Cardiac implantable electronic device pocket infection
Suspect a pocket infection in patients with signs of inflammation around the cardiac implantable electronic device (CIED). Signs of inflammation include localised erythema, cellulitis, swelling, pain, skin erosion, wound dehiscence, purulent discharge or sinus formation at the pocket site. Early postimplantation inflammatory changes can be difficult to distinguish from infection and should be monitored clinically. If infection is suspected, monitor with blood tests (white cell count, C-reactive protein [CRP], blood cultures). Adhesion to the skin and threatened erosion may be indicators of pocket infection.
Perform an echocardiogram (usually a transoesophageal echocardiogram [TOE]) for patients with a pocket infection, to assess for involvement of the leads and cardiac valves. Aspiration of fluid from a suspected pocket infection can be diagnostic, but can introduce infection. Aspiration of the pocket fluid should be avoided, unless undertaken under sterile conditions by a specialist in cardiac implantable electronic device infection and removal. For further information on investigations for cardiac implantable electronic device infections, see Investigations for cardiac implantable electronic device infections.
If infection is confirmed or highly suspected, removal of the cardiac implantable electronic device and leads is necessary to cure infection – refer to a specialist in cardiac implantable electronic device infection and removal. For further information on removal of the cardiac implantable electronic device, see Management of cardiac implantable electronic device infections.
For an isolated pocket infection with negative blood culture results, treat empirically until culture results (eg pocket site swab, pocket fluid, lead tip) are available. Empirical therapy is directed against Staphylococcus aureus and coagulase-negative staphylococci because these are the most common causative organismsHan, 2021. For empirical therapy of isolated pocket infection in adults and children, use:
vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults or Intermittent vancomycin dosing for young infants and children. vancomycin vancomycin vancomycin
Modify therapy based on the results of culture and susceptibility testing.
Consider switching to oral therapy following removal of the device if there is minimal inflammation and tissue necrosis.
The total duration of treatment (intravenous + oral) is usually 10 to 14 days after cardiac implantable electronic device removal. A longer duration may be required if Staphylococcus aureus is cultured or there is extensive tissue damage.
If blood culture results are positive or vegetations are present, the infection is not a simple soft tissue pocket infection and needs to be treated as for cardiac implantable electronic device lead endocarditis.