.1159/000508472 . | Open in Read by QxMD
  29. Kilic A, Arnaoutakis DJ, Reifsnyder T, et al. Management of infected vascular grafts. Vasc Med. 2015; 21 (1): p.53-60.doi: 10.1177/1358863x15612574 . | Open in Read by QxMD

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer