Implantable cardiac electric device (ICED/CIED) infections

• Infections of cardiac device pocket or lead
• Includes implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy devices(CRTDs) in addition to permanent pacemakers (PPMs)

Microbiology

• Gram-positive (70-90%)
  • Staphylococci
    • S. aureus
    • Coagulase-negative staphylococci, especially for pocket infections
  • Enterococci, viridans group streptococci, and S. pneumoniae
  • Cutibacterium acnes
• Gram-negative (15-20%)
  • Klebsiella and Serratia
• Fungal (1%)
• Culture-negative (15%)

Classification

• Blood cultures positive
  • TEE positive: lead infection, infective endocarditis
  • TEE negative: not infected, I guess?
• Blood cultures negative
  • Pocket site infection
  • Lead erosion

Risk Factors

• Number of prior procedures, including generator replacements
• Lack of antimicrobial prophylaxis at the time of procedure
• "Pickers" at the pocket site
• Diabetes mellitus
• More than two leads
• Rapid weight loss
• Shallow pocket
• Trauma

Pathophysiology

• Infection may be acquired in a number of ways:
  • Device manufacturing
  • During procedure
  • Surgical site infection
  • Hematogenous seeding
  • Erosion through skin
• Asymptomatic colonization of the device and leads is common, and can develop into infection later on
  • Most common organisms were coagulase-negative staphylococci and Cutibacterium

Investigations

• Labs
  • Blood cultures
  • TEE if blood cultures positive
  • Swab of generator pocket intraoperatively

Management

• SOURCE CONTROL
  • Get intraoperative pocket swab, if possible
• If infective endocarditis, treat per guidelines
• If lead infection (BCx pos/TEE neg)
  • Uncomplicated: 2 weeks of antibiotics
  • Complicated: 4-6 weeks of antibiotics
• If pocket site infection:
  • Swab positive: 10-14 days of antibiotics
  • Swab negative: 7-10 days of antibiotics
• If lead erosion: 7-10 days of antibiotics

Prognosis

• Mortality ranges from 0 to 35%
• CKD has worse prognosis

Further Reading

• European guidelines: Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. J Antimicrob Chemother, 2015;70(2):325–359.