CIED Infection Prevention and Management: Key Points

Prevention:

1. Hematoma prevention is probably the most important intervention in the prevention of CIED infection, along with preoperative antibiotic administration and operative infection prevention and control measures.
2. In patients receiving warfarin, it is reasonable to perform ClED implantation with a therapeutic international normalized ratio between 2 and 3.5. Continued or interrupted direct oral anticoagulants at the time of ClED implantation/revision are both acceptable because both are associated with a low risk of hematoma formation.
3. The use of preprocedural intravenous first-generation cephalosporin is supported by a large body of scientific evidence. In the PADIT trial, which compared preoperative cefazolin with an incremental strategy of preoperative cefazolin plus vancomycin, intraprocedural bacitracin pocket wash, and 2-day postprocedural cephalexin, there was no statistically significant difference in hospitalization for device infection at 1 year.
4. WRAP-IT, a multicenter randomized trial of patients undergoing ClED procedure, showed that the absorbable antibiotic envelope (TYREX) afforded a 40% relative risk reduction in CIED infection. Use of the antimicrobial envelope may be considered in patients at high risk of CIED infection, including patients at high risk of perioperative hematoma formation.

Diagnosis:

1. Definite criteria for pocket infection include physical examination findings involving the generator pocket, such as fluctuance, purulent drainage, device erosion through skin, or sinus tract formation.
2. Isolation of coagulase-negative staphylococci and S aureus in blood cultures is another criterion for definite infection.
3. The presence of lead echo-densities on transesophageal echocardiography in the setting of staphylococcal bloodstream infection is highly suggestive of ClED lead infection.
4. In the setting of nonstaphylococcal bacteremia, flourine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18FFDG PET/CT) uptake along leads may provide support for the diagnosis of ClED lead infection.
5. Procalcitonin may be considered in conjunction with other clinical, laboratory, and imaging data to determine if CIED infection is present.

Management:

1. It is recommended that patients with a definite CIED infection and those with valvular infectious endocarditis (IE) without definite device and lead involvement undergo complete device removal. ClED removal within 7 days of diagnosis is associated with a threefold decrease in 1-year mortality compared with delay in removal beyond 7 days.
2. A period after ClED removal of ≥3 days of negative blood cultures (to 14 days in patients with valvular IE) seems reasonable before re-implantation. The new device should be implanted on the contralateral side, the iliac vein, or epicardial position. It is reasonable to use a leadless pacemaker and totally subcutaneous implantable cardioverter-defibrillator (S-ICD) in patients at high risk of infection or re-infection.
3. In cases where the risk of harm from system removal outweighs the benefit, it is reasonable to consider chronic antimicrobial suppression (CAS) therapy.
4. Continuous, in situ-targeted, ultrahigh concentration of antibiotics may be an alternative in patients with CIED infection due to non–S aureus when the risk of complete device removal is unacceptably high. However, more investigation is needed before this becomes a standard management option.
5. In patients with incomplete device removal, 18FFDG PET/CT may be useful to evaluate for residual infection to determine whether CAS therapy is warranted.