Checklist for Detecting and Managing Implant Infections

By Jonathan Carlson, MD
Interventional Pain Specialist/Anesthesiologist, Pain Doctor, LLC
President, Medical Services, Xanthus Services
Clinical Assistant Professor, MidWestern Medical School
Glendale, AZ

Background

Detection and management of implantable therapy infection requires provider vigilance to decrease morbidity and, in severe cases, mortality. Most device infections occur within the first few weeks after surgery, but they can occur months to years later.[1] The incidence of device infection is typically 2%-14%.[1],[2] Risk factors for infection include autoimmune disorders, immunosuppressive medication, diabetes, smoking and alcohol use, and malnourishment.[3]

Clinical Pearl: Never manage possible device infections over the phone. Patient may downplay acuity. Major settlements have been awarded for lack of provider attentiveness. Always have the patient promptly come to your clinic or meet you at the ER for a physical exam.

Checklist[1],[3],[4],[5]

  1. Conduct history and physical exam.
    • Signs and symptoms: Backache, increased pain, fever, temperature greater than 100.4 F. Implant sites: Tenderness, rubor, erythema, induration, fluctuance , discharge, wound dehiscence. Conduct a thorough physical exam to assess for new neurological deficits.
  2. Determine whether or not the infection is superficial or deep.
    • Superficial: More common; can be managed outpatient with oral or IV antibiotics. Possible antibiotics include cefazolin, clindamycin, doxycycline, or IV vancomycin. A high degree of vigilance and close follow-up is mandatory. Imaging and infectious disease consult is recommended.
    • Deep: Less common and involves infection at the level of the device; typically requires hospital admission and device explant, infectious disease consult, PICC line for IV antibiotics such as vancomycin.
    • Evaluate and rule out meningitis and epidural abscess.
  3. Obtain labs to evaluate the following.
    • Elevated white blood cell count (WBC)
    • Increased C-reactive protien (CRP)
    • Elevated sedimentation rate (ESR)
    • Some experts advocate wound swab for culture and sensitivity.
  4. Obtain the following imaging tests.
    • CT scan versus MRI with/without contrast for the following.
      • Thoracic and lumbar to evaluate midline lead implant site.
      • Abdominal/chest imaging to evaluate IPG battery site.
      • Work closely with radiology department to assure they understand why imaging is being requested. Check on MRI compatibility of device.
    • Review imaging immediately to rule out epidural abscess. It may be helpful to directly review with radiologist.
  5. Evaluate for epidural abscess.
    • If neurological deficits, it is a neurosurgical emergency; typically a 36-hour window for surgical decompression.[6]
  6. Consult infectious disease department.
  7. If explant of device is indicated, proceed with the following measures.
    • Conduct copious irrigation.
    • Remove all sutures and necrotic tissue.
    • If closing, consider vancomycin powder.[7]
    • If infection is severe and wound is unable to close, allow wound to heal via secondary intention or wound vac; consider wound care consult.
    • If infection is deep and MRI non-compatible device was a barrier, consider post-explant MRI to rule out epidural abscess.
  8. Consider re-implant in 3 months

References

  1. Deer TR, Stewart CD. Complications of Spinal Cord Stimulation: Identification, Treatment, and Prevention. Pain Med 2008 (Suppl):S93-S101.
  2. Bendersky D, Yampolsky C. Is Spinal Cord Stimulation Safe? A Review of Its Complications. World Neurosurgery 2014; 82[6]:1359-68.
  3. Engle et al. Infectious Complications Related to Intrathecal Drug Delivery System and Spinal Cord Stimulator System Implantations at a Comprehensive Cancer Pain Center. Pain Physician 2013; 16:251-7
  4. Kumar K et al. Avoiding complications from spinal cord stimulation: practical recommendations ?from an international panel of experts. Neuromodulation 2007; 10:24-33.
  5. Follett KA et al. Prevention and management of intrathecal drug delivery and spinal cord stimulation system infections. Anesthesiology 2004; 100:1582-94.
  6. Danner RL, Hartman BJ. Update on spinal epidural abscess: 35 cases and review of the literature. Rev Infect Dis 1987; 9:265-74.
  7. Molinari RW, Khera OA, Molinari III, WJ. Prophylactic intraoperative powdered vancomycin and postoperative deep spinal wound infection: 1,512 consecutive surgical cases over a 6-year period. European Spine Journal 2012; [21]4:476-82

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