Management of Cardiac Device Infections: A Collaboration Between Electrophysiologists and Infectious Disease Specialists

Dear Readers, Anyone involved in pacemaker and defibrillator implantation understands that there is a significant risk of infection after device implantation and that the management of these infections can be particularly challenging. Two important papers were published early this year related to implantable device infections and their management. The first was a Scientific Statement from the American Heart Association entitled “Update on Cardiovascular Implantable Electronic Device Infections and Their Management.”1 The purpose of the update was to educate clinicians about device infections, provide explicit recommendations, and highlight opportunities for research. The paper provides a summary table of recommendations. Below is a paraphrased and abbreviated list of those recommendations. Recommendations for antibiotic prophylaxis at the time of device implantation. 1. 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 one hour before incision; if vancomycin is given, then it should be administered intravenously within two hours before incision. Recommendations for diagnosis of device infection and associated complications. 1. When a device infection is suspected, two sets of blood cultures should be drawn before starting antibiotics. 2. Gram stain and cultures should be obtained from the hardware when a device is explanted. 3. Adult patients with suspected device infection should undergo a transesophageal echocardiogram. In pediatric patients with good views, a surface echocardiogram may be sufficient. 4. Patients should seek evaluation for device infection by cardiologists or infectious disease specialists if they develop fever or bloodstream infection for which there is no initial explanation. 5. Percutaneous aspiration of the generator pocket should not be performed as part of the diagnostic evaluation of device infection. Recommendations for antibiotics for device infections. 1. Choice of antibiotics should be based on the results of culture and sensitivities. 2. 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. Recommendations for removal of infected devices. 1. Complete device and lead removal is recommended for all patients with: • Definite device infection with sepsis. • Pocket infection involving the device even when it is not clear if the leads are infected. • Endocarditis without definite involvement of the device or leads. • Occult staphylococcal bacteremia. 2. Device removal is not indicated for a superficial or incisional infection without involvement of the device or leads. Recommendations for re-implantation after infection. 1. Each patient should be evaluated carefully to determine whether there is a continued need for a new device. 2. Re-implantation should not be on the same side as the extraction site if possible. 3. Blood cultures should be negative for at least 72 hours before re-implantation. 4. New transvenous lead placement should be delayed for at least 14 days after device system removal when there is evidence of valvular infection. A second important paper that was published related to device infections was the LExiCon Study.2 This study described the outcome of 1,500 consecutive patients who underwent laser lead extraction of almost 2,500 leads at 13 centers. The success rate for lead removal was high at 96.5%, and the rate of major complications was low at 1.4%, including a 0.28% death rate. The failure rate was higher for leads implanted for >10 years and when performed in low volume centers. There is evidence that the number of device infections is growing. The publications above suggest that when there is evidence that a device is infected, an aggressive approach is indicated. This approach includes complete removal of the device and leads — a procedure that can be performed safely and effectively using a laser lead extraction system at experienced centers.