Management of cardiac implantable electronic device infection

Cardiac implantable electronic device infection may involve the device pocket, leads, cardiac valve leaflets or endocardial surface (or any combination of these sites). Lead endocarditis may result from a pocket site infection or spread from another site of infection.

Cardiac implantable electronic device infections are classified asBlomstrom-Lundqvist, 2020Palmeri, 2021:

• superficial incisional infection following cardiac implantable electronic device insertion
• cardiac implantable electronic device pocket infection – these may be isolated (ie no vegetations are seen on echocardiogram and blood culture results are negative) or associated with bacteraemia. Erosion or exposure of the pulse generator or leads is considered a pocket infection. If pocket infection is associated with bacteraemia, treat as for lead endocarditis
• lead endocarditis – when vegetations are seen on echocardiography with positive blood cultures, which may or may not be associated with a pocket infection
• bacteraemia where cardiac implantable electronic device infection is suspected but not proven – when blood culture results are positive but no vegetations are seen on echocardiogram and no alternative site of infection is found. Management differs depending on the organism isolated; seek expert advice.

Removal of the cardiac implantable electronic device (including the leads) is essential to cure cardiac implantable electronic device pocket infections and lead endocarditis. Antibiotic therapy alone without removal of the cardiac implantable electronic device is associated with a high rate of infection recurrence and mortality. Seek early advice from and referral to both:

• a specialist in cardiac implantable electronic device infection and removal – accredited specialists (including those that specialise in lead extraction) are available in most Australian state capital cities
• an infectious diseases physician.

Do not delay referral by attempting salvage of an infected cardiac implantable electronic device pocket by ‘washing out’ and repositioning the device, because this is rarely effective. Removal (extraction) of chronically implanted leads carries a small risk of damage to thoracic veins or the heart (approximately 1 to 2%, based on Australian and international registry dataBongiorni, 2017Strathmore, 2018). However, when performed by an experienced specialist, with cardiac surgical support, mortality is less than 0.5%, even in older and frail patients (based on Australian and international registry dataBongiorni, 2017Strathmore, 2018).

In rare cases when the risks associated with lead removal are very high or the patient is extremely frail, management with long-term suppressive antibiotics (with or without pocket debridement) may be considered – seek advice from a specialist in cardiac implantable electronic device removalBlomstrom-Lundqvist, 2020Ngiam, 2022Phillips, 2022.

In patients who undergo removal of the cardiac implantable electronic device, consider the need and timing for temporary pacing and re-implantation of the device. If the patient is pacemaker-dependent, temporary pacing may be required until the infection is cleared – seek expert advice.