Cardiovascular implantable electronic device infection: A stepwise approach to diagnosis and management
ABSTRACTInfection related to cardiovascular implantable electronic devices is a serious complication, necessitating removal of the device and prolonged parenteral antibiotic therapy. Accurate diagnosis and optimal management of these infections are challenging. This review highlights the critical management decisions.
KEY POINTS
- Although inflammatory signs at the generator pocket are the most common presentation of an infection occurring soon after the device is implanted, positive blood cultures may be the sole manifestation of a late-onset endovascular infection.
- Staphylococci are the most common pathogens in both pocket infections and endovascular infections.
- Two sets of blood cultures should be obtained in all patients suspected of having a cardiac device infection.
- Transesophageal echocardiography should be ordered in all patients with suspected cardiac device infection who have positive blood cultures, as it can identify intracardiac complications of infection and assess for evidence of cardiac valve involvement.
OUTCOMES OF INFECTION
Despite improvements in our understanding of how to manage CIED-related infection, the rates of morbidity and death remain significant.
The outcome, in part, depends on the clinical presentation and the patient’s comorbid conditions. In general, the death rate in patients with a pocket infection is less than 5%. However, in patients with endovascular infection, it may be as high as 20%.16–18 Other factors that affect the outcome include complications such as septic thrombosis, valvular endocarditis, or osteomyelitis; complications during device extraction; the need for open heart surgery; and the overall health of the patient.
Complete removal of the device system is a requisite for successful outcome, and the risk of death tends to be higher if only part of the infected CIED system is extracted.26
STRATEGIES TO PREVENT DEVICE INFECTION
Preventive efforts should focus on strategies to minimize the chances of contamination of the generator, leads, and pocket during implantation.29 Patients who are known to be colonized with methicillin-resistant S aureus may benefit from decolonization programs, which should include nasal application of mupirocin (Bactroban) ointment preoperatively.30 In addition, use of chlorhexidine for surgical-site antisepsis has been shown to reduce the risk of surgical site infection.31
Moreover, all patients should receive antibiotic prophylaxis before implantation of a CIED.32,33 Most institutions use a first-generation cephalosporin, such as cefazolin (Ancef), for this purpose.34 However, the increasing rate of methicillin resistance in staphylococci has led to the routine use of vancomycin for preoperative prophylaxis at some centers.18
Regardless of the antibiotic chosen for prophylaxis, protocols that ensure that all patients receive an appropriate antibiotic at the appropriate time are a key determinant in the success of these infection-control programs.
