"Foreign Body" (Device) Infections

Implanted Devices Vulnerable to Infection

Indwelling Intravenous catheters

Prosthetic cardiac valves
Prosthetic orthopedic devices (joint replacements) Cerebrospinal fluid
shunts/Ventriculostomy drains Peritoneal dialysis catheters
Arterious-venous anastomoses (dialysis) Vascular grafts
Mesh soft tissue support
Silicon Implants (plastic surgery)
Cardiac pacemakers

CPT Coding

Complication of an Internal Prosthesis, Implant or

Graft--infection or Inflammation
996.60 Unspecified 996.61 Cardiac 996.62 Vascular
996.63 Nervous system
996.64 Urinary catheter
(indwelling)
996.65 Genitourinary other
996.66 Joint prosthesis internal
996.67 Orthopedic other internal
996.69 Other Internal prosthesis

Intravascular Device Infections Types (Examples)

Peripheral Short Lines (Angiocath)

Peripheral Long Lines (Landmark)
Percutaneous CVP (Cooke triple lumen)
Pulmonary artery catheter (Swann-Ganz)
Tunnel/Cuff (Broviac)
Implanted Port (Port-a-Cath)

Intravascular Device Infections

Risk factors
Cutdowns > Percutaneous Insertion Central lines > peripheral Femoral >
Jugular • Subclavian
Long duration • short duration (< 72 hours) Polyvinyl chloride • Teflon or
silastic Direct insertion • tunneled Frequent access > Infrequent access
Parenteral nutrition • noninitiative fluids •
antibiotics
Tegaderm • open air dressings

Intravascular Device Infections

Pathogenesis
Contamination of Intradermal Insertion
wound (+ bleeding)
Formation of intravascular "fibrin
sheath"
 Colonization of catheter, formation of
"bifilms" and "macrocolonies" Infection of "fibrin sheath" Release of
"planktonic" organisms Local or generalized intravascular
infection

Intravascular Device Infections

Common organisms Coagulase-negative staphylococci Staph. aureus
(including MRSA) Candida albicans Klebsiella - Enterobacter
Enterococci (now including VRE) Pseudomonas aeruginosa

Intravascular Device Infections

Unusual organisms Corynebacterium jeikeium Pseudomonas cepacia Serratia

marcescens Acinetobacter calcoaceticus Torulopsis glabrata Malassezia
furfur Candida lusitaniae

Intravascular Device Infections

Clinical Manifestations Occult bacteremia Exit site Infections "Tunnel" infections

Sepsis/septic shock
Septic thrombophlebitis - peripheral or
central vein
Metastatic spread - eyes, CNS, lungs operative sites, other prosthetic devices,
heart

Intravascular Device Infections

Line Removal

Pros
Removes focus of infection
Shortens duration of therapy
Reduces chances of metastatic spread Cons
Local/systemic antibiotics may cure Multiple lines/uncertain source
Limited access
Need for line may be time-limited

Intravascular Device Infection

Antibiotics

Treat through all incriminated venous

lines and lumens
Synergistic/additive combinations Antibiotic "lock" technique
(heparin/antibiotic compatibility)
Don't use vancomycin unnecessarily Duration determined by response
and
presence of metastatic infection

Intravascular Device Infections

Prevention
Block adhesion of organisms new polymers, detergents, disaccharides
Prevent bacterial growth impregnated antibiotics, infused antibiotics, antibiotic
"lock" technique

Intravascular Device Infections

Diagnosis

Criteria for "significant" bacteremia < 48 hours to positive result 2/2 bottles
positive Repeated cultures positive

Intravascular Device Infections

Diagnosis

Other culture criteria Semiquantitative cath tip pneltive Pus expressed from
tunnel positive Persistent bacteremia despite appropriate Rx Higher level
bacteremia from incriminated
catheter

Intravascular Device Infections

Treatment options Line removal Antibiotics Both

Strategy, sites of new lines

Neurologic Device Infections Types of Devices (Examples)

External ventricular drains

(ventriculostomy)
Subcutaneous access ports (Ommaya) Ventriculo-peritoneal shunts
(Hakim) V-atrial, V-jugular, V-pleural Subarachnoid screws/bolts (El
Camino)

Neurologic Device Infections

Epidemiology/Risk Factors

Timing close to operation (<2 months) Overall rates 5-35%

Thin cortex • thick cortex High protein > low protein Low pressure > high
pressure July • rest of academic year Repeat surgery • initial surgery
Head shaving night before • shave at
operation

Neurologic Device Infections

Organisms

Coagulase-negative Staphylococci
Staph. aureus
Corynebacterium sp.
Propionibacterium acnes
Enteric gram negative rods
Candida sp.

Neurologic Device Infections Clinical Manifestations

Shunt malfunction-headache, vomiting,

irritability, mental status changes, coma Shunt reservoir doesn't "pump"
properly Fever (not invariably present) Peritonitis (VP shunts)
Bacteremia/sepsis/nephritis (V-A and V-J)

Neurologic Device Infections

Diagnosis
Ventricular fluid examination
Plate as well as broth processing of
culture
CT scan or U/S (enlarging ventricles) Abdominal U/S ("CSFoma") Paracentesis
(V-P shunt) Blood culture (V-A or V-J) Lumbar puncture (if meningitis)

Neurologic Device Infection

Treatment
Device removal or externalization with or
without ventriculostomy
Systemic antibiotics (choice based on
organisms and CSF penetration)
_+ Systemic synergistic antibiotics (rifampin, TMP/SMX)
+_ Intraventricular antibiotics (vancomycin)
Duration: CSF sterilization + 7 - 21 days Continue through replacement
operation

Neurologic Device Infections

Prevention

Operative site preparation

Surgical technique
Prophylactic antibiotics (methanolyses
suggest benefit)
Preoperative cultures "know your enemy"
Perioperative systemic antibiotics Intraoperative ventricular antibiotics

Peritoneal Dialysis Infections Epidemiology/Pathogenesis

Incidence: I per 7 patient-months Prevalence: 60% of dialyzed patients

Usual pathogenesis: skin colonization-
exit site-tunnel-peritoneum
Other mechanisms: Contamination of dialysate Suboptimal technique of
hookup Mechanical bowel perforation Ascending infection from
Fallopian
tubes

Peritoneal Dialysis Infections

Organisms

Coagulase-negative staphylococci Staph. aureus (including MRSA)

Enteric gram negative rods Pseudomonads
Enterococci (including VRE)
Candida albicans
Atypical mycobacteria

Peritoneal Dialysis Infections Clinical Manifestations/Diagnosis Fever,

abdominal pain, cloudy dialysate Leukocyte count of dialysate >501ul
No consensus on optimal culture method -broth inoculation of 1-5 ml
sample --membrane filtration of larger volumes/plate Inoculation
Consider frugal/mycobacterial cultures

Peritoneal Dialysis Infections

Treatment

Bolus instillation of antibiotics or mix with

dialysate
Systemic antibiotics at appropriate
Intervals, with level monitoring Removal of catheter/short term
hemodialysis If treatment failure. Usually necessary with fungal,
pseudomonal, or enterococcal Infection

Peritoneal Dialysis Infections

Prevention

Aseptic technique during

insertion and manipulation Elimination of staph, aureus
nasal and skin colonization (mupirocin, rifampin)

Orthopedic Device Infections Types of Devices (Examples)

Operative fracture stabilization

(screws, plates)
External fixators (pins) Lengthening devices (11izarov) Prosthetic joints
(limb salvage) Scoliosis repair (Luque rod)

Orthopedic Device Infections

Pathogenesis/Risk Factors

Skin flora (elective surgery) Environmental flora (trauma) Reactivation

(repeat/revision
surgery)
Airborne operating room transmission probably quite rare

Orthopedic Device Infections Organisms/Sources

Staph. aureus (including MRSA) Coagulase negative staphylococci Group

A streptococci
Enteric gram negative rods
Pseudomonads
Biopsy versus drainage cultures

Orthopedic Device Infections

Clinical Manifestations/Diagnosis

Fever, pain (not always present) Wound Infection, dehiscence, or fistula

Radiographs (lucent, sclerotic areas or
periosteal reaction)
Hematologic/acute phase reactants Anemia of chronic disease Elevated
or increasing ESR/CRP Leukocytosis, thrombocytosis
Limitations of CT, MRI, and nuclear scans

Orthopedic Device Infections

Treatment

Removal of device, hardware, and cement

 (immediate or staged)
Specific antimicrobial therapy
Cidal drugs (;idactams)
Bone accumulation (clindamycin)
Antibiotic beads (tobramycin or vancomycin) Achieve control of
infection with
parenteral therapy
Frequent monitoring (CBC, ESR)

Orthopedic Device Infections

Prevention

Cultures ("know your enemy") Prophylactic/suppressive

antibiotics