58_起搏器相关感染

植入器械感染植入器械感染 —— 个棘手的临床问题个棘手的临床问题 北北 京京 医医 院院 杨杰孚杨杰孚 植入器械感染 为什么棘手？ • 有起搏系统这个异物在体内，因此不同 于一般感染：于 般感染： – 处理起来要困难的多 由此而导致的医疗纠纷也明显多– 由此而导致的医疗纠纷也明显多 – 严重感染有时需要拔出起搏系统 植入器械感染 一、植入器械感染的一般知识、植入器械感染的 般知识 二、处理 --- 保守治疗 初步临床体会初步临床体会 植入器械感染 定义--duke ： • 全身感染 与植入器械相关性感染性心内膜炎与植入器械相关性感染性心内膜炎 • 局部感染: 红肿 化脓 窦道形成 破溃红肿, 化脓, 窦道形成, 破溃 植入器械感染 发生率： • 约 1-2% • 变异大：从 0.13 to 12.6% • 发生率缺乏准确性 感染的定义不–感染的定义不同 –是否感染有时很难确定 局部切口发红• 局部切口发红 • 浅表破溃 • 血肿 • 各种培养阴性 植入器械感染 发生率发生率 • 首次植入 0 5%0.5% • 更换或升级 2-7%2 7% Bruce L et al Heart Rhythm 2007;4:1467-1470Bruce L et al Heart Rhythm 2007;4:1467 1470 植入器械感染 感染发生的时间（有文献报道）感染发 的时间 有文献报道 • 比较少发生在 术后3个月内术后3个月内 • 通常发生在: 手术三个月后 • 平均平均 一年以上 有时发生在几年之后有时发生在几年之后 植入器械感染 感染发生的时间： One study in 2,564 consecutive patients who received implantable PM or ICD devices between1994 and 2002 were studied(Lakkireddy D er al :PACE 2005; 28:789–794)were studied(Lakkireddy D er al :PACE 2005; 28:789–794) –早期感染 : 39% (7/18)早期感染 : 39% (7/18) –晚期感染 : 61% (11/18) 平均感染时间 天–平均感染时间： 45天 Early infection mean prior to 60 days postprocedure Device Infections 总的发生率: 0.7% –浅表感染 22% (4/18)浅表感染 22% (4/18) –深部感染 78% (14/18) Lakkireddy D er al :PACE 2005; 28:789–794 Device Infections • Background: a multicenter prospective survey of the infective incidence aftera multicenter, prospective survey of the infective incidence after implantative device. • Methods: Between January 1, 2000, and December 31, 2000, 6319 consecutive recipients of implantable systems were enrolled followed up for 12 months. • Results At 12 months, device-related infections were reported in 42 patients (0.68%; 95% CI, 0.47 to 0.89). Didier K et al. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators Circulation 2007; 116:1349-1355 Device Infections 死亡率死亡率 ～1.3%0 Didier K et al Risk factors related to infections of implanted pacemakers andDidier K et al. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators Circulation 2007; 116:1349-1355 植入器械感染 感染相关因素 • 术前24小时发烧 术前放置临时起搏电极• 术前放置临时起搏电极 • 未使用预防性抗菌素未使用预防性抗菌素 • 早期再手术 如电极导管脱位 手术清除血肿 冠脉介入等如电极导管脱位、手术清除血肿、冠脉介入等 Didier K et al Circulation 2007; 116:1349-1355Didier K et al. Circulation 2007; 116:1349-1355 Device Infections Uncertained predictive factors A• Age • Diabetes mellitus • ImmunosuppressionImmunosuppression • Antiplatelet therapies • Oral anticoagulant • Infection at another site • Single or dual or biventricular system Proced re d ration• Procedure duration • Hematoma Didier K et al. Circulation 2007; 116:1349-1355 Incidence of Device Implantation–RelatedIncidence of Device Implantation Related Complications Over 12 Months ___________________________________ Requiring All n(%) Reintervention n (%)All,n(%) Reintervention, n (%) ___________________________________________________ Hematoma 328 (5.34) 26 (0.42) L d di l d t 112 (1 82) 102 (1 66)Lead dislodgment 112 (1.82) 102 (1.66) Pacing threshold elevation 59 (0.96) 1 (0.01) Impending erosion 34 (0.55) 31 (0.50) Erosion 15 (0.24) 15 (0.24) Overall 548 (8.93) 175 (2.85)( ) ( ) _______________________________________________________ Didier K et al. Circulation 2007; 116:1349-1355; 植入器械感染 病原学 • 1/2- 1/3： 葡萄球菌 • 其它 G iti b–Gram-positive aerobes, –Gram-negative aerobes • 少见的病原菌 – 真菌等 P thPathogens (in 123 patients reported by Chua et al) Microorganisms Pacemaker ICD Total n(%) n(%) n(%)n(%) n(%) n(%) Staphylococcus 61(50) 22(17) 83(67) epidermidis Staphylococcus 20(16) 9(8) 29(24)Staphylococcus 20(16) 9(8) 29(24) aureus Klebsiella 1(1) 1(1) 2(2) ipneunonia Pseudomonas 4(3) 0(0) 4(3) Aeruginosa Serratia marcesens 2(1) 1(1) 3(2) Escherichia coli 1(1) 2(1) 3(2) Enterobacter 2(1) 1(1) 3(2) aerogenes P thPathogens (in 123 patients reported by Chua et al) Microorganisms Pacemaker ICD Total n(%) n(%) n(%)n(%) n(%) n(%) Propionobacter 1(1) 0(0) 1(1) acne Klebsiella axytoca 1(1) 0(0) 1(1)Klebsiella axytoca 1(1) 0(0) 1(1) Enterococcus sp. 2(1) 1(1) 3(2) Proteus mirabilis 0(0) 2(2) 2(2) S hi 0(0) 2(2) 2(2)Sphingomonas 0(0) 2(2) 2(2) malthophilia Group B 1(1) 0(0) 1(1) Streptococcus Candida albicans 0(0) 1(1) 1(1) Citrobacter freundi 0(0) 1(1) 1(1) Total 99 39 141 Signs and Symptoms (in 123 patients reported by Chua et al) Signs and symptoms n(%)g y p ( ) Pocket erythema 67 (55) Pocket warmth 28 (23)Pocket warmth 28 (23) Pocket pain 68 (55) Erosion 39 (32) Si t t t k t 52 (42)Sinus tract to pocket 52 (42) Sinus tract to pocket (purulent) 28 (32) Pocket swollen 44 (36) Fever (history) 35 (29) Fever (physical exam) 23 (19) Chills 27 (22)( ) Sepsis 14 (11) Tachycardia 10 (8) Malaise 26 (21)Malaise 26 (21) Anorexia 14 (11) Nausea 10 (8) Device Infections Superficial cellulitis and remodeling of the anterior chest wall f ftissues caused by fat necrosis due to a pacemaker pocket infection. There is a small amount of bruising in the middle of the erythema Device Infections Erosion of the ICD with part of the header and can visible. There is also a sinus tract over the leads medial to the device. There is evidence of drainage of purulent material and blood from both eruptionsevidence of drainage of purulent material and blood from both eruptions. Note the lack of cellulitis. There is a slight bluish discoloring of tissues immediately medial to the exposed header. Device InfectionsDevice Infections This is a breast cancer patient post extensive operation with SSS.Erosion of pacemaker is visible because of large area of chest skin removed. Device InfectionsDevice Infections Cellulitis, erythema and pus can be seen in the pacemaker pocket area 细菌培养细菌培养 • 血培养 • 局部面纱培养 • 剔除的坏死组织培养• 剔除的坏死组织培养 Not identified in one-thirdNot identified in one third 细菌培养细菌培养 为什么约1/3-1/2阴性： • 带菌的样本不容易得到 病原菌多样化• 病原菌多样化 • 使用抗菌素后使用抗菌素后 治疗治疗 抗菌素： 国外有的中心主张术前使用预防性用药• 国外有的中心主张术前使用预防性用药 There are few good data specifically supporting the use of perioperative antibiotics in device operations, but there are good data for general surgical proceduresg g p 治疗治疗 抗菌素 • 如何选用? –大多数对头孢类抗菌素不敏感大多数对头孢类抗菌素不敏感 –万古霉素适合与多数感染者万古霉素适合与多数感染者 Unless there is an indentified pathogen with sensitity to another antibioticy B L t l H t Rh th 2007 4 1467 1470Bruce L et al Heart Rhythm 2007;4:1467-1470 TreatmentTreatment 抗菌素 • 使用多久? –对于电极导管拔出中： 至少2周对于电极导管拔出中： 至少2周 –感染性心内膜炎： 至少4周 • 给药途径：静脉 Bruce L et al Heart Rhythm 2007;4:1467-1470 北京医院的处理方法北京医院的处理方法 一、全身治疗、全身治疗 二、局部处理 三、物理疗法 北京医院的处理方法北京医院的处理方法 一、全身治疗-抗菌素、全身治疗 抗菌素 •途径-静脉 •种类 头孢三代 万古霉素或美平–头孢三代→万古霉素或美平 –根据药敏用药根据药敏用药 •时间10-14天 北京医院的处理方法北京医院的处理方法 部嚢袋处二、局部嚢袋处理 1 彻底清除坏死 纤维及疤痕组织1. 彻底清除坏死、纤维及疤痕组织 2. 彻底止血 3. 嚢袋冲洗 4 最好将起搏器埋在新的嚢袋内4. 最好将起搏器埋在新的嚢袋内 北京医院的处理方法北京医院的处理方法 三 嚢袋冲洗三、嚢袋冲洗： 1. 碘伏擦起搏器及电极导管2-3次碘伏擦 搏 极 管 次 2. 庆大霉素盐水 3 灭滴灵液体3. 灭滴灵液体 4. 双氧水4. 双氧水 5. 盐水 每 种液体冲洗 次每一种液体冲洗2-3次 北京医院的处理方法北京医院的处理方法 四 嚢袋处理：四、嚢袋处理： • 局部间断缝合 • 一般不使用胶皮引流条• 般不使用胶皮引流条 • 一般不加压包扎 北京医院的处理方法北京医院的处理方法 五 结合物理疗法五、结合物理疗法 1、紫外线：杀菌 2、超短波?:促进吸收 • 感染不重者或有血肿者可首选 • 配合局部及全身抗感染治疗 北京医院处理方法北京医院处理方法 从2000 2008年共8例起搏器嚢袋慢从2000-2008年共8例起搏器嚢袋慢 性感染者使用上述保守治疗： • 男性5例、女性2例 – 本院4例本院 例 – 院外4例 • 感染时间：1个月-8.5年（平均3.3年） 北京医院处理方法北京医院处理方法 结果结果： • 6例完全成功：• 6例完全成功： – 在同侧安装原起搏器 平均随访 年无感染征象– 平均随访2.5年无感染征象 • 一例一年后再次感染例 年后再次感染 – 同侧失败，在对侧植入起搏系统 另 例第二次处理失败• 另一例第二次处理失败 – 取出起搏器，处理局部电极 治疗治疗 拔电极 • 保守治疗无效保守治疗无效 • 拔出电极是最有效的治疗手段 但在我国现实不可能推广使用• 但在我国现实不可能推广使用 TreatmentTreatment Lead extraction techniquesead e t act o tec ques • Manual traction without tools • Traction mediated by some sort of weight or by application of a clamp to the stretched lead • Mechanical sheaths, with or without use of a locking stylet El t h i l di ti h th ith ith t• Electromechanical dissection sheaths, with or without use of a locking stylet • Laser-assisted lead extraction, with or without use of a lockingLaser assisted lead extraction, with or without use of a locking stylet • Open chest extraction, with or without transvenous extraction t ltools • Transthoracic extraction using a parasternal, subxiphoid, or intercostal approachor intercostal approach TreatmentTreatment Lead extractionead e t act o Leads ready for extraction with locking stylets inserted and insulation sutures attached Lead extraction Ventricular lead tip fibrosis; lead extracted with laser technique.The leads had been implanted for approximately 8 years.p pp y y Treatment- Lead extractionTreatment Lead extraction Severe lead fibrosis, partially calcified, and infected vegetation removed during transvenous lead extraction. The inner laser sheath is shown but the lead extraction was completed when the larger outer sheathshown, but the lead extraction was completed when the larger outer sheath was advanced over the inner sheath enclosing the large amount of tissue for removal. Treatment- Lead extractionTreatment Lead extraction Lobulated vegetation on this active fixation atrial lead visualized through an atriotomy during surgical extraction. 预后预后 平均使用抗菌素时间 35 ± 23 36 需要拔出起搏器及电极比例 72%(13/18)需要拔出起搏器及电极比例 72%(13/18) 保守治疗成功率 22% (4/18) 重置手术比例 56%(10/18) 平均住院时间 45 ± 16平均住院时间 45 ± 16 死亡率 11%(2/18) 需 终 起搏治疗比例 ( )需要终止起搏治疗比例 11% (2/18) Lakkireddy D er al :PACE 2005; 28:789–794 THANKS THANKS