Cardiac implantable electronic device infection
Cardiac implantable electronic device (CIED) infection is infection of a permanent pacemaker or defibrillator presenting as a generator-pocket infection or as bacteremia with lead endocarditis, caused by staphylococci in two-thirds of cases. Pocket infection is a clinical diagnosis that is never aspirated; at least 2 blood cultures and transesophageal echocardiography define systemic infection, and cure requires complete removal of the generator and all leads plus 7 days to 6 weeks of pathogen-directed antibiotics before reimplantation at a new site.
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What this article covers
- Overview
Definition: Cardiac implantable electronic device (CIED) infection is infection of a permanent pacemaker, implantable cardioverter-defibrillator (ICD), or other cardiac device, presenting either as a…
- Epidemiology
Growing population at risk: Use of permanent pacemakers, ICDs, and resynchronization devices is increasing, enlarging the population exposed to device infection.
- Risk factors
Recent pocket instrumentation: Initial implantation and generator change are the strongest risks, because skin flora are introduced into the pocket at surgery.
- Pathophysiology
Inoculation at surgery: Skin organisms enter the pocket during implantation or generator change and adhere to the generator and proximal leads.
- Clinical features
Pocket infection, the hallmark: Erythema, warmth, swelling, tenderness, or purulent drainage over the generator; it may be insidious and limited to localized pain or erythema without fever or leukocytosis.
- Differential diagnosis
Infective endocarditis of a native or prosthetic valve: Bacteremia with a valve vegetation on transesophageal echocardiography and left-sided embolic signs; see infective endocarditis and prosthetic valve endocarditis.
- Diagnosis
What establishes the diagnosis: Pocket infection is a clinical diagnosis made on inspection (erythema, warmth, swelling, drainage, or erosion over the generator), and the pocket is never aspirated…
- Management
First, draw blood cultures and refer urgently for device extraction: Every patient with suspected CIED infection needs urgent specialist evaluation; clinical observation, topical mupirocin, or…
- Complications
Lead and valve endocarditis: Untreated pocket infection progresses to bacteremia and endocarditis of the leads or tricuspid valve.
- Prognosis
Driver of outcome: Prompt complete extraction plus a full antibiotic course is the requisite for cure, regardless of organism or presentation.
- Prevention
Prefer hardware with less infection risk when it fits the indication: A subcutaneous ICD, with no transvenous lead, carries a reduced risk of device infection.
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