Infection from cardiac implantable devices (CIEDs) is a serious complication, and addressing discrepancies such as guideline education and streamlining care or referral pathways are key to bridging the gaps and improving patient outcomes, according to results from the COGNITO survey published Feb. 3 in JACC: Advances.

An observational survey was conducted by the American College of Cardiology to assess current practices in diagnosis and management of CIED infections and explore potential extraction barriers. The survey assessed 387 U.S.-based electrophysiologists (EPs), non-EP cardiologists and primary care physicians (PCPs), and included eight demographic questions and 17 CIED-related knowledge and experience questions. Data were collected from Feb. 11, 2022 to March 10, 2022.

Results showed that 49% of the 387 physicians who completed the survey (20% response rate) were familiar with current CIED infection guidelines. EPs (91%) were more familiar with current guidelines when compared with non-EP cardiologists (29%) and PCPs (23%). “Only 30% of physicians specified that their institution had guideline-based protocols in place for managing patients with CIED infection. When presented with pocket infection cases, approximately 89% of EPs and 50% of non-EP cardiologists would follow guideline recommendation to do complete CIED system removal, while 70% of primary care physicians did not recommend guideline-directed treatment,” the authors write.

Dhanunjaya R. Lakkireddy, MBBS, FACC, et al., write that the COGNITO study is the largest professional society-based survey of practicing physicians in assessing approaches to management of CIED infection. It found very low familiarity with identification and management of CIED infections among non-EP cardiologists and PCPs; fewer than a third of respondents had knowledge of local institutional CIED management protocols, and even among EPs who routinely implant CIEDs, only 42% reported being aware of institutional CIED infection protocols. About 40% of EPs who do not perform lead extraction reported managing the patient themselves without a referral to a lead extraction specialist, as did 11% of PCPs. A quarter of PCPs and non-EP cardiologists perceived lead extraction as a procedure with high or very high risk of major complications, which was a major determinant of referral practices for lead extraction for 86% of respondents.

Focusing on education to address the low rates of familiarity with guidelines for CIED infection necessitating device extraction may help improve outcomes in patients with CIED infections, write the authors.

In a related editorial comment, Andrew H. Voigt, MD, FACC; Saketram Komanduri, MD; and Krishna Kancharla, MD, write that, these “findings should encourage us to reflect on the state of affairs in CIED infection management. Lead extraction may indeed have an image problem in the wider medical and cardiology communities. These perceptions may be limiting appropriate referrals and care.” They note that more institutions need a clear pathway for infection management and highlight the call for education to address the gaps in knowledge and further efforts to streamline care and referral pathways for appropriate management of patients with CIED infection.