AHA Recommendations for Management of CIED Infections
The following is abstracted from Baddour, L.M., Epstein, A.E., Erickson, C.C., Knight, B.P., Levison, M.E., Lockhart, P.B., et al. (2010). Update on cardiovascular implantable electronic device infections and their management: A scientific statement from the American Heart Association. Circulation, 121, 458-477.
- Complete device and lead removal is recommended for all patients with:
- Definite device infection as evidenced by valvular and/or lead endocarditis or sepsis.
- Pocket infection as evidenced by abscess formation, device erosion, skin adherence, or chronic draining sinus without clinically evident involvement of the transvenous portion of the lead system.
- Valvular endocarditis without definite involvement of the lead(s) and/or device.
- Occult staphycoccal bacteremia.
- Persistent occult Gram-negative bacteremia despite appropriate antibiotic therapy.
- Device removal is not indicated for a superficial or incisional infection without involvement of the device or leads.
- Prophylaxis with an antibiotic that has in vitro activity against staphylococci should be administered. If cefazolin is selected for use, then it should be administered intravenously within 1 hour before incision; if vancomycin is given, then it should be administered intravenously within 2 hours before incision.
- When a device infection is suspected, two sets of blood cultures should be drawn before starting antibiotics.
- Gram stain and cultures should be obtained from the hardware when a device is explanted.
- Patients with suspected CIED infection who either have positive blood cultures or have negative blood cultures but have had recent anti-microbial therapy before blood cultures were obtained should undergo transesophogeal echocardiogram (TEE) for CIED infection or valvular endocarditis.
- Adult patients with suspected device infection should undergo a TEE. In young adults with good views, a surface echocardiogram may be sufficient.
- Patients should seek evaluation for device infection by cardiologists or infectious disease specialists if they develop fever or bloodstream infection for which there is not initial explanation.
- Percutaneous aspiration of the generator pocket should not be performed as part of the diagnostic evaluation of device infection.
- Choice of antibiotics should be based on the results of culture and sensitivities.
- Duration of antibiotics after device removal should be:
- 10 to 14 days for a pocket-site infection.
- ≥ 14 days for a bloodstream infection.
- ≥ 4 to 6 weeks for a complicated infection such as endocarditis.
- Each patient should be evaluated carefully to determine whether there is a continued need for a new device.
- Re-implantation should not be on the same side as the extraction site if possible.
- Blood cultures should be negative for at least 72 hours before re-implantation.
- New transvenous lead placement should be delayed for at least 14 days after device system removal when there is evidence of valvular infection.
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