Cardiovascular implantable electronic device (CIED) (IDSA 2017)

Diagnosis

Definitions

• Isolated generator pocket infection: localized erythema, swelling, pain, tenderness, warmth, or drainage with negative blood cultures
• Isolated pocket erosion: device and/or lead(s) are through the skin, with exposure of the generator or leads, with or without local signs of infection
• Pocket site infection with bacteremia: local infection signs and positive blood cultures
• Lead infection: lead vegetation and positive blood cultures Pocket site infection with lead/valvular endocarditis: local signs and positive blood cultures and lead or valvular vegetation(s)
• CIED endocarditis without pocket infection: positive blood cultures and lead or valvular vegetation(s)
• Occult bacteremia with probable CIED infection: absence of alternative source, resolves after CIED extraction
• Superficial incisional infection: involves only skin and subcutaneous tissue of the incision, not the deep soft tis- sues (eg, fascia and/or muscle) of the incision

Clinical Manifestations

• Pocket infection can occur at any time, characterized by erythema, swelling, pain, warmth, drainage, or hardware exposure
• Devices may non-infectiously erode through the soft tissue and skin; once exposed, it is considered infected
• In the early post-procedural period, try to differentiate between superficial infection and pocket infection (which would potentially track to the leads)
  • Early infection is <6 months
  • Superficial generally lacks signs of systemic infection
• May present with bacteremia, most commonly staphylococci (60-80%), especially S. aureus (25%), though coagulase-negative staphylococci are the most common cause of device pocket infection

Blood and Device Pocket Culture

• Blood cultures x2 should be done before antibiotics
• Tissue culture is better than pocket swab, and both are useful, but a connector culture is the best
  • If Gram stain is negative, a tissue culture should be sent for mycobacteria and fungal stains
  • The lead tip should be sent for culture

Imaging Diagnosis

• TEE is useful, and better than TTE
  • It should always be considered in patients with bacteremia or suspected pocket infections

Predictors of Infection and Prognosis

Patient Risk Factors

• Older age
• Number and severity of comorbidities
• Especially CKD

Procedure-Related Factors

• Reopening the pocket, including generator change, CIED upgrade, and lead or pocket revision or manipulation
• Postoperative hematoma

Microbes

• Devices and pockets are often colonized (20-30%)
• Staph. aureus and coagulase-negative staphylococci are the most common organisms to cause infection

Antimicrobial Therapy

• Empirically, cover Gram-positives and Gram-negatives
• 97% cure with lead extraction and antibiotics
• Duration
  • Pocket erosion: 10 days
  • Pocket infection: 2 weeks after lead extraction
  • Complicated infections, including endocarditis and persistent bacteremia: 4 to 6 weeks
• Duration is calculated from first negative or from lead extraction, whichever occurred last

New Device Implantation

• May need temporary pacemaker
• At least wait until blood cultures are negative for 72 hours
• Reimplant at a distant site from the original infection

Summary

Diagnosis

• If antibiotics are going to be prescribed, drawing at least two sets of blood cultures before starting antibiotic therapy is recommended for all patients with suspected CIED infection to improve the precision and minimize the duration of antibiotic therapy.
• Gram stain and culture of generator pocket tissue and the explanted lead(s) are recommended at the time of CIED removal to improve the precision and minimize the duration of antibiotic therapy.
• Preprocedural transesophageal echocardiography (TEE) is recommended for patients with suspected systemic CIED infection to evaluate the absence or size, character, and potential embolic risk of identified vegetations.
• TEE can be useful for patients with CIED pocket infection with and without positive blood cultures to evaluate the absence or size, character, and potential embolic risk of identified vegetations.

Management

• Complete course of antibiotics is recommended for all patients
  • 2 weeks after lead extraction for pocket infections
  • 10 days for pocket erosion
  • Minimum 2 weeks after extraction if bacteremic
  • 4-6 weeks for endocarditis
  • Durations can be counted from lead extraction or from negative blood cultures (whichever occurred last)
• Complete device and lead removal for
  • all patients with definite infections, ideally within 3 days of diagnosis
  • all patients with endocarditis, regardless of lead or device involvement
  • patients with persistnet or recurrent bacteremia or fungemia despite appropriate therapy
• Complete epicardial lead and patch removal for all patients with confirmed purulence around the intrathoracic lead