Episode 128
128: StAR: Complexities in CIED Infection
This StAR episode features the CID State-of-the-Art Review on Complexities in Cardiac Implantable Electronic Device Infections: A Contemporary Practical Approach.
Our guest stars this episode are from the Division of Public Health, Infectious Diseases and Occupational Medicine at Mayo Clinic, Rochester, Minnesota:
Supavit Chesdachai
Hussam Tabaja
Daniel DeSimone
Journal companion article - Executive summary link: Chesdachai S, Baddour LM, Tabaja H, Madhavan M, Anavekar N, Zwischenberger BA, Erba PA, DeSimone DC. Executive Summary: State-of-the-Art Review: Complexities in Cardiac Implantable Electronic Device Infections: A Contemporary Practical Approach. Clin Infect Dis. 2025 Feb 5;80(1):1-3. doi: 10.1093/cid/ciae454. PMID: 39908173.
From Clinical Infectious Diseases
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Febrile is produced with support from the Infectious Diseases Society of America (IDSA)
Transcript
Hi everyone.
Speaker:Welcome to Febrile, a cultured podcast about all things infectious disease.
Speaker:We use consult questions to dive into ID clinical reasoning, diagnostics
Speaker:and antimicrobial management.
Speaker:I'm Sara Dong, your host and a Med Peds ID doc.
Speaker:We are back today with a StAR episode, State of the Art Review.
Speaker:These focus on recent state of the art reviews that were published in
Speaker:Clinical Infectious Diseases, or CID.
Speaker:So I'll start by introducing our guest stars today who are all joining us from
Speaker:the Division of Public Health, Infectious Diseases, and Occupational Medicine at
Speaker:Mayo Clinic in Rochester, Minnesota.
Speaker:Hi.
Speaker:I am Hassam Tabaja.
Speaker:I'm really happy to be back on the podcast with you.
Speaker:I'm really thankful for you having me here again.
Speaker:Dr. Hassam Tabaja is an Assistant Professor of Medicine.
Speaker:His clinical research is focused on hardware associated infections, including
Speaker:both cardiovascular device infection and orthopedic device infection.
Speaker:Hi, this is Mac Chesdachai.
Speaker:Really happy to be here and thank you so much for having me.
Speaker:Dr. Supavit Chesdachai, or Mac, he is also an Assistant Professor of Medicine.
Speaker:His clinical and research interest include cardiovascular infections and infections
Speaker:in solid organ transplant recipients.
Speaker:Hi, I'm Dan De Simone.
Speaker:Thank you so much for having me back.
Speaker:I love Febrile StAR.
Speaker:Thank you so much.
Speaker:We have Dr. Daniel DeSimone or Dan.
Speaker:He is a Consultant and now Professor of Medicine at Mayo Clinic.
Speaker:He also holds a joint appointment in the Department of Cardiovascular Diseases.
Speaker:He has chaired and vice chaired several American Heart Association
Speaker:scientific statements in cardiovascular infectious diseases.
Speaker:His clinical and research interests focus on the prevention, diagnosis and
Speaker:management of infective endocarditis, cardiac implantable electronic device
Speaker:infections and vascular graft infections.
Speaker:All right, let's jump in.
Speaker:Well, Febrile is everyone's favorite cultured podcast.
Speaker:I know you guys have shared a little piece of culture before, but I'm gonna
Speaker:ask you to share something new today.
Speaker:So what have you guys been interested in recently?
Speaker:I'll go first.
Speaker:So what I've been getting into particularly with these, with the past
Speaker:couple of months where it's about minus 20 out and can't go out on my grill
Speaker:or do any smoking, uh, on the grill.
Speaker:Uh, I've gotten into sous vide, um, if is anyone familiar with that?
Speaker:I, yeah, it's,
Speaker:Yeah, I have one!
Speaker:It's pretty cool.
Speaker:It's, uh, you're essentially cooking steak, or you name it in nice hot water.
Speaker:Um, and it's, it's cooking it to the perfect temperature you want and then
Speaker:do whatever you wanna do after that.
Speaker:But yeah, I've been getting into that a lot.
Speaker:Now that the weather's starting to turn around, I'm getting the,
Speaker:breaking the grill out more.
Speaker:But, uh, but I'll tell you what, that sous vide is, is pretty cool.
Speaker:Highly recommended for, for anybody who, who, if you, if you can't cook, it's
Speaker:a good way to, to not mess things up.
Speaker:And if you can cook, you can, you can tailor things around pretty nice.
Speaker:So yeah, I've gotten into that.
Speaker:Um, be careful because once you get into it, you just start to go down
Speaker:a rabbit hole, but it's, it's fun.
Speaker:Yeah, it is really fun.
Speaker:It makes you feel very professional when you use it.
Speaker:Oh, yeah.
Speaker:Yeah, absolutely.
Speaker:I start speaking French.
Speaker:I, I have to ask for tips from Dan, because I did it in the past and
Speaker:sometime the plastic bag is just like ballooning and it just flows up.
Speaker:So
Speaker:yeah, you gotta get a good sealer sometimes.
Speaker:Double seal.
Speaker:Yeah.
Speaker:I, yeah, that's, there are, there is a learning curve.
Speaker:There's a small learning curve.
Speaker:Um, but once you do it, it's, it's, it's worth it.
Speaker:So for me, I don't have any new activity apart from the pickleball that
Speaker:we discussed last time with Hassam.
Speaker:Um, but lately I, I, I was very interesting in how time different travel
Speaker:and jet lag work, because we just came back from trip to Thailand and then
Speaker:that's the first time that my 20 month old daughter flew transpacific and then
Speaker:we were so concerned about like the time difference, 13 hour time difference.
Speaker:It turned out to be, she was fine in one day, but the problem is that
Speaker:there, her parents is doing so badly in like five days, not recover at all.
Speaker:So I'm really surprised that, you know, when you talk about 13 hour
Speaker:difference jet lag, it doesn't apply to 20 months old daughter.
Speaker:And I feel like that must have been your daughter that I saw at ID week, right?
Speaker:Yes you did.
Speaker:Yeah.
Speaker:Very cute.
Speaker:What about you, Hussam?
Speaker:So I'll go.
Speaker:Yeah.
Speaker:I haven't also been engaging in a lot of new activities, but I, I have
Speaker:been very busy 'cause I'm actually a, a new father now, so I have twins
Speaker:and, um, I think there's a lot of culture around that to, to be said.
Speaker:Um, surely a lot of, um, family visits that I was not expecting.
Speaker:And, uh, a lot of gifts, which I'm very happy with, a lot, a lot of gifts
Speaker:and a lot of things to learn really.
Speaker:So I've just been busy trying to figure out how to become a father.
Speaker:Uh
Speaker:Oh, congrats!
Speaker:I'm sure you have your hands full.
Speaker:Um, well I'm very glad to welcome you guys back.
Speaker:I'll, um, just plug that you were here on Febrile back for a State
Speaker:of the Art Review on vascular graft infections, which I'll put a link to, um,
Speaker:hopefully people have listened to that.
Speaker:But this is a different article that focused on complexities of cardiac
Speaker:device infections, and I think all of these questions that we know sound
Speaker:simple, but actually are quite complex.
Speaker:Is the device infected?
Speaker:Should it be taken out?
Speaker:When it is taken out, when is it safe to put it back in?
Speaker:Um, and so we will walk through a case today, but I just wanna start more
Speaker:generally and would love to hear about how you think about the way these infections
Speaker:should be handled or maybe your experience handling them at your institution.
Speaker:Yeah.
Speaker:Sara, that's great.
Speaker:Thank you so much for having us.
Speaker:You know, these, as you mentioned, these are, are not always so
Speaker:straightforward to make the diagnosis of the device being infected.
Speaker:And I think that's probably the, the big issue here is or at least the
Speaker:common goal that we share is we wanna keep devices that are not infected
Speaker:in the patient's body, and when they are infected, we wanna take them out.
Speaker:And that's much more easy, easier said than done.
Speaker:In some cases, it's readily apparent it's infected, and in a lot of other cases
Speaker:where it becomes very challenging, it's difficult to make that diagnosis, and
Speaker:hopefully through this podcast, we'll be able to provide our listeners with a
Speaker:good strategy on how to approach these patients and, and hopefully make it a
Speaker:little bit easier to achieve that goal.
Speaker:When a patient gets admitted to our institution with concern
Speaker:for a device infection, it, this is not a one person show, it's
Speaker:gonna be multiple teams involved.
Speaker:They may be admitted to, let's say, our hospital medicine service, so that
Speaker:involves our hospitalists as the main care team and will often require consultation
Speaker:with infectious disease, uh, as well as our heart rhythm or electrophysiology
Speaker:team as well, to be involved.
Speaker:That's just a couple elements of the team.
Speaker:Then you have to factor in the possible need for echocardiography, so that brings
Speaker:in our echocardiographers, uh, possibly PET imaging, NDM scans and so on, uh,
Speaker:radiology, nuclear radiology as well.
Speaker:And that's just part of the team and beyond.
Speaker:So if you do think it's infected.
Speaker:You may have to get general surgery on board for device removal and involved in
Speaker:pocket management after device removed, possibly even plastic surgery depending
Speaker:on the situation and the location as well as cardiovascular or thoracic
Speaker:surgery to be on, on standby as backup.
Speaker:As taking the device out is not without risk, risk of significant bleeding,
Speaker:major bleeding, and possibly death.
Speaker:So having cardiovascular surgery or thoracic surgery on standby for backup
Speaker:support following device removal for any complications is, is critical.
Speaker:So that's kind of start to somewhat finish.
Speaker:And there's even more to that is okay, a device comes out, does the device need,
Speaker:does a new device need to go back in?
Speaker:And that's where our cardiologists and heart rhythm specialists come into play.
Speaker:So that's kind of the approach.
Speaker:And again, there's some things that go on in between.
Speaker:Are they bacteremic or not?
Speaker:Is there something on the echo, on the heart valve or do the lead itself or both?
Speaker:And then do they need a new device put back in and when
Speaker:do you put that back in it?
Speaker:So with that I'll turn things over to, uh, to Mac and Hussam to
Speaker:go further into those scenarios.
Speaker:Excellent.
Speaker:Alright, well I'm gonna introduce our patient that we're gonna be
Speaker:taking care of in the hospital.
Speaker:We meet a 65-year-old woman with morbid obesity, diabetes and a cardiac
Speaker:device who presented to clinic with three days of pain, redness, and
Speaker:swelling at the generator pocket.
Speaker:So we're gonna pause right here this early and ask about how
Speaker:should we start our assessment?
Speaker:Yeah.
Speaker:Uh, as Dan mentioned, CIED infection is a very complex syndrome that
Speaker:require the whole village of multiple people help taking care of this.
Speaker:And the definition of the CIED infection itself has changed multiple times since
Speaker:the first statement came out in 2003, and then the most recent one that Dan is
Speaker:a lead author came out in 2023 to 2024, um, provide a variety of the definition
Speaker:of the infection, but in general, um, when we talk about a CIED infection,
Speaker:we need to think about two main thing.
Speaker:The first one is that the pocket part, and then the second one is
Speaker:the infection of the lead or valve.
Speaker:So when we talk about infection of the lead and valve, we call
Speaker:that CIED-related endocarditis.
Speaker:The pocket itself can happen without endocarditis.
Speaker:So that's the reason why any part of the device is infected, the
Speaker:whole system become infected.
Speaker:That's the reason how we, um, define the infection.
Speaker:So the most challenging thing is how to diagnose the CIED
Speaker:related infective endocarditis.
Speaker:Because with the pocket generator side infection, you can get that from the
Speaker:physical exam in most of the case, which is, if we ask what is the most common
Speaker:presentation of CIED infection, it is mainly the pocket generator site, which
Speaker:has happened in two-thirds of the cases, so one third of the cases will have the
Speaker:device endocarditis as well, but we can talk more of why it's so challenging to
Speaker:diagnose whether the patient has device related infective endocarditis or not.
Speaker:So we learned a little bit more.
Speaker:This patient had their device implanted eight years earlier for a history of
Speaker:sudden cardiac death with a recent generator revision two months ago.
Speaker:She also had fatigue, fever, and chills.
Speaker:And our physical exam shows erythema, tenderness, and fluctuation
Speaker:at the generator pocket site.
Speaker:There isn't any purulent drainage, sinus tract formation or device exposure noted.
Speaker:Um, so what is our best next step?
Speaker:Yes.
Speaker:So basically, if, if I summarize this question, you're basically, I'm being
Speaker:asked to, uh, see a patient who's presenting with pocket site inflammation.
Speaker:That's, that's called it inflammation.
Speaker:And so my job here is to figure out whether or not this
Speaker:inflammation is related to infection or not infectious, right?
Speaker:Because this soon after a revision only two months out, there are
Speaker:other non-infectious causes of pocket site inflammation, uh,
Speaker:such as allergic reaction to the component or maybe a hematoma.
Speaker:There are certain tools that we could use to help us make that, uh, decision.
Speaker:And the first tools are history and physical exam, which is just
Speaker:similar to what we use with any syndrome that we encounter, right?
Speaker:So there are certain things in history that are important to tease out.
Speaker:Uh, for example, in order to assess the risk of infection, you have
Speaker:to look at the age of the patient.
Speaker:You need to look at the complexity of the device.
Speaker:Is this a multiple lead?
Speaker:Is this a pacemaker?
Speaker:A CRT-D, you need to know whether or not that this is the first device.
Speaker:Is this a revision?
Speaker:How many times has it been revised before?
Speaker:Uh, what are the comorbidities of the other cardiovascular devices?
Speaker:So all of this, this helps you define the host and then you'll get an understanding
Speaker:of what is the, uh, risk of infection.
Speaker:The next thing is you wanna, uh, look for signs and symptoms that will
Speaker:give you a definite diagnosis of CIED infection because based on history
Speaker:and physical exam, there are certain signs that can actually confirm
Speaker:that you have an infection without having to do any additional testing.
Speaker:Um, and those are not frequent.
Speaker:There's not too much of those.
Speaker:There's maybe three to four signs and some of those, you know, pus
Speaker:coming out from the pocket, uh, sinus tract, uh, device exposure,
Speaker:which this patient does not have.
Speaker:So if this patient had those signs, then just by history and physical
Speaker:exam, I will be able to tell there is a CIED infection and the next
Speaker:step will be to do a blood culture.
Speaker:Because you wanna know whether or not the patient is bacteremic, not to make the
Speaker:diagnosis, the diagnosis is already made.
Speaker:The blood cultures help you, uh, because if they're positive, they're gonna
Speaker:determine your next step in management.
Speaker:Okay.
Speaker:But this patient does not fall in this category.
Speaker:She's presenting with, uh, signs of inflammation, but there is
Speaker:no signs or symptoms that are definite for CIED infection.
Speaker:So then the question is, what other tools can we use?
Speaker:And really this soon after revision in my mind, the only thing that we would do is
Speaker:a blood culture for this patient because I won't rely on CRP, ESR, white blood
Speaker:cell count this soon after the revision?
Speaker:Because they're not gonna be specific for CIED infection.
Speaker:I also don't rely so much on imaging like ultrasound, CT scans or PET CT this early
Speaker:after revision because I would expect to see something and it'll still not tell
Speaker:me whether or not this is an infected abscess, for example, or a hematoma.
Speaker:So in my mind, uh, for those patients, the only thing that you could rely on is
Speaker:really, is a blood culture at this point, because if the blood culture is positive.
Speaker:Then that also will upgrade this patient from an uncertain category to a
Speaker:confirmed or a definite CIED infection.
Speaker:Whenever you have a local pocket inflammation and you have a positive
Speaker:blood culture, that by definition is CIED infection, and so then
Speaker:we would manage it accordingly.
Speaker:The more difficult situation is if there is negative blood culture because
Speaker:then you're stuck again with this challenging question, how do I prove
Speaker:that this patient has a CIED infection?
Speaker:And it becomes more challenging if there is no systemic symptoms.
Speaker:You know, this patient actually has systemic symptoms, so
Speaker:maybe it's a bit easier.
Speaker:But if someone comes in with mild inflammation, maybe just minimal
Speaker:swelling, no systemic symptoms, this could just be a hematoma and inflammatory
Speaker:reaction from allergic reaction.
Speaker:It could be even a superficial cellulitis.
Speaker:So this is where it becomes controversial.
Speaker:Some physicians in those situations would put patients on oral antibiotics
Speaker:empirically, uh, considering this may be a superficial cellulitis.
Speaker:And then they will just follow very closely to see how they respond.
Speaker:Other physicians would not put antibiotics and they will just follow
Speaker:them clinically and see how things change because, you know, give it some time
Speaker:and let it declare itself basically.
Speaker:But I would say this is, these situations are the less straightforward situations.
Speaker:I, I think it might be helpful to comment on pocket infection and,
Speaker:and not aspirating the pocket.
Speaker:Because I think maybe for residents and earlier trainees that that
Speaker:might not seem intuitive when we're usually asking for a sample.
Speaker:Would you be willing to just say a couple sentences on that
Speaker:so you know there is some physicians that might consider doing an ultrasound
Speaker:guided aspiration if there's a fluid pocket, send that to for culture,
Speaker:see if it looks like pus or not.
Speaker:Um, in, in our center, we really don't like to do that.
Speaker:We try to avoid that as much as possible.
Speaker:And the main reason is because if you're not able to confirm the
Speaker:diagnosis of CIED infection based on blood cultures and physical exam.
Speaker:We worry that if it's not infected, we're gonna now introduce an
Speaker:infection, uh, into the pockets.
Speaker:So we don't really like to do that much.
Speaker:And I, I, I personally have never seen it being done.
Speaker:I don't know if Dan or, or Mac has seen that done before.
Speaker:I have seen it done in other devices.
Speaker:So we do have a lot of deep brain stimulator devices, for example here,
Speaker:which they have generator pockets and a lot of times the surgeons here
Speaker:would do an aspiration of the fluid.
Speaker:Um, but I have not seen a cardiovascular disease, uh, physician or an infectious
Speaker:disease physician here in the center in Mayo Clinic that would do an
Speaker:ultrasound guided aspiration of the pocket, just because we worry that we
Speaker:might now introduce an infection and it leads to bacteremia and endocarditis.
Speaker:Yeah, I, I agree with Hassam that I, um, never done.
Speaker:Um, but Dan can also add onto that too, that, um, I think
Speaker:there was a study from Israel.
Speaker:They put a catheter directly into the pocket and try to infuse
Speaker:antibiotics into the pocket in the setting of pocket infection.
Speaker:But I don't think that has been widely used.
Speaker:And that is only in the investigational, um, study rather than clinical practice.
Speaker:Yeah.
Speaker:So, so Mac in, in that study where they put a catheter in, they
Speaker:were instilling antibiotics as a way to, to treat an infection
Speaker:rather than to make the diagnosis.
Speaker:But from a diagnostic standpoint, uh, typically why, why we would advise
Speaker:against doing an aspiration of the pocket would be, what if there is no infection?
Speaker:You may have potentially introduced infection now.
Speaker:So every time you go into that pocket, you run the risk of leading
Speaker:to infection of that device.
Speaker:So in this patient's history, in our example here, they had
Speaker:a revision two months ago.
Speaker:So that's a big red flag that they went back into that pocket and now is
Speaker:showing up with some pocket findings and systemic symptoms that your suspicion
Speaker:for infection really has to go up here.
Speaker:Now I've seen where you can get an ultrasound of the pocket and,
Speaker:sometimes you could say, Hey, this might look like an abscess.
Speaker:That might tilt you more towards this being infected, but, uh, but
Speaker:putting a needle and entering that pocket is very uncommon to do and
Speaker:typically advise against that.
Speaker:Thanks guys.
Speaker:The team has grabbed two sets of blood cultures.
Speaker:These were drawn before vancomycin was administered, and in these
Speaker:cultures we have gram positive cocci resembling Streptococci
Speaker:that grew after about 14 hours.
Speaker:Um, so what would be our approach now?
Speaker:Yeah, so this gets interesting now.
Speaker:So given this patient's history, now findings of positive blood
Speaker:cultures, I think doing the right thing is starting the vancomycin.
Speaker:You know, this could either be a Streptococcus or an Enterococcus.
Speaker:So I think starting the antibiotic at this point, would recommend
Speaker:that and encourage that.
Speaker:I think the big thing here is the organism is very important when you
Speaker:approach cardiac device infections.
Speaker:This is your pretest probability of when you get that echocardiogram with
Speaker:a, in a patient who has a positive blood culture is gonna be critical.
Speaker:So in somebody like this with their history with an organism that's growing
Speaker:either Strep or Enterococcus, now my suspicion is, is very high, uh,
Speaker:that this device is infected and the recommendation would be to take it out.
Speaker:There's more discussion there, and we'll likely talk about this
Speaker:later when it comes time to make that decision to take things out.
Speaker:But I think your, your next best step here is, does this patient
Speaker:have valvular or lead endocarditis?
Speaker:And, and really the focus is on valvular endocarditis as that
Speaker:has downstream ramifications if the valve has a vegetation.
Speaker:So if there's valvular endocarditis, your duration of therapy is gonna be longer.
Speaker:So you're not gonna treat this as just a standard bloodstream
Speaker:infection or bacteremia with, say, two weeks of antibiotics.
Speaker:You're likely gonna go down the route of four to six weeks.
Speaker:Uh, so you can see how that changes your therapy there.
Speaker:As well as it'll have implications on reimplantation if, if the patient
Speaker:needs it, on timing of reimplantation.
Speaker:So instead of 72 hours, you may wait up to two weeks to put a new
Speaker:device back in if it's needed.
Speaker:That's the next step in this patient's, uh, route here of
Speaker:getting an echocardiogram, a TTE and TEE would be recommended.
Speaker:And again, you're looking for valvular vegetations or
Speaker:any vegetations on the lead..
Speaker:That's, that's again, gonna direct us to our next step.
Speaker:That's perfect.
Speaker:And, um, you guys in the, for those who have the paper, that figure two roadmap
Speaker:is about where we're talking about and Hassam started talking earlier about
Speaker:the importance of knowing if someone has a bloodstream infection or not.
Speaker:And I think one way we can also reframe this patient is how would
Speaker:we think about them differently if they had come in and we identified a
Speaker:blood infection, but there's no signs of generator pocket site infection.
Speaker:How do you reason through what to do for those patients?
Speaker:Yeah, and I think this is a very important question because you run
Speaker:into the situation all the time when the patient got hospitalized
Speaker:with bacteremia and they have
Speaker:pacemaker or ICD in place.
Speaker:Sometime, we don't' know what to do about them.
Speaker:Should we do echocardiogram?
Speaker:Should we not?
Speaker:Should we just monitor?
Speaker:So it's very, very important question and not a lot of study,
Speaker:um, looking into this scenario.
Speaker:So as you mentioned, it's very clear if the patient walk to you and have
Speaker:the pus come out of the pocket.
Speaker:We know that device need to come out no matter what, but when the patient come in
Speaker:with bacteremia, it very difficult to know whether the device is infected or not.
Speaker:I think the main principle that we would work on is the same as the patient
Speaker:with vascular graft and other device.
Speaker:So it's very depend on, um, the pathogen specific.
Speaker:For example, if the patient has a Staph aureus bacteremia, you would
Speaker:be very confident that you need to look into the device itself.
Speaker:However, if the patient has like very localized symptom of, for example, UTI
Speaker:and have a gram-negative bacteremia.
Speaker:The chance that the e coli or other gram-negative would,
Speaker:the device is very low.
Speaker:So all those situations, you do not need to specifically look at the device
Speaker:itself, either with TTE or other modality.
Speaker:We always run into the issue when we encounter the
Speaker:pathogen that we're uncertain.
Speaker:For example, Staph aureus, definitely high risk.
Speaker:Um, coag negative Staph, definitely high risk.
Speaker:Enterococci.
Speaker:I would also throw, throw into the high risk category as well.
Speaker:The same as Strep viridans group.
Speaker:But from time to time when we run into other gram positives,
Speaker:other streptococci or high risk gram-negatives, such
Speaker:as Serratia or Pseudomonas.
Speaker:From time to time's, very difficult to tell.
Speaker:So we need to, um, think about other factors as well.
Speaker:For example, does the patient has prolonged, um, bloodstream
Speaker:infection, um, are we able to identify the source of infection?
Speaker:Does the patient have cardiac device or other valvular processes as well.
Speaker:The more factor that the patient has, um, the more we think that the
Speaker:device might be infected, for example, prolonged bacteremia, community
Speaker:onset, and we could not find a source.
Speaker:So that's the time when we need to look closely into the device.
Speaker:And one thing that I also wanna mention is that, the prior study also came up with a
Speaker:multiple scoring system to see, especially with the Staph aureus, um, in the past, in
Speaker:around 2015, a score called predict SAB.
Speaker:So we try to, um, plug in the clinical factors that I just mentioned in, um,
Speaker:how long has the patient been bacteremic, and everything like that into to see
Speaker:that if the patient has a Staph aureus bacteremia, what is the likelihood
Speaker:of the underlying device is infected?
Speaker:And then the most recent one, the study group from Europe also came out with
Speaker:a score called a CTEPP score, which coming from like community acquisition,
Speaker:time to positivity, embolization, risk factors for IE, and persistent bacteremia.
Speaker:So we can use those score to fit into the clinical contact and see how
Speaker:how high of a risk that the patient who come in with bacteremia has to
Speaker:have underlying device infection.
Speaker:For other organisms, we still do not have a good score.
Speaker:We apply the same score that out there to predict the endocarditis, for example,
Speaker:like HANDOC for streptococci or DENOVA score for enterococci, but all of those
Speaker:are not specific to the device itself, but I think it's good enough plus the clinical
Speaker:judgment to see whether we really need to send the patient to transesophageal
Speaker:echocardiogram or do additional PET CT.
Speaker:So I think it's two main thing, depend on the pathogen specific virulence,
Speaker:and then depend on the nature of the bact itself and the host factor.
Speaker:So for this patient, uh, they underwent TEE, which demonstrated
Speaker:a small echo density at the atrial aspect of the CIED lead.
Speaker:There's no valvular vegetations observed.
Speaker:Here we can talk about challenges in interpreting TEE findings.
Speaker:And then I think the other question that we've started alluding to
Speaker:is, um, when when to use PET CT.
Speaker:And so I'd love to hear about how you decide on when to reach for that modality.
Speaker:Okay, perfect.
Speaker:To best answer this question, really figure three in the article that we have,
Speaker:uh, actually talks a lot about this.
Speaker:Um, so if we are looking at the patient.
Speaker:Our main question, you know, what is the role of the ECHO here?
Speaker:Um, to me, you know, we've already made the diagnosis of CIED infection for
Speaker:this specific patient just based on physical exam and positive blood culture.
Speaker:So the echo here is not really for diagnostic purposes specifically
Speaker:because we are already labeling this patient as having CIED infection
Speaker:and we're gonna treat accordingly.
Speaker:The purpose of the echo here is to tell us what is the duration of treatment.
Speaker:When is it okay to reimplant a device?
Speaker:And this will really depend on whether or not the valve has, uh, vegetations
Speaker:or is there any vegetations only on the lead or is there no vegetation?
Speaker:So really the echo helps us determine these two questions for this patient.
Speaker:The more challenging situation is if the patient had come in with bloodstream
Speaker:infection and no pocket site infection, or no pocket site inflammation.
Speaker:So in those patients, the echo, uh, is done for diagnostic purposes.
Speaker:We are trying to get more information to decide whether or not the device
Speaker:is actually infected and if whether or not we should treat it as such.
Speaker:So this is where the role of ECHO becomes more critical.
Speaker:And when we're thinking about echo findings, I can think
Speaker:of three scenarios really.
Speaker:The first scenario is you do an echo and you find valve vegetations, so that is
Speaker:actually the most straightforward scenario because if you do see that, then you're
Speaker:saying this patient has endocarditis, valvular endocarditis, and that in itself
Speaker:equates to device infection, and you're going to have to discuss extracting the
Speaker:device and treating for endocarditis with six weeks of antibiotics.
Speaker:The other two scenarios are less straightforward, and those include the
Speaker:second scenario, which is you do an echo and you find a lesion on the lead, but
Speaker:you're not seeing lesions elsewhere.
Speaker:So kind of similar to the echo we're seeing here.
Speaker:The third scenario is you do an echo and you don't see any lesions.
Speaker:Now, none of these two scenarios are either sensitive or specific for device
Speaker:infection because you could have a lesion on the lead that is a sterile
Speaker:thrombus, and it's actually common to have clots on those leads, especially if
Speaker:those leads have been there for a while.
Speaker:And there is nothing on the echo that can specifically tell you if
Speaker:this clot is infected or sterile.
Speaker:I cannot tell whether or not this lead vegetation or this echo density on
Speaker:the lead is a, an infected vegetation or it's a thrombus that's sterile.
Speaker:Even the third scenario where you don't see any lesions, I'm still not able to
Speaker:confidently rule out, uh, a device lead endocarditis because you could still
Speaker:miss that on the echo, especially if you can't visualize the entire lead.
Speaker:And so when it comes to these two scenarios, I think your decision
Speaker:has to be based on other factors like the type of pathogen, which
Speaker:Mac has spoken about just now, and also the burden of the bacteremia.
Speaker:Community acquired bacteremia.
Speaker:High grade multiple sets, persistent.
Speaker:No primary focus.
Speaker:If you have this high burden bacteremia and if you have a high
Speaker:risk pathogen like staph aureus, then in my mind I would still
Speaker:consider this device likely infected.
Speaker:And a lot of experts actually would go ahead and discuss extracting the device
Speaker:without doing further testing because in their mind, the pretest probability
Speaker:for device infection is already very high with things like Staph aureus
Speaker:bacteremia, high burden of bacteremia.
Speaker:But when you're talking about other bacterias, like maybe gram-negatives,
Speaker:uh, Clostridium, Cutibacterium, er, other types of bacteria, you cannot make that
Speaker:assumption because the pretest probability that the device is infected is not
Speaker:that high, not similar to staph aureus.
Speaker:And that's when you start wondering, is there any other test that I could
Speaker:do to help me make that decision?
Speaker:And that's where PET CT comes in.
Speaker:And you really, if you look at, there are so many different societies
Speaker:now that have strengthened their language and statement about using
Speaker:pet CT for, uh, device infection.
Speaker:Ever since 2019 up until now, they've been talking about the
Speaker:use of PET CT for those cases.
Speaker:And we know that PET CT actually has a very decent sensitivity and
Speaker:specificity for device infection.
Speaker:And so a lot of big centers that have PET CTs, they will probably go ahead
Speaker:and get a PET CT for those cases.
Speaker:And if it's positive, they call the device infected.
Speaker:If it's negative, they say the device is probably not infected.
Speaker:But we have to be very careful and cautious because there is,
Speaker:there are cons to the PET ct.
Speaker:The biggest con really is that not every center will have it
Speaker:accessible or readily accessible.
Speaker:So some centers can't just get a PET CT and the longer you wait and the
Speaker:longer that the patient has been on antibiotics, the less reliable that
Speaker:PET CT becomes because we think the antibiotic can decrease inflammation
Speaker:and, and so, you know, if you're not able to get PET CT very quickly.
Speaker:It might not be such a tempting test to get.
Speaker:The other cons for the PET CT is that while we think, and we know
Speaker:it's sensitive and specific, it's mostly for pocket site infections.
Speaker:So it's not that sensitive for lead site infection.
Speaker:And, and that's why some experts, when they have a high pretest probability
Speaker:for, uh, device infection, like with Staph aureus high burden bacteremia,
Speaker:they would not get a PET CT.
Speaker:They will just discuss extracting the device because they think even
Speaker:if we do a PET CT and it comes back negative, it still does not rule
Speaker:out a lead endocarditis because it's not as sensitive for leads as
Speaker:it's for pocket site infections.
Speaker:So that's actually one very important thing to keep in mind.
Speaker:So to summarize things, the role of PET CT seems to be more tempting
Speaker:when you have an intermediate pretest probability for device infection.
Speaker:Because in those cases you think that if it's a negative PET ct, then it adds
Speaker:another reassuring layer that the patient probably does not have a device infection.
Speaker:Now we spoke about the PET CT, what about centers that can't get a PET CT?
Speaker:What is one other approach that they could consider?
Speaker:Again, if they think that their pretest probability for, uh, device infection
Speaker:is not that high, one approach would be to actually treat the bacteremia.
Speaker:Stop the antibiotics after treatment and do surveillance of blood
Speaker:cultures about five to seven days after you stop the antibiotics.
Speaker:If the bacteremia recurs and you still don't have another source, then it's
Speaker:probably a device infection and then you have to treat it accordingly.
Speaker:And so that's kind of, you know, talking about the echoes and PET CTs and, and what
Speaker:to do if you can't do a PET CT as well.
Speaker:Yeah, I, I just wanna add one point is that apart from the accessibility of the
Speaker:PET CT, the cost is also, um, another concern, especially when we have a
Speaker:different reimbursement system, whether it's gonna cover outpatient, gonna cover
Speaker:inpatient or whether it's a cancer or non-cancer indication, but surprisingly
Speaker:in Europe, they have no issue with this.
Speaker:With the reimbursement.
Speaker:That's the reason why if you look at the European CIED guideline, um, in
Speaker:2019, and also the update in guideline in 2023, they, they state very clearly
Speaker:that if the patient has a Staph aureus bacteremia with the device in place,
Speaker:um, they recommend every single patient to get a PET CT because apart from the
Speaker:device itself, it can also identify those metastatic foci and everything like that.
Speaker:But that's also reflects that in Europe, they don't have a lot
Speaker:of problem in reimbursement that we still seeing here in the us.
Speaker:One, one other question that I think needs a lot of thought and more
Speaker:studies to, to answer that question is the mortality and morbidity benefit
Speaker:of getting those PET CTs right?
Speaker:Especially like when we're talking about finding out where other sites of seeding.
Speaker:Uh, you know, like for example, if you have staph aureus bacteremia,
Speaker:did it seed somewhere else?
Speaker:Is there a deep abscess?
Speaker:And the PET CT will help you find that out.
Speaker:But there are studies showing that it does not really maybe affect
Speaker:mortality or morbidity that much.
Speaker:So I think that's a very important question also to look more into in
Speaker:the, in future studies, if I get a pet CT for those cases, does it
Speaker:really change the overall outcome in terms of morbidity and mortality?
Speaker:Yeah.
Speaker:Thank you guys so much for covering that.
Speaker:It's a, it's a big topic and obviously a conversation point on many consults.
Speaker:Well, despite some of her comorbid conditions, the cardiology team
Speaker:does recommend complete CIED extraction for this patient.
Speaker:The patient and her family have expressed some reluctance due to
Speaker:concerns about the complications.
Speaker:And so how do you structure your discussion when you're
Speaker:in this type of scenario?
Speaker:Yeah, it's a great question and that comes up in every case, right?
Speaker:It's a procedure that carries significant risk and potential bad outcomes.
Speaker:Granted, it's, it's low for it to happen.
Speaker:It's quoted anywhere between one to 2%, depending on the center and their
Speaker:experience and expertise available.
Speaker:And, and they can be very serious complications that include bleeding
Speaker:to the superior vena cava, you can get a tear, uh, you can get cardiac
Speaker:tamponade among other things.
Speaker:Uh, and, and death is, is a potential risk.
Speaker:So those are real complications from device removal.
Speaker:So that's why we wanna be as certain as possible that the
Speaker:device is infected, taking it out.
Speaker:Uh, which again, as we, as we've been talking about, it's not always
Speaker:as straightforward, but you have to balance that with, well, what
Speaker:if we just keep the device in and put the patient on antibiotics?
Speaker:How well does that work?
Speaker:There's been very limited data, uh, out there looking long term
Speaker:suppression with chronic antibiotic use.
Speaker:Actually only one study I can think of that looked at that, and the data
Speaker:from there showed that it's an option.
Speaker:But it should be one of your final options of suppression.
Speaker:And every effort should be made to, to remove the device.
Speaker:And the reason for that is there's risk of relapse with device
Speaker:retention, uh, especially if there's valvular or CIED related infective
Speaker:endocarditis, keeping a device in is associated with high mortality, uh,
Speaker:as well as high rates of relapse.
Speaker:So, so again, you're in this balancing act of, well, if we keep the device in,
Speaker:there's risks the infection can come back or potentially we may not be able
Speaker:to control the infection versus while there's real risk to the procedure, as
Speaker:I mentioned, uh, ways to approach the patient is, is making them aware of these
Speaker:potential risks and complications from going for device removal, but also the
Speaker:risk of not going for device removal.
Speaker:This is something where you're gonna make a shared decision
Speaker:approach with the patient.
Speaker:And, other things that are important to consider is these devices should be
Speaker:extracted at centers of excellence where they're doing this on, on a regular basis.
Speaker:The providers that are removing these devices should have significant
Speaker:experience, uh, with this and have a support system, backing them up.
Speaker:And what I mean by that is vascular surgery if there is a tear to the
Speaker:SVC or other, other major vessels.
Speaker:Cardiothoracic surgery, on standby, ready to go if there is a complication as
Speaker:these patients may require opening their chest to repair from these complications.
Speaker:So, um, so again, it's a discussion you gotta have with each and every patient,
Speaker:and come together what you think is best for that patient at that time.
Speaker:There's so many variables that come into play and listening to the patient and
Speaker:their family and what are their concerns.
Speaker:You know, it may be they're not worried about the one in a hundred chance, they're
Speaker:more worried about the pain or something else happening, or maybe they, they have
Speaker:a tough time waking up from sedation and so, so really asking the patient and their
Speaker:family, what, what are their concerns?
Speaker:We have our concerns and what we think is concerns, but may not
Speaker:always match what the patient is concerned about or their family.
Speaker:Oh, we left this case a little broad.
Speaker:I was gonna ask now about how you guys set your final antibiotic plan
Speaker:and the question of when you can reimplant when a device is removed.
Speaker:Uh, we didn't pinpoint a specific bug.
Speaker:'cause I think maybe today our goal is to talk more broadly.
Speaker:But yeah, how would you approach that?
Speaker:Yeah, so I think that's the question that we all get asked about.
Speaker:After the device is removed, when is the appropriate time to place this back.
Speaker:I think it's very depend on what kind of syndrome that the patient has.
Speaker:So the principle is that, if the patient has the vegetation on the
Speaker:valve, we would prolong the time of reimplantation as long as possible.
Speaker:And most of the time we use 14 days.
Speaker:Because our hypothetical concern is that if we put the new device too soon
Speaker:and the patient has the vegetation persistently on the valve, we concerned
Speaker:that vegetation will become a new foci and eventually infect that device,
Speaker:the new device that was just placed.
Speaker:If a patient has vegetation on the valve, we would wanna wait as long
Speaker:as possible, 14 day if possible.
Speaker:Um, if the patient doesn't have vegetation on the valve, just a lead
Speaker:vegetation or no vegetation at all.
Speaker:At all.
Speaker:And then the device got extracted, we would wait for 48 to 72 hours, um,
Speaker:after the first negative blood culture.
Speaker:So as long as the patient has clear from the bacteremia perspective we
Speaker:should be able to put the new device in.
Speaker:Some study in Europe also, if the patient doesn't have bacteremia, um, the sooner
Speaker:that you can place a new device in actually in the same day, so they put a
Speaker:new device in, in the contralateral side if the patient doesn't have bacteremia.
Speaker:So I think the key is that as long as the patient is no longer bacteremic, it should
Speaker:be safe to place a new device unless the patient has a vegetation on the valve.
Speaker:So I'm going to touch a little bit about interim strategy because that's also an
Speaker:important topic that we need to discuss.
Speaker:Um, mainly what device gonna be placed is depend on what was the indication that
Speaker:the patient has device in the first place.
Speaker:Maybe the patient no longer need device, which is great.
Speaker:We don't need to have a time or new device implant.
Speaker:But let's say if the patient continues to have indication, for example,
Speaker:ventricular arrhythmia or cardiac pacing that need a new device.
Speaker:So that's need to be discussed with the electrophysiologist.
Speaker:Because if, for example, if they do not wanna put the intravascular
Speaker:device, maybe we have the alternative.
Speaker:For example, if the patient who need a cardiac pacing without the ICD
Speaker:function, we can use the leadless pacemaker in that situation.
Speaker:But if the patient doesn't need a cardiac pacing but need the ICD function,
Speaker:we can use the subcutaneous or the extravascular ICD, um, in that situation.
Speaker:But from time to time, if the patient needs both, we may not be
Speaker:able to find any interim strategy, especially when the patient that
Speaker:we wanna prolong the implantation.
Speaker:So that's the reason why I said prolong as much as possible because
Speaker:when we say 14 day, it's not always possible in the clinical practice.
Speaker:And regarding the antibiotics after the extraction, if the patient has
Speaker:a valve vegetation, we would treat the same as infective endocarditis,
Speaker:which is four to six weeks.
Speaker:But if the patient doesn't have the vegetation on the valve, we can do
Speaker:shorter than that which is 2-4 weeks.
Speaker:Great.
Speaker:And after some discussion of risk, risks and benefits, the patient and
Speaker:family declined the device extraction.
Speaker:At this point, the patient's been on vancomycin, blood cultures have cleared.
Speaker:So what would be your strategy here and planning for follow-up once
Speaker:they're in the outpatient setting?
Speaker:As long as the device remains, unfortunately there is no objective
Speaker:test that we could do after a treatment.
Speaker:So let's say we we're gonna treat the syndrome for four
Speaker:to six weeks with antibiotics.
Speaker:After we finish this treatment, there is no objective test that
Speaker:will tell us the infection is completely eradicated from the device.
Speaker:And so to simplify things, those cases would require to be on
Speaker:antimicrobial suppression after you finish the treatment phase.
Speaker:Of course it's not as simple as I'm making it sound because, we're in
Speaker:the era of antimicrobial resistance.
Speaker:A lot of times we might not have good or tolerable oral options to suppress
Speaker:these patients after the treatment.
Speaker:We don't know how long to suppress them for.
Speaker:We don't have very good longitudinal studies to tell
Speaker:us or answer this question.
Speaker:Dan had talked about one study which had 48 patients where they suppressed.
Speaker:And you know, in that study, they had about 18% relapse.
Speaker:So we also don't, I mean, we don't have much studies to tell us about relapse,
Speaker:how long to keep the patient antibiotic, what happens when we stop the antibiotics,
Speaker:how much of those patients tolerate the antibiotics and things like that.
Speaker:So it is really, uh, not an easy thing to, to, to manage, I would say
Speaker:as long as the device is retained.
Speaker:You wanna try to keep this patient on antimicrobial
Speaker:suppression as much as possible.
Speaker:So, you know, in my mind what I would do is I would finish the
Speaker:treatment course again, four to six weeks, depending on the syndrome.
Speaker:See the patient at that point, make sure that the pocket looks good, make
Speaker:sure that the patient looks good, and then have a discussion with the
Speaker:patient about getting them on an oral antibiotic that will potentially help
Speaker:suppress their infection as long as possible, as long as they tolerate it.
Speaker:Usually it's not an easy discussion, especially when you're trying to
Speaker:tell the patient that you're likely going to need to be on antibiotics
Speaker:for the rest of your life.
Speaker:And so a lot of patients, they might not be very excited about that, so it's
Speaker:very important to mention this plan, even early on during their treatment,
Speaker:don't wait until they're done with their treatment and say, hey, we're
Speaker:gonna put you on oral antibiotics now to suppress you indefinitely.
Speaker:I think this is something that you have to discuss during the shared
Speaker:decision making, which Dan talked about, and this should be early during
Speaker:the hospitalization course itself.
Speaker:So you guys covered a real, quite a big topic in a pretty short amount of time.
Speaker:To end, I was just going to ask you separate from this case, what things
Speaker:you're most excited about in this subset of ID, cardiac device infections.
Speaker:What things are you most interested in learning about?
Speaker:Um, maybe studies that are underway that you're looking
Speaker:forward to hearing results on.
Speaker:I think we all can share this answer.
Speaker:For me is that I, I wanna see, um, more accurate diagnosis in this
Speaker:field because as Hassam mentioned, even though we have TEE, PET-CT.
Speaker:We still in a lot of, um, conundrum whether this device is infected
Speaker:or not, whether we should extract it or not, because everything
Speaker:that we offer to the patient is impact their life substantially.
Speaker:For example, if we say that, Hey, we are unsure, but we should remove your device.
Speaker:It's not just easy as we say, because that would involve multiple people.
Speaker:So that's why I'm excited to see whether, is there any new tools,
Speaker:any new modality that coming out and regarding the treatment perspective.
Speaker:We don't have a lot of thing in, in the pipeline right now, but I would
Speaker:like to see if, is there any way that we can treat the device infection
Speaker:without a chronic suppression or suppression in very limited time.
Speaker:The thing that I excited for.
Speaker:Especially with like using biofilm active agents in those treatments,
Speaker:is there any role for rifampin?
Speaker:Does quinolone have a different efficacy than other antibiotics?
Speaker:'cause we know that it has biofilm activity, so, you know, what is
Speaker:the role of adding those types of agents to the treatment and does it
Speaker:really help us get the patient off suppression if we retain the device?
Speaker:So that's one thing I would like, like to look at.
Speaker:It would be really nice if there is something that could be done about the
Speaker:device itself to make it more resistant to, to, to infections in the first place.
Speaker:And I, I know there has been other things that have, that have been looked at in
Speaker:the past, like this antibiotic envelope.
Speaker:Dan, you spoke to us multiple times about this in the past, and so, you
Speaker:know, what are advances that are being, are happening in the field to
Speaker:somehow make this device resistant to getting those bacteria seeding on it?
Speaker:Yeah, I think that's definitely the future.
Speaker:We're seeing some of it already with leadless pacemakers.
Speaker:I think that's, that's really the, the future for this.
Speaker:I mean, it's, we're putting leadless pacemakers in patients, uh, you
Speaker:know, over the last several years.
Speaker:Uh, the issue is you can't do a leadless in everybody based on, you
Speaker:know, does it need atrial sensing?
Speaker:And certain people rely on on that.
Speaker:It gets beyond, uh, the, the infectious disease doc in me.
Speaker:It goes more towards the electrophysiologist to comment on
Speaker:that, but I know they're working on developing those leadless pacemakers to,
Speaker:to kind of be the go-to for patients.
Speaker:Uh, it's very easy to take out as compared to a device that has
Speaker:been in the chest pocket for 10 years, so there's benefits there.
Speaker:The material itself is different compared to the current, uh,
Speaker:uh, CIEDs, like pacemaker ICDs.
Speaker:So the, these organisms, like the staphylococci, like that,
Speaker:what they have on their surface and what they like to stick to.
Speaker:It's less likely to be sticky to the leadless pacemakers.
Speaker:So it doesn't mean leadless pacemakers don't get infected.
Speaker:They do, um, just much less likely plus the size and surface area.
Speaker:So if you have like a big bulky CRT with three leads, compare that to something
Speaker:that's maybe the size of a little bigger than a reasonable size pill of Augmentin.
Speaker:You know, there's only so much surface area for that organism
Speaker:to attach compared to multiple leads and a big pocket generator.
Speaker:And you think of your patients, a lot of these patients are
Speaker:gonna be elderly, frail.
Speaker:There's only so much skin soft tissue to, uh, that pocket.
Speaker:This is endovascular.
Speaker:Uh, so, so I think that's, that is definitely the future is going leadless.
Speaker:There's also subcutaneous where you can go outside of the bloodstream, and go subq
Speaker:and tunnel these leads, and have external leads, rather than be in the bloodstream.
Speaker:And I think that's a big factor here.
Speaker:So I know Hussam you mentioned about, uh, deep brain stimulators,
Speaker:you know, and again, that, and their management is a little bit different
Speaker:than complete device extraction.
Speaker:Sometimes it's just taking out the generator and the lead leads
Speaker:in, or, there's a lot of ways to go about it, but it's different.
Speaker:And sometimes suppression works really well.
Speaker:It's, it's these devices that are intravascular, they're in the bloodstream.
Speaker:Those are tough to suppress compared to say a prosthetic joint, deep
Speaker:brain stimulator where its not endovascular, in that bloodstream.
Speaker:So I'm excited for the future in that regard.
Speaker:And then probably PET imaging, but rather than using FDG, looking at more
Speaker:like organism specific to where, Hey, I know there's staph aureus in the blood.
Speaker:Let's do a staph aureus specific biomarker tracer, uh, that
Speaker:we can, we can search for.
Speaker:Maybe that'll give us better uptake than just FDG avidity because
Speaker:those device leads are, are only gonna have so much surface area.
Speaker:They're only so much uptake and as you get further away from pocket,
Speaker:that sensitivity of PET goes down.
Speaker:So I think that's my big thing, our available tools to make the
Speaker:diagnosis of device infections.
Speaker:Echo and, and PET scan are not great.
Speaker:So I said a lot there.
Speaker:But I'm excited for the future and I think leadless is the way to go.
Speaker:For this paper, we collaborated with multiple subspecialties, cardiology,
Speaker:electrophysiology, nuclear medicine expert, and also CV surgery.
Speaker:So, the co-author who wrote the paper also reflects like the real life that when we
Speaker:manage a CIED infection, as Dan mentioned earlier, we need the whole village.
Speaker:We need to talk to patient, we need to talk to family, and we need to talk
Speaker:to multiple, multiple people in order to make a decision for one patient.
Speaker:Thank you so much, Hussam Mac and Dan for joining Febrile today.
Speaker:You can find their article, State of the Art Review, complexities in
Speaker:Cardiac Implantable Electronic Device Infections, A Contemporary Practical
Speaker:Approach in Clinical Infectious Diseases.
Speaker:This is linked on the webpage as well as in the episode information.
Speaker:You can check out their prior StAR episode on vascular graft
Speaker:infections, episode number 110.
Speaker:If you're looking to hear another episode related to cardiac device infection,
Speaker:diagnosis, and management, you can check out episode number 78 featuring some of
Speaker:our both ID and cardiology colleagues.
Speaker:Don't forget to check out the website, Febrile podcast.com to find the consult
Speaker:notes, which are written supplements to the episodes with links to references,
Speaker:our library of ID infographics, and a link to our merch store.
Speaker:Febrile is produced with support from the Infectious Diseases Society of America.
Speaker:IDSA.
Speaker:Please reach out if you have any suggestions for future shows or
Speaker:wanna be more involved with Febrile.
Speaker:Thanks for listening.
Speaker:Stay safe and I'll see you next time.
