Approach to managing cardiac implantable electronic device lead endocarditis
Diagnosis of cardiac implantable electronic device (CIED) lead endocarditis can be challenging because the presenting symptoms are usually nonspecific, including fever, chills and night sweats. Pneumonia due to septic pulmonary embolism may be present. Diagnosis relies on blood cultures and imaging, including transoesophageal echocardiography (TOE) and, in difficult cases, fluorine-18 positron emission tomography/computed tomography (18F-FDG PET). In addition to the modified Duke diagnostic criteria1Li, 2000, the diagnostic criteria for cardiac implantable electronic device lead endocarditis include a relapsing bacteraemia, signs of pocket infection and pulmonary embolism. For further information on investigations for cardiac implantable electronic device infections, see Investigations for cardiac implantable electronic device infections.
Before starting antibiotic therapy, take 3 sets of blood for culture (from separate venipuncture sites). Coagulase-negative staphylococci, which are common causative pathogens of lead endocarditis, are common contaminants in a poorly sampled blood culture. For advice on obtaining good quality blood samples for culture, see Principles of obtaining blood for culture.
In patients with lead endocarditis who have sepsis or septic shock (life-threatening organ dysfunction in response to infection), prompt antibiotic therapy is important. However, obtaining good quality blood samples for culture before starting antibiotic therapy is equally important to ensure an accurate diagnosis. For patients with sepsis or septic shock, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock. Antibiotics should be administered immediately after blood samples are taken for culture. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.
Removal of the generator and leads is essential to cure lead endocarditis. Seek early advice from and referral to both:
- a specialist in cardiac implantable electronic device infection and removal
- an infectious diseases physician.