1 00:00:07,710 --> 00:00:08,460 Hi everyone. 2 00:00:08,460 --> 00:00:12,690 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:12,780 --> 00:00:16,710 We use consult questions to dive into ID clinical reasoning, diagnostics 4 00:00:16,710 --> 00:00:18,300 and antimicrobial management. 5 00:00:18,390 --> 00:00:21,325 I'm Sara Dong, your host and a Med Peds ID doc. 6 00:00:21,915 --> 00:00:26,205 We are back today with a StAR episode, State of the Art Review. 7 00:00:26,564 --> 00:00:29,625 These focus on recent state of the art reviews that were published in 8 00:00:29,625 --> 00:00:31,875 Clinical Infectious Diseases, or CID. 9 00:00:32,174 --> 00:00:36,525 So I'll start by introducing our guest stars today who are all joining us from 10 00:00:36,525 --> 00:00:40,575 the Division of Public Health, Infectious Diseases, and Occupational Medicine at 11 00:00:40,575 --> 00:00:42,614 Mayo Clinic in Rochester, Minnesota. 12 00:00:43,080 --> 00:00:43,380 Hi. 13 00:00:43,380 --> 00:00:44,500 I am Hassam Tabaja. 14 00:00:44,520 --> 00:00:47,370 I'm really happy to be back on the podcast with you. 15 00:00:47,370 --> 00:00:49,590 I'm really thankful for you having me here again. 16 00:00:49,890 --> 00:00:52,860 Dr. Hassam Tabaja is an Assistant Professor of Medicine. 17 00:00:53,070 --> 00:00:56,850 His clinical research is focused on hardware associated infections, including 18 00:00:56,850 --> 00:01:00,390 both cardiovascular device infection and orthopedic device infection. 19 00:01:01,170 --> 00:01:02,740 Hi, this is Mac Chesdachai. 20 00:01:02,760 --> 00:01:05,610 Really happy to be here and thank you so much for having me. 21 00:01:05,940 --> 00:01:11,340 Dr. Supavit Chesdachai, or Mac, he is also an Assistant Professor of Medicine. 22 00:01:11,400 --> 00:01:16,260 His clinical and research interest include cardiovascular infections and infections 23 00:01:16,260 --> 00:01:18,090 in solid organ transplant recipients. 24 00:01:18,450 --> 00:01:19,620 Hi, I'm Dan De Simone. 25 00:01:19,620 --> 00:01:20,880 Thank you so much for having me back. 26 00:01:20,880 --> 00:01:22,080 I love Febrile StAR. 27 00:01:22,380 --> 00:01:22,785 Thank you so much. 28 00:01:23,774 --> 00:01:26,475 We have Dr. Daniel DeSimone or Dan. 29 00:01:26,865 --> 00:01:30,765 He is a Consultant and now Professor of Medicine at Mayo Clinic. 30 00:01:30,975 --> 00:01:35,054 He also holds a joint appointment in the Department of Cardiovascular Diseases. 31 00:01:35,235 --> 00:01:38,595 He has chaired and vice chaired several American Heart Association 32 00:01:38,595 --> 00:01:41,955 scientific statements in cardiovascular infectious diseases. 33 00:01:42,185 --> 00:01:46,325 His clinical and research interests focus on the prevention, diagnosis and 34 00:01:46,325 --> 00:01:51,155 management of infective endocarditis, cardiac implantable electronic device 35 00:01:51,155 --> 00:01:53,705 infections and vascular graft infections. 36 00:01:54,035 --> 00:01:55,235 All right, let's jump in. 37 00:01:55,595 --> 00:01:58,655 Well, Febrile is everyone's favorite cultured podcast. 38 00:01:58,655 --> 00:02:01,565 I know you guys have shared a little piece of culture before, but I'm gonna 39 00:02:01,565 --> 00:02:04,384 ask you to share something new today. 40 00:02:04,475 --> 00:02:06,755 So what have you guys been interested in recently? 41 00:02:07,265 --> 00:02:07,985 I'll go first. 42 00:02:08,255 --> 00:02:12,704 So what I've been getting into particularly with these, with the past 43 00:02:12,704 --> 00:02:16,484 couple of months where it's about minus 20 out and can't go out on my grill 44 00:02:16,484 --> 00:02:18,554 or do any smoking, uh, on the grill. 45 00:02:19,005 --> 00:02:23,174 Uh, I've gotten into sous vide, um, if is anyone familiar with that? 46 00:02:23,174 --> 00:02:24,440 I, yeah, it's, 47 00:02:24,550 --> 00:02:25,120 Yeah, I have one! 48 00:02:26,479 --> 00:02:27,255 It's pretty cool. 49 00:02:27,255 --> 00:02:33,695 It's, uh, you're essentially cooking steak, or you name it in nice hot water. 50 00:02:33,934 --> 00:02:37,924 Um, and it's, it's cooking it to the perfect temperature you want and then 51 00:02:38,434 --> 00:02:39,605 do whatever you wanna do after that. 52 00:02:39,605 --> 00:02:41,075 But yeah, I've been getting into that a lot. 53 00:02:41,135 --> 00:02:43,595 Now that the weather's starting to turn around, I'm getting the, 54 00:02:43,775 --> 00:02:44,855 breaking the grill out more. 55 00:02:44,855 --> 00:02:48,005 But, uh, but I'll tell you what, that sous vide is, is pretty cool. 56 00:02:48,005 --> 00:02:52,405 Highly recommended for, for anybody who, who, if you, if you can't cook, it's 57 00:02:52,405 --> 00:02:54,025 a good way to, to not mess things up. 58 00:02:54,025 --> 00:02:57,355 And if you can cook, you can, you can tailor things around pretty nice. 59 00:02:57,355 --> 00:02:58,614 So yeah, I've gotten into that. 60 00:02:59,065 --> 00:03:02,815 Um, be careful because once you get into it, you just start to go down 61 00:03:02,815 --> 00:03:04,285 a rabbit hole, but it's, it's fun. 62 00:03:05,095 --> 00:03:06,025 Yeah, it is really fun. 63 00:03:06,025 --> 00:03:08,185 It makes you feel very professional when you use it. 64 00:03:08,815 --> 00:03:09,055 Oh, yeah. 65 00:03:09,285 --> 00:03:10,015 Yeah, absolutely. 66 00:03:10,015 --> 00:03:12,745 I start speaking French. 67 00:03:15,655 --> 00:03:19,735 I, I have to ask for tips from Dan, because I did it in the past and 68 00:03:19,735 --> 00:03:23,605 sometime the plastic bag is just like ballooning and it just flows up. 69 00:03:23,755 --> 00:03:23,935 So 70 00:03:25,075 --> 00:03:27,385 yeah, you gotta get a good sealer sometimes. 71 00:03:27,385 --> 00:03:28,255 Double seal. 72 00:03:28,440 --> 00:03:28,730 Yeah. 73 00:03:29,090 --> 00:03:31,885 I, yeah, that's, there are, there is a learning curve. 74 00:03:31,915 --> 00:03:33,265 There's a small learning curve. 75 00:03:33,415 --> 00:03:36,330 Um, but once you do it, it's, it's, it's worth it. 76 00:03:37,705 --> 00:03:42,445 So for me, I don't have any new activity apart from the pickleball that 77 00:03:42,445 --> 00:03:44,695 we discussed last time with Hassam. 78 00:03:45,355 --> 00:03:51,415 Um, but lately I, I, I was very interesting in how time different travel 79 00:03:51,415 --> 00:03:57,445 and jet lag work, because we just came back from trip to Thailand and then 80 00:03:57,445 --> 00:04:05,410 that's the first time that my 20 month old daughter flew transpacific and then 81 00:04:05,470 --> 00:04:10,895 we were so concerned about like the time difference, 13 hour time difference. 82 00:04:12,040 --> 00:04:16,795 It turned out to be, she was fine in one day, but the problem is that 83 00:04:16,885 --> 00:04:22,735 there, her parents is doing so badly in like five days, not recover at all. 84 00:04:23,065 --> 00:04:26,625 So I'm really surprised that, you know, when you talk about 13 hour 85 00:04:26,625 --> 00:04:30,750 difference jet lag, it doesn't apply to 20 months old daughter. 86 00:04:34,815 --> 00:04:38,445 And I feel like that must have been your daughter that I saw at ID week, right? 87 00:04:38,445 --> 00:04:39,315 Yes you did. 88 00:04:39,465 --> 00:04:39,855 Yeah. 89 00:04:40,155 --> 00:04:40,695 Very cute. 90 00:04:41,580 --> 00:04:42,340 What about you, Hussam? 91 00:04:42,405 --> 00:04:42,855 So I'll go. 92 00:04:42,855 --> 00:04:43,035 Yeah. 93 00:04:43,035 --> 00:04:47,385 I haven't also been engaging in a lot of new activities, but I, I have 94 00:04:47,385 --> 00:04:52,295 been very busy 'cause I'm actually a, a new father now, so I have twins 95 00:04:52,955 --> 00:04:57,155 and, um, I think there's a lot of culture around that to, to be said. 96 00:04:57,695 --> 00:05:02,850 Um, surely a lot of, um, family visits that I was not expecting. 97 00:05:02,940 --> 00:05:08,610 And, uh, a lot of gifts, which I'm very happy with, a lot, a lot of gifts 98 00:05:08,610 --> 00:05:10,140 and a lot of things to learn really. 99 00:05:10,140 --> 00:05:13,950 So I've just been busy trying to figure out how to become a father. 100 00:05:14,280 --> 00:05:14,550 Uh 101 00:05:18,600 --> 00:05:19,740 Oh, congrats! 102 00:05:19,740 --> 00:05:21,665 I'm sure you have your hands full. 103 00:05:24,035 --> 00:05:27,005 Um, well I'm very glad to welcome you guys back. 104 00:05:27,005 --> 00:05:32,255 I'll, um, just plug that you were here on Febrile back for a State 105 00:05:32,255 --> 00:05:35,885 of the Art Review on vascular graft infections, which I'll put a link to, um, 106 00:05:35,885 --> 00:05:37,445 hopefully people have listened to that. 107 00:05:37,505 --> 00:05:43,005 But this is a different article that focused on complexities of cardiac 108 00:05:43,005 --> 00:05:47,785 device infections, and I think all of these questions that we know sound 109 00:05:47,805 --> 00:05:49,845 simple, but actually are quite complex. 110 00:05:50,775 --> 00:05:52,125 Is the device infected? 111 00:05:52,275 --> 00:05:53,445 Should it be taken out? 112 00:05:53,745 --> 00:05:56,235 When it is taken out, when is it safe to put it back in? 113 00:05:56,295 --> 00:06:01,815 Um, and so we will walk through a case today, but I just wanna start more 114 00:06:01,815 --> 00:06:06,015 generally and would love to hear about how you think about the way these infections 115 00:06:06,015 --> 00:06:09,825 should be handled or maybe your experience handling them at your institution. 116 00:06:11,315 --> 00:06:11,705 Yeah. 117 00:06:11,855 --> 00:06:12,635 Sara, that's great. 118 00:06:12,635 --> 00:06:13,745 Thank you so much for having us. 119 00:06:14,045 --> 00:06:18,365 You know, these, as you mentioned, these are, are not always so 120 00:06:18,365 --> 00:06:21,565 straightforward to make the diagnosis of the device being infected. 121 00:06:21,715 --> 00:06:25,225 And I think that's probably the, the big issue here is or at least the 122 00:06:25,300 --> 00:06:29,500 common goal that we share is we wanna keep devices that are not infected 123 00:06:29,680 --> 00:06:33,610 in the patient's body, and when they are infected, we wanna take them out. 124 00:06:33,610 --> 00:06:36,445 And that's much more easy, easier said than done. 125 00:06:36,865 --> 00:06:40,495 In some cases, it's readily apparent it's infected, and in a lot of other cases 126 00:06:40,495 --> 00:06:44,455 where it becomes very challenging, it's difficult to make that diagnosis, and 127 00:06:44,455 --> 00:06:48,580 hopefully through this podcast, we'll be able to provide our listeners with a 128 00:06:48,580 --> 00:06:51,810 good strategy on how to approach these patients and, and hopefully make it a 129 00:06:51,810 --> 00:06:53,740 little bit easier to achieve that goal. 130 00:06:53,840 --> 00:06:57,440 When a patient gets admitted to our institution with concern 131 00:06:57,440 --> 00:07:01,040 for a device infection, it, this is not a one person show, it's 132 00:07:01,040 --> 00:07:02,990 gonna be multiple teams involved. 133 00:07:03,040 --> 00:07:06,910 They may be admitted to, let's say, our hospital medicine service, so that 134 00:07:06,910 --> 00:07:12,910 involves our hospitalists as the main care team and will often require consultation 135 00:07:12,910 --> 00:07:17,200 with infectious disease, uh, as well as our heart rhythm or electrophysiology 136 00:07:17,200 --> 00:07:18,580 team as well, to be involved. 137 00:07:19,030 --> 00:07:21,670 That's just a couple elements of the team. 138 00:07:21,820 --> 00:07:25,870 Then you have to factor in the possible need for echocardiography, so that brings 139 00:07:25,870 --> 00:07:31,210 in our echocardiographers, uh, possibly PET imaging, NDM scans and so on, uh, 140 00:07:31,240 --> 00:07:33,260 radiology, nuclear radiology as well. 141 00:07:33,830 --> 00:07:36,290 And that's just part of the team and beyond. 142 00:07:36,290 --> 00:07:37,490 So if you do think it's infected. 143 00:07:38,315 --> 00:07:42,055 You may have to get general surgery on board for device removal and involved in 144 00:07:42,055 --> 00:07:46,465 pocket management after device removed, possibly even plastic surgery depending 145 00:07:46,505 --> 00:07:50,344 on the situation and the location as well as cardiovascular or thoracic 146 00:07:50,344 --> 00:07:53,195 surgery to be on, on standby as backup. 147 00:07:53,340 --> 00:07:58,389 As taking the device out is not without risk, risk of significant bleeding, 148 00:07:58,629 --> 00:08:00,339 major bleeding, and possibly death. 149 00:08:00,549 --> 00:08:04,690 So having cardiovascular surgery or thoracic surgery on standby for backup 150 00:08:04,690 --> 00:08:08,409 support following device removal for any complications is, is critical. 151 00:08:08,409 --> 00:08:12,344 So that's kind of start to somewhat finish. 152 00:08:12,344 --> 00:08:15,705 And there's even more to that is okay, a device comes out, does the device need, 153 00:08:15,915 --> 00:08:17,384 does a new device need to go back in? 154 00:08:17,755 --> 00:08:21,320 And that's where our cardiologists and heart rhythm specialists come into play. 155 00:08:21,379 --> 00:08:23,330 So that's kind of the approach. 156 00:08:23,359 --> 00:08:25,249 And again, there's some things that go on in between. 157 00:08:25,249 --> 00:08:26,659 Are they bacteremic or not? 158 00:08:26,659 --> 00:08:30,290 Is there something on the echo, on the heart valve or do the lead itself or both? 159 00:08:30,804 --> 00:08:33,330 And then do they need a new device put back in and when 160 00:08:33,330 --> 00:08:34,350 do you put that back in it? 161 00:08:34,400 --> 00:08:38,299 So with that I'll turn things over to, uh, to Mac and Hussam to 162 00:08:38,299 --> 00:08:39,769 go further into those scenarios. 163 00:08:40,279 --> 00:08:40,849 Excellent. 164 00:08:40,939 --> 00:08:44,179 Alright, well I'm gonna introduce our patient that we're gonna be 165 00:08:44,519 --> 00:08:46,049 taking care of in the hospital. 166 00:08:46,439 --> 00:08:53,144 We meet a 65-year-old woman with morbid obesity, diabetes and a cardiac 167 00:08:53,144 --> 00:08:57,224 device who presented to clinic with three days of pain, redness, and 168 00:08:57,224 --> 00:08:58,904 swelling at the generator pocket. 169 00:08:59,894 --> 00:09:03,944 So we're gonna pause right here this early and ask about how 170 00:09:03,944 --> 00:09:05,324 should we start our assessment? 171 00:09:05,414 --> 00:09:05,594 Yeah. 172 00:09:06,014 --> 00:09:12,895 Uh, as Dan mentioned, CIED infection is a very complex syndrome that 173 00:09:12,895 --> 00:09:17,305 require the whole village of multiple people help taking care of this. 174 00:09:18,025 --> 00:09:23,364 And the definition of the CIED infection itself has changed multiple times since 175 00:09:23,364 --> 00:09:28,584 the first statement came out in 2003, and then the most recent one that Dan is 176 00:09:28,584 --> 00:09:36,624 a lead author came out in 2023 to 2024, um, provide a variety of the definition 177 00:09:36,624 --> 00:09:41,709 of the infection, but in general, um, when we talk about a CIED infection, 178 00:09:41,709 --> 00:09:44,499 we need to think about two main thing. 179 00:09:44,679 --> 00:09:48,969 The first one is that the pocket part, and then the second one is 180 00:09:48,969 --> 00:09:52,119 the infection of the lead or valve. 181 00:09:52,509 --> 00:09:56,649 So when we talk about infection of the lead and valve, we call 182 00:09:56,649 --> 00:09:59,709 that CIED-related endocarditis. 183 00:10:00,099 --> 00:10:04,599 The pocket itself can happen without endocarditis. 184 00:10:05,049 --> 00:10:10,060 So that's the reason why any part of the device is infected, the 185 00:10:10,060 --> 00:10:11,589 whole system become infected. 186 00:10:11,739 --> 00:10:15,279 That's the reason how we, um, define the infection. 187 00:10:16,269 --> 00:10:21,530 So the most challenging thing is how to diagnose the CIED 188 00:10:21,549 --> 00:10:23,589 related infective endocarditis. 189 00:10:23,919 --> 00:10:27,930 Because with the pocket generator side infection, you can get that from the 190 00:10:27,930 --> 00:10:32,390 physical exam in most of the case, which is, if we ask what is the most common 191 00:10:32,390 --> 00:10:36,629 presentation of CIED infection, it is mainly the pocket generator site, which 192 00:10:36,629 --> 00:10:41,689 has happened in two-thirds of the cases, so one third of the cases will have the 193 00:10:41,689 --> 00:10:47,959 device endocarditis as well, but we can talk more of why it's so challenging to 194 00:10:47,959 --> 00:10:52,280 diagnose whether the patient has device related infective endocarditis or not. 195 00:10:52,579 --> 00:10:54,050 So we learned a little bit more. 196 00:10:54,079 --> 00:10:58,939 This patient had their device implanted eight years earlier for a history of 197 00:10:58,939 --> 00:11:02,869 sudden cardiac death with a recent generator revision two months ago. 198 00:11:03,510 --> 00:11:06,359 She also had fatigue, fever, and chills. 199 00:11:06,869 --> 00:11:10,709 And our physical exam shows erythema, tenderness, and fluctuation 200 00:11:10,709 --> 00:11:12,030 at the generator pocket site. 201 00:11:12,869 --> 00:11:17,910 There isn't any purulent drainage, sinus tract formation or device exposure noted. 202 00:11:17,999 --> 00:11:20,189 Um, so what is our best next step? 203 00:11:20,280 --> 00:11:20,670 Yes. 204 00:11:20,670 --> 00:11:24,270 So basically, if, if I summarize this question, you're basically, I'm being 205 00:11:24,270 --> 00:11:29,435 asked to, uh, see a patient who's presenting with pocket site inflammation. 206 00:11:29,435 --> 00:11:30,964 That's, that's called it inflammation. 207 00:11:31,714 --> 00:11:35,254 And so my job here is to figure out whether or not this 208 00:11:35,254 --> 00:11:39,185 inflammation is related to infection or not infectious, right? 209 00:11:39,185 --> 00:11:43,295 Because this soon after a revision only two months out, there are 210 00:11:43,295 --> 00:11:47,134 other non-infectious causes of pocket site inflammation, uh, 211 00:11:47,134 --> 00:11:50,699 such as allergic reaction to the component or maybe a hematoma. 212 00:11:51,120 --> 00:11:55,110 There are certain tools that we could use to help us make that, uh, decision. 213 00:11:55,560 --> 00:11:58,470 And the first tools are history and physical exam, which is just 214 00:11:58,470 --> 00:12:02,050 similar to what we use with any syndrome that we encounter, right? 215 00:12:02,650 --> 00:12:06,670 So there are certain things in history that are important to tease out. 216 00:12:06,730 --> 00:12:11,110 Uh, for example, in order to assess the risk of infection, you have 217 00:12:11,110 --> 00:12:13,060 to look at the age of the patient. 218 00:12:13,390 --> 00:12:16,090 You need to look at the complexity of the device. 219 00:12:16,150 --> 00:12:17,920 Is this a multiple lead? 220 00:12:18,010 --> 00:12:19,300 Is this a pacemaker? 221 00:12:19,300 --> 00:12:23,410 A CRT-D, you need to know whether or not that this is the first device. 222 00:12:23,410 --> 00:12:24,460 Is this a revision? 223 00:12:24,460 --> 00:12:26,740 How many times has it been revised before? 224 00:12:27,190 --> 00:12:30,970 Uh, what are the comorbidities of the other cardiovascular devices? 225 00:12:31,220 --> 00:12:35,470 So all of this, this helps you define the host and then you'll get an understanding 226 00:12:35,470 --> 00:12:37,540 of what is the, uh, risk of infection. 227 00:12:37,750 --> 00:12:41,560 The next thing is you wanna, uh, look for signs and symptoms that will 228 00:12:42,815 --> 00:12:46,595 give you a definite diagnosis of CIED infection because based on history 229 00:12:46,595 --> 00:12:50,195 and physical exam, there are certain signs that can actually confirm 230 00:12:50,195 --> 00:12:54,215 that you have an infection without having to do any additional testing. 231 00:12:54,635 --> 00:12:56,865 Um, and those are not frequent. 232 00:12:56,920 --> 00:12:58,090 There's not too much of those. 233 00:12:58,090 --> 00:13:02,360 There's maybe three to four signs and some of those, you know, pus 234 00:13:02,380 --> 00:13:06,850 coming out from the pocket, uh, sinus tract, uh, device exposure, 235 00:13:06,850 --> 00:13:08,380 which this patient does not have. 236 00:13:08,500 --> 00:13:12,210 So if this patient had those signs, then just by history and physical 237 00:13:12,210 --> 00:13:16,590 exam, I will be able to tell there is a CIED infection and the next 238 00:13:16,590 --> 00:13:18,210 step will be to do a blood culture. 239 00:13:18,210 --> 00:13:21,630 Because you wanna know whether or not the patient is bacteremic, not to make the 240 00:13:21,630 --> 00:13:23,430 diagnosis, the diagnosis is already made. 241 00:13:23,460 --> 00:13:27,090 The blood cultures help you, uh, because if they're positive, they're gonna 242 00:13:27,090 --> 00:13:29,160 determine your next step in management. 243 00:13:29,400 --> 00:13:29,460 Okay. 244 00:13:30,665 --> 00:13:33,275 But this patient does not fall in this category. 245 00:13:33,935 --> 00:13:36,814 She's presenting with, uh, signs of inflammation, but there is 246 00:13:36,814 --> 00:13:40,985 no signs or symptoms that are definite for CIED infection. 247 00:13:41,285 --> 00:13:43,925 So then the question is, what other tools can we use? 248 00:13:44,464 --> 00:13:49,204 And really this soon after revision in my mind, the only thing that we would do is 249 00:13:49,265 --> 00:13:55,135 a blood culture for this patient because I won't rely on CRP, ESR, white blood 250 00:13:55,204 --> 00:13:57,305 cell count this soon after the revision? 251 00:13:57,305 --> 00:13:59,975 Because they're not gonna be specific for CIED infection. 252 00:14:00,545 --> 00:14:06,395 I also don't rely so much on imaging like ultrasound, CT scans or PET CT this early 253 00:14:06,395 --> 00:14:09,755 after revision because I would expect to see something and it'll still not tell 254 00:14:09,755 --> 00:14:13,295 me whether or not this is an infected abscess, for example, or a hematoma. 255 00:14:13,985 --> 00:14:18,305 So in my mind, uh, for those patients, the only thing that you could rely on is 256 00:14:18,305 --> 00:14:21,755 really, is a blood culture at this point, because if the blood culture is positive. 257 00:14:21,835 --> 00:14:25,705 Then that also will upgrade this patient from an uncertain category to a 258 00:14:25,705 --> 00:14:27,895 confirmed or a definite CIED infection. 259 00:14:28,225 --> 00:14:32,515 Whenever you have a local pocket inflammation and you have a positive 260 00:14:32,515 --> 00:14:36,655 blood culture, that by definition is CIED infection, and so then 261 00:14:36,655 --> 00:14:38,275 we would manage it accordingly. 262 00:14:38,455 --> 00:14:42,625 The more difficult situation is if there is negative blood culture because 263 00:14:42,625 --> 00:14:46,285 then you're stuck again with this challenging question, how do I prove 264 00:14:46,285 --> 00:14:48,475 that this patient has a CIED infection? 265 00:14:48,760 --> 00:14:51,980 And it becomes more challenging if there is no systemic symptoms. 266 00:14:51,980 --> 00:14:54,440 You know, this patient actually has systemic symptoms, so 267 00:14:54,800 --> 00:14:55,940 maybe it's a bit easier. 268 00:14:55,940 --> 00:15:00,170 But if someone comes in with mild inflammation, maybe just minimal 269 00:15:00,170 --> 00:15:04,910 swelling, no systemic symptoms, this could just be a hematoma and inflammatory 270 00:15:04,910 --> 00:15:06,530 reaction from allergic reaction. 271 00:15:06,530 --> 00:15:08,540 It could be even a superficial cellulitis. 272 00:15:09,080 --> 00:15:10,880 So this is where it becomes controversial. 273 00:15:10,880 --> 00:15:14,810 Some physicians in those situations would put patients on oral antibiotics 274 00:15:14,810 --> 00:15:18,479 empirically, uh, considering this may be a superficial cellulitis. 275 00:15:18,500 --> 00:15:21,500 And then they will just follow very closely to see how they respond. 276 00:15:21,560 --> 00:15:24,710 Other physicians would not put antibiotics and they will just follow 277 00:15:24,710 --> 00:15:28,640 them clinically and see how things change because, you know, give it some time 278 00:15:28,640 --> 00:15:30,170 and let it declare itself basically. 279 00:15:30,290 --> 00:15:34,220 But I would say this is, these situations are the less straightforward situations. 280 00:15:34,270 --> 00:15:38,395 I, I think it might be helpful to comment on pocket infection and, 281 00:15:38,395 --> 00:15:40,310 and not aspirating the pocket. 282 00:15:40,310 --> 00:15:44,839 Because I think maybe for residents and earlier trainees that that 283 00:15:44,839 --> 00:15:48,530 might not seem intuitive when we're usually asking for a sample. 284 00:15:48,800 --> 00:15:51,260 Would you be willing to just say a couple sentences on that 285 00:15:51,530 --> 00:15:56,305 so you know there is some physicians that might consider doing an ultrasound 286 00:15:56,305 --> 00:16:00,605 guided aspiration if there's a fluid pocket, send that to for culture, 287 00:16:00,605 --> 00:16:02,375 see if it looks like pus or not. 288 00:16:02,795 --> 00:16:06,245 Um, in, in our center, we really don't like to do that. 289 00:16:06,245 --> 00:16:08,225 We try to avoid that as much as possible. 290 00:16:08,435 --> 00:16:12,425 And the main reason is because if you're not able to confirm the 291 00:16:12,425 --> 00:16:16,055 diagnosis of CIED infection based on blood cultures and physical exam. 292 00:16:16,295 --> 00:16:20,045 We worry that if it's not infected, we're gonna now introduce an 293 00:16:20,045 --> 00:16:22,055 infection, uh, into the pockets. 294 00:16:22,115 --> 00:16:24,195 So we don't really like to do that much. 295 00:16:24,195 --> 00:16:26,565 And I, I, I personally have never seen it being done. 296 00:16:26,565 --> 00:16:29,925 I don't know if Dan or, or Mac has seen that done before. 297 00:16:30,285 --> 00:16:32,685 I have seen it done in other devices. 298 00:16:32,685 --> 00:16:36,435 So we do have a lot of deep brain stimulator devices, for example here, 299 00:16:36,465 --> 00:16:39,415 which they have generator pockets and a lot of times the surgeons here 300 00:16:39,415 --> 00:16:41,745 would do an aspiration of the fluid. 301 00:16:42,435 --> 00:16:46,815 Um, but I have not seen a cardiovascular disease, uh, physician or an infectious 302 00:16:46,815 --> 00:16:49,995 disease physician here in the center in Mayo Clinic that would do an 303 00:16:49,995 --> 00:16:53,475 ultrasound guided aspiration of the pocket, just because we worry that we 304 00:16:53,475 --> 00:16:57,345 might now introduce an infection and it leads to bacteremia and endocarditis. 305 00:16:57,555 --> 00:17:00,645 Yeah, I, I agree with Hassam that I, um, never done. 306 00:17:01,305 --> 00:17:05,235 Um, but Dan can also add onto that too, that, um, I think 307 00:17:05,815 --> 00:17:07,935 there was a study from Israel. 308 00:17:08,245 --> 00:17:13,915 They put a catheter directly into the pocket and try to infuse 309 00:17:14,065 --> 00:17:17,385 antibiotics into the pocket in the setting of pocket infection. 310 00:17:17,955 --> 00:17:20,175 But I don't think that has been widely used. 311 00:17:20,175 --> 00:17:26,205 And that is only in the investigational, um, study rather than clinical practice. 312 00:17:26,415 --> 00:17:26,625 Yeah. 313 00:17:26,625 --> 00:17:30,275 So, so Mac in, in that study where they put a catheter in, they 314 00:17:30,275 --> 00:17:33,365 were instilling antibiotics as a way to, to treat an infection 315 00:17:33,815 --> 00:17:35,525 rather than to make the diagnosis. 316 00:17:35,525 --> 00:17:39,905 But from a diagnostic standpoint, uh, typically why, why we would advise 317 00:17:39,905 --> 00:17:44,885 against doing an aspiration of the pocket would be, what if there is no infection? 318 00:17:44,915 --> 00:17:47,255 You may have potentially introduced infection now. 319 00:17:47,255 --> 00:17:50,335 So every time you go into that pocket, you run the risk of leading 320 00:17:50,335 --> 00:17:52,095 to infection of that device. 321 00:17:52,095 --> 00:17:55,405 So in this patient's history, in our example here, they had 322 00:17:55,405 --> 00:17:56,575 a revision two months ago. 323 00:17:56,815 --> 00:18:02,845 So that's a big red flag that they went back into that pocket and now is 324 00:18:02,845 --> 00:18:09,225 showing up with some pocket findings and systemic symptoms that your suspicion 325 00:18:09,225 --> 00:18:11,415 for infection really has to go up here. 326 00:18:11,655 --> 00:18:15,795 Now I've seen where you can get an ultrasound of the pocket and, 327 00:18:15,865 --> 00:18:18,745 sometimes you could say, Hey, this might look like an abscess. 328 00:18:19,165 --> 00:18:22,855 That might tilt you more towards this being infected, but, uh, but 329 00:18:22,855 --> 00:18:27,395 putting a needle and entering that pocket is very uncommon to do and 330 00:18:27,395 --> 00:18:28,955 typically advise against that. 331 00:18:29,045 --> 00:18:29,295 Thanks guys. 332 00:18:30,185 --> 00:18:32,885 The team has grabbed two sets of blood cultures. 333 00:18:33,285 --> 00:18:37,515 These were drawn before vancomycin was administered, and in these 334 00:18:37,515 --> 00:18:40,905 cultures we have gram positive cocci resembling Streptococci 335 00:18:41,685 --> 00:18:43,845 that grew after about 14 hours. 336 00:18:44,325 --> 00:18:46,455 Um, so what would be our approach now? 337 00:18:46,725 --> 00:18:48,775 Yeah, so this gets interesting now. 338 00:18:48,865 --> 00:18:52,105 So given this patient's history, now findings of positive blood 339 00:18:52,105 --> 00:18:55,555 cultures, I think doing the right thing is starting the vancomycin. 340 00:18:55,615 --> 00:18:58,465 You know, this could either be a Streptococcus or an Enterococcus. 341 00:18:59,075 --> 00:19:01,735 So I think starting the antibiotic at this point, would recommend 342 00:19:01,735 --> 00:19:02,785 that and encourage that. 343 00:19:03,375 --> 00:19:07,845 I think the big thing here is the organism is very important when you 344 00:19:07,845 --> 00:19:09,675 approach cardiac device infections. 345 00:19:09,705 --> 00:19:13,935 This is your pretest probability of when you get that echocardiogram with 346 00:19:13,935 --> 00:19:17,055 a, in a patient who has a positive blood culture is gonna be critical. 347 00:19:17,085 --> 00:19:20,475 So in somebody like this with their history with an organism that's growing 348 00:19:20,475 --> 00:19:25,635 either Strep or Enterococcus, now my suspicion is, is very high, uh, 349 00:19:25,635 --> 00:19:29,115 that this device is infected and the recommendation would be to take it out. 350 00:19:29,455 --> 00:19:31,855 There's more discussion there, and we'll likely talk about this 351 00:19:31,855 --> 00:19:34,405 later when it comes time to make that decision to take things out. 352 00:19:34,405 --> 00:19:39,025 But I think your, your next best step here is, does this patient 353 00:19:39,025 --> 00:19:41,845 have valvular or lead endocarditis? 354 00:19:42,115 --> 00:19:45,355 And, and really the focus is on valvular endocarditis as that 355 00:19:45,355 --> 00:19:49,615 has downstream ramifications if the valve has a vegetation. 356 00:19:49,980 --> 00:19:54,760 So if there's valvular endocarditis, your duration of therapy is gonna be longer. 357 00:19:54,820 --> 00:19:57,500 So you're not gonna treat this as just a standard bloodstream 358 00:19:57,500 --> 00:20:00,380 infection or bacteremia with, say, two weeks of antibiotics. 359 00:20:00,800 --> 00:20:03,290 You're likely gonna go down the route of four to six weeks. 360 00:20:03,680 --> 00:20:05,690 Uh, so you can see how that changes your therapy there. 361 00:20:06,170 --> 00:20:09,850 As well as it'll have implications on reimplantation if, if the patient 362 00:20:09,850 --> 00:20:11,980 needs it, on timing of reimplantation. 363 00:20:12,010 --> 00:20:15,280 So instead of 72 hours, you may wait up to two weeks to put a new 364 00:20:15,280 --> 00:20:16,780 device back in if it's needed. 365 00:20:17,210 --> 00:20:20,810 That's the next step in this patient's, uh, route here of 366 00:20:20,810 --> 00:20:29,790 getting an echocardiogram, a TTE and TEE would be recommended. 367 00:20:29,790 --> 00:20:31,380 And again, you're looking for valvular vegetations or 368 00:20:31,380 --> 00:20:32,170 any vegetations on the lead.. 369 00:20:32,170 --> 00:20:34,385 That's, that's again, gonna direct us to our next step. 370 00:20:34,655 --> 00:20:35,285 That's perfect. 371 00:20:35,285 --> 00:20:40,205 And, um, you guys in the, for those who have the paper, that figure two roadmap 372 00:20:40,205 --> 00:20:44,745 is about where we're talking about and Hassam started talking earlier about 373 00:20:44,805 --> 00:20:48,165 the importance of knowing if someone has a bloodstream infection or not. 374 00:20:48,675 --> 00:20:52,275 And I think one way we can also reframe this patient is how would 375 00:20:52,275 --> 00:20:55,760 we think about them differently if they had come in and we identified a 376 00:20:55,760 --> 00:21:00,500 blood infection, but there's no signs of generator pocket site infection. 377 00:21:00,870 --> 00:21:04,090 How do you reason through what to do for those patients? 378 00:21:05,200 --> 00:21:08,530 Yeah, and I think this is a very important question because you run 379 00:21:08,530 --> 00:21:13,090 into the situation all the time when the patient got hospitalized 380 00:21:13,510 --> 00:21:15,320 with bacteremia and they have 381 00:21:16,000 --> 00:21:18,065 pacemaker or ICD in place. 382 00:21:18,485 --> 00:21:20,255 Sometime, we don't' know what to do about them. 383 00:21:20,375 --> 00:21:22,235 Should we do echocardiogram? 384 00:21:22,235 --> 00:21:23,045 Should we not? 385 00:21:23,045 --> 00:21:24,125 Should we just monitor? 386 00:21:24,125 --> 00:21:27,965 So it's very, very important question and not a lot of study, 387 00:21:28,085 --> 00:21:30,545 um, looking into this scenario. 388 00:21:31,175 --> 00:21:36,065 So as you mentioned, it's very clear if the patient walk to you and have 389 00:21:36,335 --> 00:21:37,925 the pus come out of the pocket. 390 00:21:38,045 --> 00:21:42,455 We know that device need to come out no matter what, but when the patient come in 391 00:21:42,485 --> 00:21:47,240 with bacteremia, it very difficult to know whether the device is infected or not. 392 00:21:47,990 --> 00:21:52,550 I think the main principle that we would work on is the same as the patient 393 00:21:52,550 --> 00:21:54,620 with vascular graft and other device. 394 00:21:55,190 --> 00:21:59,450 So it's very depend on, um, the pathogen specific. 395 00:22:00,050 --> 00:22:05,690 For example, if the patient has a Staph aureus bacteremia, you would 396 00:22:05,690 --> 00:22:09,830 be very confident that you need to look into the device itself. 397 00:22:10,400 --> 00:22:16,055 However, if the patient has like very localized symptom of, for example, UTI 398 00:22:16,055 --> 00:22:18,145 and have a gram-negative bacteremia. 399 00:22:18,675 --> 00:22:22,025 The chance that the e coli or other gram-negative would, 400 00:22:22,595 --> 00:22:23,885 the device is very low. 401 00:22:23,915 --> 00:22:28,025 So all those situations, you do not need to specifically look at the device 402 00:22:28,025 --> 00:22:30,755 itself, either with TTE or other modality. 403 00:22:32,315 --> 00:22:36,245 We always run into the issue when we encounter the 404 00:22:36,245 --> 00:22:38,795 pathogen that we're uncertain. 405 00:22:39,305 --> 00:22:41,735 For example, Staph aureus, definitely high risk. 406 00:22:42,095 --> 00:22:44,885 Um, coag negative Staph, definitely high risk. 407 00:22:45,845 --> 00:22:46,635 Enterococci. 408 00:22:46,655 --> 00:22:49,685 I would also throw, throw into the high risk category as well. 409 00:22:49,775 --> 00:22:51,035 The same as Strep viridans group. 410 00:22:51,695 --> 00:22:55,415 But from time to time when we run into other gram positives, 411 00:22:56,095 --> 00:22:59,795 other streptococci or high risk gram-negatives, such 412 00:22:59,795 --> 00:23:01,605 as Serratia or Pseudomonas. 413 00:23:01,835 --> 00:23:03,815 From time to time's, very difficult to tell. 414 00:23:04,475 --> 00:23:07,775 So we need to, um, think about other factors as well. 415 00:23:07,925 --> 00:23:11,705 For example, does the patient has prolonged, um, bloodstream 416 00:23:11,705 --> 00:23:17,015 infection, um, are we able to identify the source of infection? 417 00:23:17,415 --> 00:23:22,795 Does the patient have cardiac device or other valvular processes as well. 418 00:23:23,345 --> 00:23:27,155 The more factor that the patient has, um, the more we think that the 419 00:23:27,155 --> 00:23:30,285 device might be infected, for example, prolonged bacteremia, community 420 00:23:31,025 --> 00:23:33,185 onset, and we could not find a source. 421 00:23:33,185 --> 00:23:37,025 So that's the time when we need to look closely into the device. 422 00:23:37,805 --> 00:23:43,585 And one thing that I also wanna mention is that, the prior study also came up with a 423 00:23:43,585 --> 00:23:49,025 multiple scoring system to see, especially with the Staph aureus, um, in the past, in 424 00:23:49,285 --> 00:23:52,395 around 2015, a score called predict SAB. 425 00:23:53,115 --> 00:23:58,930 So we try to, um, plug in the clinical factors that I just mentioned in, um, 426 00:23:58,960 --> 00:24:03,160 how long has the patient been bacteremic, and everything like that into to see 427 00:24:03,160 --> 00:24:06,730 that if the patient has a Staph aureus bacteremia, what is the likelihood 428 00:24:06,730 --> 00:24:08,980 of the underlying device is infected? 429 00:24:10,090 --> 00:24:14,833 And then the most recent one, the study group from Europe also came out with 430 00:24:14,833 --> 00:24:19,908 a score called a CTEPP score, which coming from like community acquisition, 431 00:24:19,938 --> 00:24:25,538 time to positivity, embolization, risk factors for IE, and persistent bacteremia. 432 00:24:25,988 --> 00:24:30,498 So we can use those score to fit into the clinical contact and see how 433 00:24:30,768 --> 00:24:34,638 how high of a risk that the patient who come in with bacteremia has to 434 00:24:34,638 --> 00:24:36,478 have underlying device infection. 435 00:24:37,568 --> 00:24:40,398 For other organisms, we still do not have a good score. 436 00:24:40,548 --> 00:24:45,438 We apply the same score that out there to predict the endocarditis, for example, 437 00:24:45,438 --> 00:24:51,463 like HANDOC for streptococci or DENOVA score for enterococci, but all of those 438 00:24:51,673 --> 00:24:56,488 are not specific to the device itself, but I think it's good enough plus the clinical 439 00:24:56,488 --> 00:25:00,928 judgment to see whether we really need to send the patient to transesophageal 440 00:25:00,928 --> 00:25:02,803 echocardiogram or do additional PET CT. 441 00:25:03,733 --> 00:25:08,113 So I think it's two main thing, depend on the pathogen specific virulence, 442 00:25:08,293 --> 00:25:12,363 and then depend on the nature of the bact itself and the host factor. 443 00:25:13,828 --> 00:25:19,678 So for this patient, uh, they underwent TEE, which demonstrated 444 00:25:19,678 --> 00:25:24,268 a small echo density at the atrial aspect of the CIED lead. 445 00:25:24,808 --> 00:25:27,538 There's no valvular vegetations observed. 446 00:25:27,818 --> 00:25:31,778 Here we can talk about challenges in interpreting TEE findings. 447 00:25:31,808 --> 00:25:34,718 And then I think the other question that we've started alluding to 448 00:25:34,718 --> 00:25:38,318 is, um, when when to use PET CT. 449 00:25:38,628 --> 00:25:42,558 And so I'd love to hear about how you decide on when to reach for that modality. 450 00:25:42,663 --> 00:25:43,473 Okay, perfect. 451 00:25:43,473 --> 00:25:48,078 To best answer this question, really figure three in the article that we have, 452 00:25:48,108 --> 00:25:50,238 uh, actually talks a lot about this. 453 00:25:50,298 --> 00:25:53,238 Um, so if we are looking at the patient. 454 00:25:53,708 --> 00:25:57,728 Our main question, you know, what is the role of the ECHO here? 455 00:25:58,118 --> 00:26:02,528 Um, to me, you know, we've already made the diagnosis of CIED infection for 456 00:26:02,528 --> 00:26:06,638 this specific patient just based on physical exam and positive blood culture. 457 00:26:07,148 --> 00:26:11,348 So the echo here is not really for diagnostic purposes specifically 458 00:26:11,498 --> 00:26:14,738 because we are already labeling this patient as having CIED infection 459 00:26:15,068 --> 00:26:16,418 and we're gonna treat accordingly. 460 00:26:16,448 --> 00:26:20,768 The purpose of the echo here is to tell us what is the duration of treatment. 461 00:26:21,583 --> 00:26:24,313 When is it okay to reimplant a device? 462 00:26:24,463 --> 00:26:29,203 And this will really depend on whether or not the valve has, uh, vegetations 463 00:26:29,203 --> 00:26:33,013 or is there any vegetations only on the lead or is there no vegetation? 464 00:26:33,013 --> 00:26:37,053 So really the echo helps us determine these two questions for this patient. 465 00:26:37,443 --> 00:26:41,793 The more challenging situation is if the patient had come in with bloodstream 466 00:26:41,793 --> 00:26:45,898 infection and no pocket site infection, or no pocket site inflammation. 467 00:26:46,618 --> 00:26:51,838 So in those patients, the echo, uh, is done for diagnostic purposes. 468 00:26:51,898 --> 00:26:55,678 We are trying to get more information to decide whether or not the device 469 00:26:55,678 --> 00:26:59,638 is actually infected and if whether or not we should treat it as such. 470 00:26:59,998 --> 00:27:02,938 So this is where the role of ECHO becomes more critical. 471 00:27:03,748 --> 00:27:06,538 And when we're thinking about echo findings, I can think 472 00:27:06,538 --> 00:27:07,978 of three scenarios really. 473 00:27:08,583 --> 00:27:14,793 The first scenario is you do an echo and you find valve vegetations, so that is 474 00:27:14,793 --> 00:27:18,843 actually the most straightforward scenario because if you do see that, then you're 475 00:27:18,843 --> 00:27:23,913 saying this patient has endocarditis, valvular endocarditis, and that in itself 476 00:27:23,913 --> 00:27:28,083 equates to device infection, and you're going to have to discuss extracting the 477 00:27:28,083 --> 00:27:31,653 device and treating for endocarditis with six weeks of antibiotics. 478 00:27:32,803 --> 00:27:37,303 The other two scenarios are less straightforward, and those include the 479 00:27:37,303 --> 00:27:41,983 second scenario, which is you do an echo and you find a lesion on the lead, but 480 00:27:41,983 --> 00:27:43,543 you're not seeing lesions elsewhere. 481 00:27:43,633 --> 00:27:45,703 So kind of similar to the echo we're seeing here. 482 00:27:46,453 --> 00:27:49,693 The third scenario is you do an echo and you don't see any lesions. 483 00:27:51,123 --> 00:27:54,963 Now, none of these two scenarios are either sensitive or specific for device 484 00:27:54,963 --> 00:27:58,863 infection because you could have a lesion on the lead that is a sterile 485 00:27:58,893 --> 00:28:03,363 thrombus, and it's actually common to have clots on those leads, especially if 486 00:28:03,363 --> 00:28:04,863 those leads have been there for a while. 487 00:28:04,983 --> 00:28:08,448 And there is nothing on the echo that can specifically tell you if 488 00:28:08,448 --> 00:28:10,568 this clot is infected or sterile. 489 00:28:12,718 --> 00:28:16,918 I cannot tell whether or not this lead vegetation or this echo density on 490 00:28:16,918 --> 00:28:20,428 the lead is a, an infected vegetation or it's a thrombus that's sterile. 491 00:28:21,628 --> 00:28:25,438 Even the third scenario where you don't see any lesions, I'm still not able to 492 00:28:25,528 --> 00:28:31,198 confidently rule out, uh, a device lead endocarditis because you could still 493 00:28:31,198 --> 00:28:34,588 miss that on the echo, especially if you can't visualize the entire lead. 494 00:28:35,548 --> 00:28:39,358 And so when it comes to these two scenarios, I think your decision 495 00:28:39,358 --> 00:28:43,738 has to be based on other factors like the type of pathogen, which 496 00:28:43,738 --> 00:28:48,388 Mac has spoken about just now, and also the burden of the bacteremia. 497 00:28:48,668 --> 00:28:50,598 Community acquired bacteremia. 498 00:28:50,733 --> 00:28:53,293 High grade multiple sets, persistent. 499 00:28:53,313 --> 00:28:54,633 No primary focus. 500 00:28:55,083 --> 00:28:58,113 If you have this high burden bacteremia and if you have a high 501 00:28:58,113 --> 00:29:03,003 risk pathogen like staph aureus, then in my mind I would still 502 00:29:03,003 --> 00:29:06,393 consider this device likely infected. 503 00:29:06,903 --> 00:29:10,893 And a lot of experts actually would go ahead and discuss extracting the device 504 00:29:10,893 --> 00:29:16,443 without doing further testing because in their mind, the pretest probability 505 00:29:16,443 --> 00:29:20,708 for device infection is already very high with things like Staph aureus 506 00:29:20,708 --> 00:29:22,798 bacteremia, high burden of bacteremia. 507 00:29:23,698 --> 00:29:28,518 But when you're talking about other bacterias, like maybe gram-negatives, 508 00:29:28,878 --> 00:29:34,188 uh, Clostridium, Cutibacterium, er, other types of bacteria, you cannot make that 509 00:29:34,188 --> 00:29:37,788 assumption because the pretest probability that the device is infected is not 510 00:29:37,788 --> 00:29:40,008 that high, not similar to staph aureus. 511 00:29:40,278 --> 00:29:43,708 And that's when you start wondering, is there any other test that I could 512 00:29:43,708 --> 00:29:45,898 do to help me make that decision? 513 00:29:46,288 --> 00:29:48,448 And that's where PET CT comes in. 514 00:29:49,058 --> 00:29:52,478 And you really, if you look at, there are so many different societies 515 00:29:52,478 --> 00:29:55,958 now that have strengthened their language and statement about using 516 00:29:55,958 --> 00:29:58,778 pet CT for, uh, device infection. 517 00:29:59,108 --> 00:30:03,268 Ever since 2019 up until now, they've been talking about the 518 00:30:03,268 --> 00:30:05,278 use of PET CT for those cases. 519 00:30:05,638 --> 00:30:09,118 And we know that PET CT actually has a very decent sensitivity and 520 00:30:09,118 --> 00:30:11,128 specificity for device infection. 521 00:30:11,638 --> 00:30:15,958 And so a lot of big centers that have PET CTs, they will probably go ahead 522 00:30:15,958 --> 00:30:17,848 and get a PET CT for those cases. 523 00:30:17,848 --> 00:30:20,218 And if it's positive, they call the device infected. 524 00:30:20,218 --> 00:30:22,978 If it's negative, they say the device is probably not infected. 525 00:30:23,723 --> 00:30:26,153 But we have to be very careful and cautious because there is, 526 00:30:26,243 --> 00:30:28,403 there are cons to the PET ct. 527 00:30:28,493 --> 00:30:32,163 The biggest con really is that not every center will have it 528 00:30:32,163 --> 00:30:33,963 accessible or readily accessible. 529 00:30:33,963 --> 00:30:38,073 So some centers can't just get a PET CT and the longer you wait and the 530 00:30:38,073 --> 00:30:41,793 longer that the patient has been on antibiotics, the less reliable that 531 00:30:41,793 --> 00:30:45,803 PET CT becomes because we think the antibiotic can decrease inflammation 532 00:30:45,803 --> 00:30:50,043 and, and so, you know, if you're not able to get PET CT very quickly. 533 00:30:50,213 --> 00:30:53,458 It might not be such a tempting test to get. 534 00:30:54,593 --> 00:30:58,073 The other cons for the PET CT is that while we think, and we know 535 00:30:58,073 --> 00:31:02,543 it's sensitive and specific, it's mostly for pocket site infections. 536 00:31:02,813 --> 00:31:06,143 So it's not that sensitive for lead site infection. 537 00:31:06,653 --> 00:31:10,763 And, and that's why some experts, when they have a high pretest probability 538 00:31:11,063 --> 00:31:15,443 for, uh, device infection, like with Staph aureus high burden bacteremia, 539 00:31:15,923 --> 00:31:17,403 they would not get a PET CT. 540 00:31:17,403 --> 00:31:21,168 They will just discuss extracting the device because they think even 541 00:31:21,168 --> 00:31:24,168 if we do a PET CT and it comes back negative, it still does not rule 542 00:31:24,168 --> 00:31:29,408 out a lead endocarditis because it's not as sensitive for leads as 543 00:31:29,408 --> 00:31:31,058 it's for pocket site infections. 544 00:31:31,718 --> 00:31:34,958 So that's actually one very important thing to keep in mind. 545 00:31:34,958 --> 00:31:39,338 So to summarize things, the role of PET CT seems to be more tempting 546 00:31:39,758 --> 00:31:43,538 when you have an intermediate pretest probability for device infection. 547 00:31:44,348 --> 00:31:48,218 Because in those cases you think that if it's a negative PET ct, then it adds 548 00:31:48,218 --> 00:31:52,148 another reassuring layer that the patient probably does not have a device infection. 549 00:31:53,108 --> 00:31:57,278 Now we spoke about the PET CT, what about centers that can't get a PET CT? 550 00:31:57,428 --> 00:31:59,708 What is one other approach that they could consider? 551 00:32:00,428 --> 00:32:04,903 Again, if they think that their pretest probability for, uh, device infection 552 00:32:04,903 --> 00:32:09,303 is not that high, one approach would be to actually treat the bacteremia. 553 00:32:10,033 --> 00:32:13,153 Stop the antibiotics after treatment and do surveillance of blood 554 00:32:13,153 --> 00:32:15,973 cultures about five to seven days after you stop the antibiotics. 555 00:32:15,973 --> 00:32:19,513 If the bacteremia recurs and you still don't have another source, then it's 556 00:32:19,513 --> 00:32:22,303 probably a device infection and then you have to treat it accordingly. 557 00:32:23,293 --> 00:32:27,943 And so that's kind of, you know, talking about the echoes and PET CTs and, and what 558 00:32:27,943 --> 00:32:29,863 to do if you can't do a PET CT as well. 559 00:32:31,108 --> 00:32:36,538 Yeah, I, I just wanna add one point is that apart from the accessibility of the 560 00:32:36,538 --> 00:32:41,398 PET CT, the cost is also, um, another concern, especially when we have a 561 00:32:41,398 --> 00:32:45,988 different reimbursement system, whether it's gonna cover outpatient, gonna cover 562 00:32:46,018 --> 00:32:50,698 inpatient or whether it's a cancer or non-cancer indication, but surprisingly 563 00:32:50,728 --> 00:32:53,548 in Europe, they have no issue with this. 564 00:32:54,028 --> 00:32:55,018 With the reimbursement. 565 00:32:55,018 --> 00:32:59,488 That's the reason why if you look at the European CIED guideline, um, in 566 00:32:59,548 --> 00:33:06,028 2019, and also the update in guideline in 2023, they, they state very clearly 567 00:33:06,028 --> 00:33:10,768 that if the patient has a Staph aureus bacteremia with the device in place, 568 00:33:11,188 --> 00:33:15,698 um, they recommend every single patient to get a PET CT because apart from the 569 00:33:15,698 --> 00:33:21,533 device itself, it can also identify those metastatic foci and everything like that. 570 00:33:21,533 --> 00:33:24,593 But that's also reflects that in Europe, they don't have a lot 571 00:33:24,593 --> 00:33:28,493 of problem in reimbursement that we still seeing here in the us. 572 00:33:28,848 --> 00:33:33,723 One, one other question that I think needs a lot of thought and more 573 00:33:33,723 --> 00:33:38,038 studies to, to answer that question is the mortality and morbidity benefit 574 00:33:38,038 --> 00:33:39,508 of getting those PET CTs right? 575 00:33:39,538 --> 00:33:44,258 Especially like when we're talking about finding out where other sites of seeding. 576 00:33:44,823 --> 00:33:47,473 Uh, you know, like for example, if you have staph aureus bacteremia, 577 00:33:47,883 --> 00:33:49,233 did it seed somewhere else? 578 00:33:49,233 --> 00:33:50,253 Is there a deep abscess? 579 00:33:50,253 --> 00:33:51,843 And the PET CT will help you find that out. 580 00:33:51,843 --> 00:33:54,933 But there are studies showing that it does not really maybe affect 581 00:33:54,933 --> 00:33:56,523 mortality or morbidity that much. 582 00:33:56,793 --> 00:33:59,613 So I think that's a very important question also to look more into in 583 00:33:59,613 --> 00:34:03,273 the, in future studies, if I get a pet CT for those cases, does it 584 00:34:03,273 --> 00:34:07,203 really change the overall outcome in terms of morbidity and mortality? 585 00:34:07,933 --> 00:34:08,203 Yeah. 586 00:34:08,293 --> 00:34:09,853 Thank you guys so much for covering that. 587 00:34:09,853 --> 00:34:14,233 It's a, it's a big topic and obviously a conversation point on many consults. 588 00:34:14,263 --> 00:34:18,513 Well, despite some of her comorbid conditions, the cardiology team 589 00:34:18,513 --> 00:34:22,683 does recommend complete CIED extraction for this patient. 590 00:34:23,263 --> 00:34:26,233 The patient and her family have expressed some reluctance due to 591 00:34:26,233 --> 00:34:28,333 concerns about the complications. 592 00:34:28,873 --> 00:34:31,953 And so how do you structure your discussion when you're 593 00:34:31,953 --> 00:34:33,483 in this type of scenario? 594 00:34:33,783 --> 00:34:37,883 Yeah, it's a great question and that comes up in every case, right? 595 00:34:37,933 --> 00:34:43,318 It's a procedure that carries significant risk and potential bad outcomes. 596 00:34:43,978 --> 00:34:46,408 Granted, it's, it's low for it to happen. 597 00:34:46,558 --> 00:34:50,728 It's quoted anywhere between one to 2%, depending on the center and their 598 00:34:50,728 --> 00:34:52,438 experience and expertise available. 599 00:34:52,503 --> 00:34:56,538 And, and they can be very serious complications that include bleeding 600 00:34:56,538 --> 00:35:00,618 to the superior vena cava, you can get a tear, uh, you can get cardiac 601 00:35:00,648 --> 00:35:03,198 tamponade among other things. 602 00:35:03,258 --> 00:35:05,598 Uh, and, and death is, is a potential risk. 603 00:35:05,598 --> 00:35:11,258 So those are real complications from device removal. 604 00:35:11,258 --> 00:35:13,688 So that's why we wanna be as certain as possible that the 605 00:35:13,688 --> 00:35:15,458 device is infected, taking it out. 606 00:35:15,848 --> 00:35:19,088 Uh, which again, as we, as we've been talking about, it's not always 607 00:35:19,298 --> 00:35:22,388 as straightforward, but you have to balance that with, well, what 608 00:35:22,388 --> 00:35:25,238 if we just keep the device in and put the patient on antibiotics? 609 00:35:25,508 --> 00:35:26,708 How well does that work? 610 00:35:27,098 --> 00:35:30,988 There's been very limited data, uh, out there looking long term 611 00:35:31,198 --> 00:35:33,863 suppression with chronic antibiotic use. 612 00:35:33,863 --> 00:35:37,733 Actually only one study I can think of that looked at that, and the data 613 00:35:37,733 --> 00:35:39,898 from there showed that it's an option. 614 00:35:40,668 --> 00:35:43,948 But it should be one of your final options of suppression. 615 00:35:44,318 --> 00:35:46,958 And every effort should be made to, to remove the device. 616 00:35:46,958 --> 00:35:50,588 And the reason for that is there's risk of relapse with device 617 00:35:50,588 --> 00:35:55,498 retention, uh, especially if there's valvular or CIED related infective 618 00:35:55,498 --> 00:35:59,968 endocarditis, keeping a device in is associated with high mortality, uh, 619 00:35:59,968 --> 00:36:01,858 as well as high rates of relapse. 620 00:36:02,813 --> 00:36:07,613 So, so again, you're in this balancing act of, well, if we keep the device in, 621 00:36:07,733 --> 00:36:11,133 there's risks the infection can come back or potentially we may not be able 622 00:36:11,133 --> 00:36:15,093 to control the infection versus while there's real risk to the procedure, as 623 00:36:15,093 --> 00:36:21,993 I mentioned, uh, ways to approach the patient is, is making them aware of these 624 00:36:21,993 --> 00:36:27,453 potential risks and complications from going for device removal, but also the 625 00:36:27,453 --> 00:36:29,493 risk of not going for device removal. 626 00:36:29,913 --> 00:36:32,343 This is something where you're gonna make a shared decision 627 00:36:32,403 --> 00:36:33,633 approach with the patient. 628 00:36:33,783 --> 00:36:37,523 And, other things that are important to consider is these devices should be 629 00:36:37,613 --> 00:36:42,583 extracted at centers of excellence where they're doing this on, on a regular basis. 630 00:36:42,583 --> 00:36:46,423 The providers that are removing these devices should have significant 631 00:36:46,423 --> 00:36:51,623 experience, uh, with this and have a support system, backing them up. 632 00:36:51,683 --> 00:36:55,293 And what I mean by that is vascular surgery if there is a tear to the 633 00:36:55,293 --> 00:36:57,393 SVC or other, other major vessels. 634 00:36:57,723 --> 00:37:02,743 Cardiothoracic surgery, on standby, ready to go if there is a complication as 635 00:37:02,743 --> 00:37:08,143 these patients may require opening their chest to repair from these complications. 636 00:37:08,173 --> 00:37:12,223 So, um, so again, it's a discussion you gotta have with each and every patient, 637 00:37:12,353 --> 00:37:15,503 and come together what you think is best for that patient at that time. 638 00:37:15,563 --> 00:37:19,163 There's so many variables that come into play and listening to the patient and 639 00:37:19,163 --> 00:37:20,933 their family and what are their concerns. 640 00:37:20,963 --> 00:37:24,093 You know, it may be they're not worried about the one in a hundred chance, they're 641 00:37:24,093 --> 00:37:28,253 more worried about the pain or something else happening, or maybe they, they have 642 00:37:28,253 --> 00:37:32,273 a tough time waking up from sedation and so, so really asking the patient and their 643 00:37:32,273 --> 00:37:34,013 family, what, what are their concerns? 644 00:37:34,343 --> 00:37:37,133 We have our concerns and what we think is concerns, but may not 645 00:37:37,133 --> 00:37:40,103 always match what the patient is concerned about or their family. 646 00:37:41,023 --> 00:37:43,933 Oh, we left this case a little broad. 647 00:37:43,933 --> 00:37:48,763 I was gonna ask now about how you guys set your final antibiotic plan 648 00:37:48,763 --> 00:37:53,203 and the question of when you can reimplant when a device is removed. 649 00:37:53,353 --> 00:37:55,603 Uh, we didn't pinpoint a specific bug. 650 00:37:55,603 --> 00:37:58,573 'cause I think maybe today our goal is to talk more broadly. 651 00:37:58,693 --> 00:38:00,763 But yeah, how would you approach that? 652 00:38:01,183 --> 00:38:06,073 Yeah, so I think that's the question that we all get asked about. 653 00:38:06,293 --> 00:38:11,273 After the device is removed, when is the appropriate time to place this back. 654 00:38:11,688 --> 00:38:17,418 I think it's very depend on what kind of syndrome that the patient has. 655 00:38:18,018 --> 00:38:22,478 So the principle is that, if the patient has the vegetation on the 656 00:38:22,478 --> 00:38:29,038 valve, we would prolong the time of reimplantation as long as possible. 657 00:38:29,548 --> 00:38:32,208 And most of the time we use 14 days. 658 00:38:32,308 --> 00:38:37,858 Because our hypothetical concern is that if we put the new device too soon 659 00:38:38,248 --> 00:38:42,958 and the patient has the vegetation persistently on the valve, we concerned 660 00:38:42,958 --> 00:38:48,388 that vegetation will become a new foci and eventually infect that device, 661 00:38:48,388 --> 00:38:52,118 the new device that was just placed. 662 00:38:52,118 --> 00:38:57,298 If a patient has vegetation on the valve, we would wanna wait as long 663 00:38:57,298 --> 00:38:59,848 as possible, 14 day if possible. 664 00:39:00,418 --> 00:39:04,608 Um, if the patient doesn't have vegetation on the valve, just a lead 665 00:39:04,738 --> 00:39:06,508 vegetation or no vegetation at all. 666 00:39:06,508 --> 00:39:06,988 At all. 667 00:39:06,988 --> 00:39:12,098 And then the device got extracted, we would wait for 48 to 72 hours, um, 668 00:39:12,318 --> 00:39:14,578 after the first negative blood culture. 669 00:39:14,638 --> 00:39:18,588 So as long as the patient has clear from the bacteremia perspective we 670 00:39:18,588 --> 00:39:20,708 should be able to put the new device in. 671 00:39:21,078 --> 00:39:26,918 Some study in Europe also, if the patient doesn't have bacteremia, um, the sooner 672 00:39:26,918 --> 00:39:30,458 that you can place a new device in actually in the same day, so they put a 673 00:39:30,458 --> 00:39:34,278 new device in, in the contralateral side if the patient doesn't have bacteremia. 674 00:39:34,838 --> 00:39:40,133 So I think the key is that as long as the patient is no longer bacteremic, it should 675 00:39:40,133 --> 00:39:44,753 be safe to place a new device unless the patient has a vegetation on the valve. 676 00:39:45,813 --> 00:39:51,628 So I'm going to touch a little bit about interim strategy because that's also an 677 00:39:51,628 --> 00:39:54,178 important topic that we need to discuss. 678 00:39:54,388 --> 00:40:00,728 Um, mainly what device gonna be placed is depend on what was the indication that 679 00:40:00,728 --> 00:40:03,098 the patient has device in the first place. 680 00:40:03,533 --> 00:40:06,113 Maybe the patient no longer need device, which is great. 681 00:40:06,113 --> 00:40:09,413 We don't need to have a time or new device implant. 682 00:40:09,923 --> 00:40:13,643 But let's say if the patient continues to have indication, for example, 683 00:40:13,703 --> 00:40:17,303 ventricular arrhythmia or cardiac pacing that need a new device. 684 00:40:17,693 --> 00:40:20,918 So that's need to be discussed with the electrophysiologist. 685 00:40:22,123 --> 00:40:26,743 Because if, for example, if they do not wanna put the intravascular 686 00:40:27,043 --> 00:40:29,443 device, maybe we have the alternative. 687 00:40:29,503 --> 00:40:34,303 For example, if the patient who need a cardiac pacing without the ICD 688 00:40:34,318 --> 00:40:37,813 function, we can use the leadless pacemaker in that situation. 689 00:40:37,903 --> 00:40:42,783 But if the patient doesn't need a cardiac pacing but need the ICD function, 690 00:40:43,053 --> 00:40:48,138 we can use the subcutaneous or the extravascular ICD, um, in that situation. 691 00:40:48,558 --> 00:40:52,878 But from time to time, if the patient needs both, we may not be 692 00:40:52,878 --> 00:40:56,868 able to find any interim strategy, especially when the patient that 693 00:40:56,868 --> 00:40:58,998 we wanna prolong the implantation. 694 00:40:58,998 --> 00:41:02,508 So that's the reason why I said prolong as much as possible because 695 00:41:02,563 --> 00:41:07,393 when we say 14 day, it's not always possible in the clinical practice. 696 00:41:08,568 --> 00:41:12,618 And regarding the antibiotics after the extraction, if the patient has 697 00:41:12,768 --> 00:41:17,098 a valve vegetation, we would treat the same as infective endocarditis, 698 00:41:17,118 --> 00:41:18,228 which is four to six weeks. 699 00:41:18,258 --> 00:41:22,098 But if the patient doesn't have the vegetation on the valve, we can do 700 00:41:22,188 --> 00:41:24,168 shorter than that which is 2-4 weeks. 701 00:41:24,558 --> 00:41:24,888 Great. 702 00:41:25,368 --> 00:41:29,718 And after some discussion of risk, risks and benefits, the patient and 703 00:41:29,718 --> 00:41:32,898 family declined the device extraction. 704 00:41:33,318 --> 00:41:37,368 At this point, the patient's been on vancomycin, blood cultures have cleared. 705 00:41:37,678 --> 00:41:42,198 So what would be your strategy here and planning for follow-up once 706 00:41:42,198 --> 00:41:43,368 they're in the outpatient setting? 707 00:41:43,938 --> 00:41:47,868 As long as the device remains, unfortunately there is no objective 708 00:41:47,868 --> 00:41:50,298 test that we could do after a treatment. 709 00:41:50,298 --> 00:41:52,758 So let's say we we're gonna treat the syndrome for four 710 00:41:52,758 --> 00:41:54,498 to six weeks with antibiotics. 711 00:41:54,498 --> 00:41:57,978 After we finish this treatment, there is no objective test that 712 00:41:57,978 --> 00:42:00,828 will tell us the infection is completely eradicated from the device. 713 00:42:00,918 --> 00:42:04,728 And so to simplify things, those cases would require to be on 714 00:42:04,728 --> 00:42:07,908 antimicrobial suppression after you finish the treatment phase. 715 00:42:07,988 --> 00:42:11,958 Of course it's not as simple as I'm making it sound because, we're in 716 00:42:11,958 --> 00:42:14,178 the era of antimicrobial resistance. 717 00:42:14,178 --> 00:42:18,828 A lot of times we might not have good or tolerable oral options to suppress 718 00:42:18,828 --> 00:42:20,928 these patients after the treatment. 719 00:42:21,408 --> 00:42:23,778 We don't know how long to suppress them for. 720 00:42:23,838 --> 00:42:26,388 We don't have very good longitudinal studies to tell 721 00:42:26,388 --> 00:42:28,038 us or answer this question. 722 00:42:28,168 --> 00:42:32,393 Dan had talked about one study which had 48 patients where they suppressed. 723 00:42:33,083 --> 00:42:36,553 And you know, in that study, they had about 18% relapse. 724 00:42:36,643 --> 00:42:40,873 So we also don't, I mean, we don't have much studies to tell us about relapse, 725 00:42:40,873 --> 00:42:44,233 how long to keep the patient antibiotic, what happens when we stop the antibiotics, 726 00:42:44,233 --> 00:42:47,023 how much of those patients tolerate the antibiotics and things like that. 727 00:42:47,023 --> 00:42:51,913 So it is really, uh, not an easy thing to, to, to manage, I would say 728 00:42:51,913 --> 00:42:53,923 as long as the device is retained. 729 00:42:53,923 --> 00:42:56,473 You wanna try to keep this patient on antimicrobial 730 00:42:56,473 --> 00:42:58,033 suppression as much as possible. 731 00:42:58,293 --> 00:43:00,933 So, you know, in my mind what I would do is I would finish the 732 00:43:00,933 --> 00:43:03,903 treatment course again, four to six weeks, depending on the syndrome. 733 00:43:04,293 --> 00:43:08,683 See the patient at that point, make sure that the pocket looks good, make 734 00:43:08,683 --> 00:43:12,743 sure that the patient looks good, and then have a discussion with the 735 00:43:12,743 --> 00:43:17,303 patient about getting them on an oral antibiotic that will potentially help 736 00:43:17,303 --> 00:43:21,148 suppress their infection as long as possible, as long as they tolerate it. 737 00:43:23,043 --> 00:43:26,403 Usually it's not an easy discussion, especially when you're trying to 738 00:43:26,403 --> 00:43:29,613 tell the patient that you're likely going to need to be on antibiotics 739 00:43:29,613 --> 00:43:30,783 for the rest of your life. 740 00:43:30,883 --> 00:43:34,303 And so a lot of patients, they might not be very excited about that, so it's 741 00:43:34,303 --> 00:43:38,968 very important to mention this plan, even early on during their treatment, 742 00:43:38,968 --> 00:43:41,668 don't wait until they're done with their treatment and say, hey, we're 743 00:43:41,668 --> 00:43:44,608 gonna put you on oral antibiotics now to suppress you indefinitely. 744 00:43:44,668 --> 00:43:47,308 I think this is something that you have to discuss during the shared 745 00:43:47,308 --> 00:43:51,028 decision making, which Dan talked about, and this should be early during 746 00:43:51,028 --> 00:43:53,008 the hospitalization course itself. 747 00:43:53,303 --> 00:43:58,013 So you guys covered a real, quite a big topic in a pretty short amount of time. 748 00:43:58,673 --> 00:44:03,893 To end, I was just going to ask you separate from this case, what things 749 00:44:03,893 --> 00:44:10,233 you're most excited about in this subset of ID, cardiac device infections. 750 00:44:10,233 --> 00:44:12,663 What things are you most interested in learning about? 751 00:44:13,143 --> 00:44:15,813 Um, maybe studies that are underway that you're looking 752 00:44:15,813 --> 00:44:17,043 forward to hearing results on. 753 00:44:18,638 --> 00:44:21,098 I think we all can share this answer. 754 00:44:22,238 --> 00:44:27,278 For me is that I, I wanna see, um, more accurate diagnosis in this 755 00:44:27,278 --> 00:44:31,888 field because as Hassam mentioned, even though we have TEE, PET-CT. 756 00:44:32,698 --> 00:44:37,153 We still in a lot of, um, conundrum whether this device is infected 757 00:44:37,303 --> 00:44:40,213 or not, whether we should extract it or not, because everything 758 00:44:40,213 --> 00:44:44,383 that we offer to the patient is impact their life substantially. 759 00:44:44,383 --> 00:44:49,233 For example, if we say that, Hey, we are unsure, but we should remove your device. 760 00:44:49,273 --> 00:44:53,803 It's not just easy as we say, because that would involve multiple people. 761 00:44:54,223 --> 00:44:58,363 So that's why I'm excited to see whether, is there any new tools, 762 00:44:58,363 --> 00:45:02,773 any new modality that coming out and regarding the treatment perspective. 763 00:45:03,103 --> 00:45:07,298 We don't have a lot of thing in, in the pipeline right now, but I would 764 00:45:07,328 --> 00:45:12,098 like to see if, is there any way that we can treat the device infection 765 00:45:12,098 --> 00:45:17,258 without a chronic suppression or suppression in very limited time. 766 00:45:18,528 --> 00:45:19,643 The thing that I excited for. 767 00:45:20,588 --> 00:45:25,153 Especially with like using biofilm active agents in those treatments, 768 00:45:25,153 --> 00:45:27,043 is there any role for rifampin? 769 00:45:27,103 --> 00:45:30,543 Does quinolone have a different efficacy than other antibiotics? 770 00:45:30,543 --> 00:45:32,943 'cause we know that it has biofilm activity, so, you know, what is 771 00:45:32,943 --> 00:45:36,938 the role of adding those types of agents to the treatment and does it 772 00:45:36,938 --> 00:45:40,058 really help us get the patient off suppression if we retain the device? 773 00:45:40,058 --> 00:45:42,128 So that's one thing I would like, like to look at. 774 00:45:42,678 --> 00:45:46,068 It would be really nice if there is something that could be done about the 775 00:45:46,068 --> 00:45:50,688 device itself to make it more resistant to, to, to infections in the first place. 776 00:45:50,688 --> 00:45:53,783 And I, I know there has been other things that have, that have been looked at in 777 00:45:53,783 --> 00:45:55,703 the past, like this antibiotic envelope. 778 00:45:56,283 --> 00:46:00,153 Dan, you spoke to us multiple times about this in the past, and so, you 779 00:46:00,153 --> 00:46:04,083 know, what are advances that are being, are happening in the field to 780 00:46:04,113 --> 00:46:08,343 somehow make this device resistant to getting those bacteria seeding on it? 781 00:46:08,913 --> 00:46:11,163 Yeah, I think that's definitely the future. 782 00:46:11,223 --> 00:46:14,823 We're seeing some of it already with leadless pacemakers. 783 00:46:14,918 --> 00:46:19,478 I think that's, that's really the, the future for this. 784 00:46:19,478 --> 00:46:23,368 I mean, it's, we're putting leadless pacemakers in patients, uh, you 785 00:46:23,368 --> 00:46:24,538 know, over the last several years. 786 00:46:24,928 --> 00:46:28,288 Uh, the issue is you can't do a leadless in everybody based on, you 787 00:46:28,288 --> 00:46:30,058 know, does it need atrial sensing? 788 00:46:30,058 --> 00:46:31,988 And certain people rely on on that. 789 00:46:33,728 --> 00:46:36,878 It gets beyond, uh, the, the infectious disease doc in me. 790 00:46:36,878 --> 00:46:39,878 It goes more towards the electrophysiologist to comment on 791 00:46:39,878 --> 00:46:43,808 that, but I know they're working on developing those leadless pacemakers to, 792 00:46:44,198 --> 00:46:46,088 to kind of be the go-to for patients. 793 00:46:46,118 --> 00:46:50,348 Uh, it's very easy to take out as compared to a device that has 794 00:46:50,348 --> 00:46:57,983 been in the chest pocket for 10 years, so there's benefits there. 795 00:46:57,983 --> 00:47:00,783 The material itself is different compared to the current, uh, 796 00:47:00,813 --> 00:47:02,738 uh, CIEDs, like pacemaker ICDs. 797 00:47:02,738 --> 00:47:06,368 So the, these organisms, like the staphylococci, like that, 798 00:47:06,518 --> 00:47:08,528 what they have on their surface and what they like to stick to. 799 00:47:08,803 --> 00:47:11,863 It's less likely to be sticky to the leadless pacemakers. 800 00:47:11,863 --> 00:47:14,473 So it doesn't mean leadless pacemakers don't get infected. 801 00:47:14,473 --> 00:47:19,093 They do, um, just much less likely plus the size and surface area. 802 00:47:19,483 --> 00:47:25,238 So if you have like a big bulky CRT with three leads, compare that to something 803 00:47:25,238 --> 00:47:29,658 that's maybe the size of a little bigger than a reasonable size pill of Augmentin. 804 00:47:30,138 --> 00:47:32,328 You know, there's only so much surface area for that organism 805 00:47:32,328 --> 00:47:36,018 to attach compared to multiple leads and a big pocket generator. 806 00:47:36,018 --> 00:47:37,788 And you think of your patients, a lot of these patients are 807 00:47:37,788 --> 00:47:39,408 gonna be elderly, frail. 808 00:47:39,408 --> 00:47:42,798 There's only so much skin soft tissue to, uh, that pocket. 809 00:47:42,978 --> 00:47:44,178 This is endovascular. 810 00:47:44,298 --> 00:47:48,948 Uh, so, so I think that's, that is definitely the future is going leadless. 811 00:47:49,188 --> 00:47:53,988 There's also subcutaneous where you can go outside of the bloodstream, and go subq 812 00:47:53,988 --> 00:47:57,648 and tunnel these leads, and have external leads, rather than be in the bloodstream. 813 00:47:57,648 --> 00:47:59,178 And I think that's a big factor here. 814 00:47:59,178 --> 00:48:02,903 So I know Hussam you mentioned about, uh, deep brain stimulators, 815 00:48:02,963 --> 00:48:05,693 you know, and again, that, and their management is a little bit different 816 00:48:05,723 --> 00:48:07,533 than complete device extraction. 817 00:48:07,533 --> 00:48:11,268 Sometimes it's just taking out the generator and the lead leads 818 00:48:11,288 --> 00:48:13,968 in, or, there's a lot of ways to go about it, but it's different. 819 00:48:13,968 --> 00:48:15,618 And sometimes suppression works really well. 820 00:48:15,888 --> 00:48:19,428 It's, it's these devices that are intravascular, they're in the bloodstream. 821 00:48:19,788 --> 00:48:22,978 Those are tough to suppress compared to say a prosthetic joint, deep 822 00:48:22,978 --> 00:48:27,138 brain stimulator where its not endovascular, in that bloodstream. 823 00:48:27,138 --> 00:48:29,088 So I'm excited for the future in that regard. 824 00:48:29,088 --> 00:48:34,248 And then probably PET imaging, but rather than using FDG, looking at more 825 00:48:34,248 --> 00:48:38,148 like organism specific to where, Hey, I know there's staph aureus in the blood. 826 00:48:38,208 --> 00:48:42,408 Let's do a staph aureus specific biomarker tracer, uh, that 827 00:48:42,408 --> 00:48:43,638 we can, we can search for. 828 00:48:43,638 --> 00:48:47,793 Maybe that'll give us better uptake than just FDG avidity because 829 00:48:47,793 --> 00:48:50,403 those device leads are, are only gonna have so much surface area. 830 00:48:50,403 --> 00:48:53,633 They're only so much uptake and as you get further away from pocket, 831 00:48:53,633 --> 00:48:54,968 that sensitivity of PET goes down. 832 00:48:55,148 --> 00:49:00,268 So I think that's my big thing, our available tools to make the 833 00:49:00,268 --> 00:49:02,068 diagnosis of device infections. 834 00:49:02,068 --> 00:49:04,948 Echo and, and PET scan are not great. 835 00:49:05,108 --> 00:49:07,358 So I said a lot there. 836 00:49:07,538 --> 00:49:10,078 But I'm excited for the future and I think leadless is the way to go. 837 00:49:20,538 --> 00:49:22,348 For this paper, we collaborated with multiple subspecialties, cardiology, 838 00:49:22,348 --> 00:49:23,648 electrophysiology, nuclear medicine expert, and also CV surgery. 839 00:49:23,648 --> 00:49:28,488 So, the co-author who wrote the paper also reflects like the real life that when we 840 00:49:28,488 --> 00:49:33,648 manage a CIED infection, as Dan mentioned earlier, we need the whole village. 841 00:49:33,678 --> 00:49:37,158 We need to talk to patient, we need to talk to family, and we need to talk 842 00:49:37,158 --> 00:49:42,163 to multiple, multiple people in order to make a decision for one patient. 843 00:49:45,063 --> 00:49:48,723 Thank you so much, Hussam Mac and Dan for joining Febrile today. 844 00:49:49,023 --> 00:49:52,713 You can find their article, State of the Art Review, complexities in 845 00:49:52,713 --> 00:49:57,423 Cardiac Implantable Electronic Device Infections, A Contemporary Practical 846 00:49:57,423 --> 00:49:59,793 Approach in Clinical Infectious Diseases. 847 00:49:59,853 --> 00:50:03,093 This is linked on the webpage as well as in the episode information. 848 00:50:03,213 --> 00:50:06,633 You can check out their prior StAR episode on vascular graft 849 00:50:06,633 --> 00:50:08,813 infections, episode number 110. 850 00:50:09,518 --> 00:50:13,208 If you're looking to hear another episode related to cardiac device infection, 851 00:50:13,208 --> 00:50:17,888 diagnosis, and management, you can check out episode number 78 featuring some of 852 00:50:17,888 --> 00:50:20,378 our both ID and cardiology colleagues. 853 00:50:20,438 --> 00:50:24,698 Don't forget to check out the website, Febrile podcast.com to find the consult 854 00:50:24,698 --> 00:50:28,418 notes, which are written supplements to the episodes with links to references, 855 00:50:28,778 --> 00:50:32,168 our library of ID infographics, and a link to our merch store. 856 00:50:33,338 --> 00:50:37,328 Febrile is produced with support from the Infectious Diseases Society of America. 857 00:50:37,388 --> 00:50:37,869 IDSA. 858 00:50:38,823 --> 00:50:41,493 Please reach out if you have any suggestions for future shows or 859 00:50:41,493 --> 00:50:42,993 wanna be more involved with Febrile. 860 00:50:43,413 --> 00:50:44,223 Thanks for listening. 861 00:50:44,493 --> 00:50:45,948 Stay safe and I'll see you next time.