European Consensus Document on Cardiac Implantable Electronic Device Infections

Blomström-Lundqvist C, Traykov V, Erba PA, et al.
European Heart Rhythm Association (EHRA) International Consensus Document on How to Prevent, Diagnose, and Treat Cardiac Implantable Electronic Device Infections — Endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in Collaboration With the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020;Feb 26:[Epub ahead of print].

This Journal Scan reviews the European Heart Rhythm Association international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device (CIED) infections, one of the most dangerous device complications. This document is intended to fill in gaps in knowledge and lack of consensus recommendations. It includes numerous well-designed tables and figures. The following are highlights from the main sections:

  1. Risk factors for CIED infection:
    • Based on large-data type studies, patient-related factors include end-stage renal disease (ESRD), diabetes mellitus, younger age, prior device infection, malnutrition, advanced heart failure class, and fever prior to procedure.
    • Procedure-related factors include postoperative hematoma, lead dislodgement, procedure duration, CRT (cardiac resynchronization therapy) devices, reoperation, and operator experience.
    • Device-related factors include number of leads and device complexity (CRT-D highest).
  2. Prevention:
    • Preprocedure: In addition to recognizing risk factors noted above, potential benefit from a leadless pacemaker or subcutaneous implantable cardioverter-defibrillator (ICD) should be considered, as these two alternative devices may decrease infection risk. Prophylactic antibiotics should cover Staphylococcus aureus species at the minimum.
    • Periprocedure: Bridging with heparin products should be avoided. Based on the recent PADIT trial, irrigation with antibiotic within the pocket is not recommended. High-risk patients, as included in the WRAP-IT study, would benefit from an antibacterial mesh envelope around the generator.
    • Postprocedure: Also based on the PADIT trial, postoperative antibiotics are not recommended.
  3. Diagnosis of CIED and related complications:
    • Authors of this document developed new 2019 International CIED Infection Criteria. These criteria denote generator pocket swelling, erythema, warmth, pain, and purulent discharge/sinus formation or deformation of pocket, adherence, and threatened erosion or exposed generator or proximal leads as diagnostic of a definite CIED infection.
    • Intracardiac echocardiography can be utilized for detecting vegetations. Positron emission tomography and computed tomography can identify abnormal activity in the pocket or along leads that would be suggestive of CIED infection.
    • Pocket or lead culture results may satisfy microbiological minor criteria.
  4. Management of CIED infections:
    • Complete removal is required for successful treatment of definite CIED infection. Antibiotic therapy alone may increase 30-day mortality several-fold (not including superficial incision infection requiring only antibiotics).
    • Isolated pocket infection should be treated with antibiotics for 14 days before new implantation, whereas systemic infections require 4-6 weeks of antibiotics.
  5. Preventable strategies after CIED implantations, reimplantations, and alternative novel devices:
    • Antibiotic prophylaxis is not recommended for dental, respiratory, gastrointestinal, genitourinary, or cardiac procedures.
    • The leadless pacemaker and subcutaneous ICD are alternative form factors in high-risk patients.
    • The wearable cardioverter defibrillator is a bridge to reimplantation in ICD patients.
    • Telemedicine offers potential for remote incision checks.
  6. Prognosis, outcomes, and complications of CIED infections:
    • The 30-day mortality for a CIED infection is 5-8%. Female sex, endocarditis, and ESRD are factors that portend higher risk.
    • Successfully treated patients have similar prognosis to those who have never been infected.
  7. Minimum quality requirements concerning centers and operator experience and volume:
    • There is an inverse relationship between operator experience and infection rate.
    • Operators with <100 total procedures should be supervised.
    • An annual volume of ≥50 CIED procedures is recommended per operator.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Imaging, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Arrhythmias, Cardiac, Anti-Bacterial Agents, Antibiotic Prophylaxis, Cardiac Resynchronization Therapy Devices, Cardiac Surgical Procedures, Defibrillators, Defibrillators, Implantable, Diabetes Mellitus, Echocardiography, Endocarditis, Erythema, Heart Failure, Hematoma, Heparin, Kidney Failure, Chronic, Pacemaker, Artificial, Positron-Emission Tomography, Risk Factors, Secondary Prevention, Staphylococcal Infections, Telemedicine, Tomography, X-Ray Computed

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