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Heart, Lung and Circulation

Prevention and Management of Cardiac Implantable Electronic Device Infections: State-of-the-Art and Future Directions

Published:August 18, 2022DOI:https://doi.org/10.1016/j.hlc.2022.06.690
      Cardiac implantable electronic device (CIED) infection is an increasingly common complication of device therapy. CIED infection confers significant patient morbidity and health care expenditure, hence it is essential that clinicians recognise the contemporary strategies for predicting, reducing and treating these events. Recent technological advances—in particular, the development of antimicrobial envelopes, leadless devices and validated risk scores—present decision-makers with novel strategies for managing this expanding patient population. This review summarises the key issues facing CIED patients and their physicians, and explores the supporting evidence for the latest therapeutic developments in this field.

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      References

        • Greenspon A.J.
        • Patel J.D.
        • Lau E.
        • Ochoa J.A.
        • Frisch D.R.
        • Ho R.T.
        • et al.
        16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States: 1993 to 2008.
        J Am Coll Cardiol. 2011; 58: 1001-1006
        • Voigt A.
        • Shalaby A.
        • Saba S.
        Continued rise in rates of cardiovascular implantable electronic device infections in the United States: temporal trends and causative insights.
        Pacing Clin Electrophysiol. 2010; 33: 414-419
        • Krahn A.D.
        • Longtin Y.
        • Philippon F.
        • Birnie D.H.
        • Manlucu J.
        • Angaran P.
        • et al.
        Prevention of Arrhythmia Device Infection Trial: the PADIT Trial.
        J Am Coll Cardiol. 2018; 72: 3098-3109
        • Tarakji K.G.
        • Mittal S.
        • Kennergren C.
        • Corey R.
        • Poole J.E.
        • Schloss E.
        • et al.
        Antibacterial envelope to prevent cardiac implantable device infection.
        N Engl J Med. 2019; 380: 1895-1905
        • Bongiorni M.G.
        • Tascini C.
        • Tagliaferri E.
        • Cori A. Di
        • Soldati E.
        • Leonildi A.
        • et al.
        Microbiology of cardiac implantable electronic device infections.
        Europace. 2012; 14: 1334-1339
        • Sandoe J.A.T.
        • Barlow G.
        • Chambers J.B.
        • Gammage M.
        • Guleri A.
        • Howard P.
        • et al.
        Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint working party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart rh.
        J Antimicrob Chemother. 2015; 70: 325-359
        • Le K.Y.
        • Sohail M.R.
        • Friedman P.A.
        • Uslan D.Z.
        • Cha S.S.
        • Hayes D.L.
        • et al.
        Clinical features and outcomes of cardiovascular implantable electronic device infections due to staphylococcal species.
        Am J Cardiol. 2012; 110: 1143-1149
        • Hussein A.A.
        • Baghdy Y.
        • Wazni O.M.
        • Brunner M.P.
        • Kabbach G.
        • Shao M.
        • et al.
        Microbiology of cardiac implantable electronic device infections.
        JACC Clin Electrophysiol [Internet]. 2016; 2: 498-505https://doi.org/10.1016/j.jacep.2016.01.019
        • Viola G.M.
        • Awan L.L.
        • Darouiche R.O.
        Nonstaphylococcal infections of cardiac implantable electronic devices.
        Circulation. 2010; 121: 2085-2091
        • Lekkerkerker J.C.
        • Van Nieuwkoop C.
        • Trines S.A.
        • Van der Bom J.G.
        • Bernards A.
        • Van de Velde E.T.
        • et al.
        Risk factors and time delay associated with cardiac device infections: Leiden device registry.
        Heart. 2009; 95: 715-720
        • Sohail M.R.
        • Hussain S.
        • Le K.Y.
        • Dib C.
        • Lohse C.M.
        • Friedman P.A.
        • et al.
        Risk factors associated with early-versus late-onset implantable cardioverter-defibrillator infections.
        J Interv Card Electrophysiol. 2011; 31: 171-183
        • Kusumoto F.M.
        • Schoenfeld M.H.
        • Wilkoff B.L.
        • Berul C.I.
        • Birgersdotter-Green U.M.
        • Carrillo R.
        • et al.
        2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction.
        Heart Rhythm [Internet]. 2017; 14https://doi.org/10.1016/j.hrthm.2017.09.001
        • Uslan D.Z.
        • Dowsley T.F.
        • Sohail M.R.
        • Hayes D.L.
        • Friedman P.A.
        • Wilson W.R.
        • et al.
        Cardiovascular implantable electronic device infection in patients with staphylococcus aureus bacteremia.
        Pacing Clin Electrophysiol. 2010; 33: 407-413
        • Blomström-Lundqvist C.
        • Traykov V.
        • Erba P.A.
        • Burri H.
        • Nielsen J.C.
        • Bongiorni M.G.
        • 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).
        Europace. 2020; 22: 515-516
        • Habib G.
        • Lancellotti P.
        • Antunes M.J.
        • Bongiorni M.G.
        • Casalta J.P.
        • Del Zotti F.
        • et al.
        2015 ESC guidelines for the management of infective endocarditis.
        Eur Heart J. 2015; 36: 3075-3123
        • Tarakji K.G.
        • Chan E.J.
        • Cantillon D.J.
        • Doonan A.L.
        • Hu T.
        • Schmitt S.
        • et al.
        Cardiac implantable electronic device infections: presentation, management, and patient outcomes.
        Heart Rhythm [Internet]. 2010; 7: 1043-1047https://doi.org/10.1016/j.hrthm.2010.05.016
        • Baddour L.M.
        • Epstein A.E.
        • Erickson C.C.
        • Knight B.P.
        • Levison M.E.
        • Lockhart P.B.
        • et al.
        Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association.
        Circulation. 2010; 121: 458-477
        • Greenspon A.J.
        • Prutkin J.M.
        • Sohail M.R.
        • Vikram H.R.
        • Baddour L.M.
        • Danik S.B.
        • et al.
        Timing of the most recent device procedure influences the clinical outcome of lead-associated endocarditis: results of the MEDIC (Multicenter Electrophysiologic Device Infection Cohort).
        J Am Coll Cardiol. 2012; 59: 681-687
        • Narducci M.L.
        • Pelargonio G.
        • Russo E.
        • Marinaccio L.
        • Di Monaco A.
        • Perna F.
        • et al.
        Usefulness of intracardiac echocardiography for the diagnosis of cardiovascular implantable electronic device-related endocarditis.
        J Am Coll Cardiol. 2013; 61: 1398-1405
        • Downey B.C.
        • Juselius W.E.
        • Pandian N.G.
        • Estes N.A.M.
        • Link M.S.
        Incidence and significance of pacemaker and implantable cardioverter-defibrillator lead masses discovered during transesophageal echocardiography.
        Pacing Clin Electrophysiol. 2011; 34: 679-683
        • Golzio P.G.
        • Errigo D.
        • Peyracchia M.
        • Gallo E.
        • Frea S.
        • Castagno D.
        • et al.
        Prevalence and prognosis of lead masses in patients with cardiac implantable electronic devices without infection.
        J Cardiovasc Med. 2019; 20: 372-378
        • Chang D.
        • Gabriels J.
        • Laighold S.
        • Williamson A.K.
        • Ismail H.
        • Epstein L.M.
        A novel diagnostic approach to a mass on a device lead.
        Heart Case Reports [Internet]. 2019; 5: 306-309https://doi.org/10.1016/j.hrcr.2019.03.001
        • Erba P.A.
        • Lancellotti P.
        • Vilacosta I.
        • Gaemperli O.
        • Rouzet F.
        • Hacker M.
        • et al.
        Recommendations on nuclear and multimodality imaging in IE and CIED infections.
        Eur J Nucl Med Mol Imaging. 2018; 45: 1795-1815
        • Erba P.
        • Lancellotti P.
        • Vilacosta I.
        • Gaemperli O.
        • Rouzet F.
        • Hacker M.
        • et al.
        Recommendations on nuclear and multimodality imaging in IE and CIED infections.
        Eur J Nucl Med Mol Imaging. 2018; 45: 1795-1815
        • Le K.Y.
        • Sohail M.R.
        • Friedman P.A.
        • Uslan D.Z.
        • Cha S.S.
        • Hayes D.L.
        • et al.
        Impact of timing of device removal on mortality in patients with cardiovascular implantable electronic device infections.
        Heart Rhythm. 2011; 8: 1678-1685
        • Greenspon A.J.
        • Eby E.L.
        • Petrilla A.A.
        • Sohail M.R.
        Treatment patterns, costs, and mortality among Medicare beneficiaries with CIED infection.
        Pacing Clin Electrophysiol. 2018; 41: 495-503
        • Viganego F.
        • O’Donoghue S.
        • Eldadah Z.
        • Shah M.H.
        • Rastogi M.
        • Mazel J.A.
        • et al.
        Effect of early diagnosis and treatment with percutaneous lead extraction on survival in patients with cardiac device infections.
        Am J Cardiol [Internet]. 2012; 109: 1466-1471https://doi.org/10.1016/j.amjcard.2012.01.360
        • Rusanov A.
        • Spotnitz H.M.
        A 15-year experience with permanent pacemaker and defibrillator lead and patch extractions.
        Ann Thorac Surg [Internet]. 2010; 89: 44-50https://doi.org/10.1016/j.athoracsur.2009.10.025
        • Patel D.
        • Khan F.
        • Shah H.
        • Bhattacharya S.
        • Adelstein E.
        • Saba S.
        Cardiac implantable electronic device lead extraction in patients with underlying infection using open thoracotomy or percutaneous techniques.
        Cardiol J. 2015; 22: 68-74
        • Richardson T.D.
        • Lugo R.M.
        • Crossley G.H.
        • Ellis C.R.
        Use of a clot aspiration system during transvenous lead extraction.
        J Cardiovasc Electrophysiol. 2020; 31: 718-722
        • Starck C.T.
        • Eulert-Grehn J.
        • Kukucka M.
        • Eggert-Doktor D.
        • Dreizler T.
        • Haupt B.
        • et al.
        Managing large lead vegetations in transvenous lead extractions using a percutaneous aspiration technique.
        Expert Rev Med Devices [Internet]. 2018; 15: 757-761https://doi.org/10.1080/17434440.2018.1525292
        • Klug D.
        • Balde M.
        • Pavin D.
        • Hidden-Lucet F.
        • Clementy J.
        • Sadoul N.
        • et al.
        Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study.
        Circulation. 2007; 116: 1349-1355
        • Olsen T.
        • Jørgensen O.D.
        • Nielsen J.C.
        • Thøgersen A.M.
        • Philbert B.T.
        • Johansen J.B.
        Incidence of device-related infection in 97 750 patients: clinical data from the complete Danish device-cohort (1982–2018).
        Eur Heart J. 2019; 40: 1862-1869
        • Birnie D.H.
        • Wang J.
        • Alings M.
        • Philippon F.
        • Parkash R.
        • Manlucu J.
        • et al.
        Risk factors for infections involving cardiac implanted electronic devices.
        J Am Coll Cardiol. 2019; 74: 2845-2854
        • Polyzos K.A.
        • Konstantelias A.A.
        • Falagas M.E.
        Risk factors for cardiac implantable electronic device infection: a systematic review and meta-analysis.
        Europace. 2015; 17: 767-777
        • Prutkin J.M.
        • Reynolds M.R.
        • Bao H.
        • Curtis J.P.
        • Al-Khatib S.M.
        • Aggarwal S.
        • et al.
        Rates of and factors associated with infection in 200 909 medicare implantable cardioverter-defibrillator implants results from the national cardiovascular data registry.
        Circulation. 2014; 130: 1037-1043
        • Joy P.S.
        • Kumar G.
        • Poole J.E.
        • London B.
        • Olshansky B.
        Cardiac implantable electronic device infections: who is at greatest risk?.
        Heart Rhythm [Internet]. 2017; 14: 839-845https://doi.org/10.1016/j.hrthm.2017.03.019
        • de Oliveira J.C.
        • Martinelli M.
        • D’Orio Nishioka S.A.
        • Varejão T.
        • Uipe D.
        • Pedrosa A.A.A.
        • Costa R.
        • et al.
        Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter-defibrillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial.
        Circ Arrhythmia Electrophysiol. 2009; 2: 29-34
        • Essebag V.
        • Verma A.
        • Healey J.S.
        • Krahn A.D.
        • Kalfon E.
        • Coutu B.
        • et al.
        Clinically significant pocket hematoma increases long-term risk of device infection: BRUISE CONTROL INFECTION study.
        J Am Coll Cardiol. 2016; 67: 1300-1308
        • Al-Khatib S.M.
        • Lucas F.L.
        • Jollis J.G.
        • Malenka D.J.
        • Wennberg D.E.
        The relation between patients’ outcomes and the volume of cardioverter-defibrillator implantation procedures performed by physicians treating medicare beneficiaries.
        J Am Coll Cardiol [Internet]. 2005; 46: 1536-1540https://doi.org/10.1016/j.jacc.2005.04.063
        • Sohail M.R.
        • Uslan D.Z.
        • Khan A.H.
        • Friedman P.A.
        • Hayes D.L.
        • Wilson W.R.
        • et al.
        Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections.
        J Am Coll Cardiol. 2007; 49: 1851-1859
        • Ahmed F.Z.
        • Blomström-Lundqvist C.
        • Bloom H.
        • Cooper C.
        • Ellis C.
        • Goette A.
        • et al.
        Use of healthcare claims to validate the Prevention of Arrhythmia Device Infection Trial cardiac implantable electronic device infection risk score.
        EP Eur. 2021; 23: 1446-1455
        • Lin G.
        • Zou T.
        • Dong M.
        • Liu J.
        • Cui W.
        • Tong J.
        • et al.
        Risk stratifying and prognostic analysis of subclinical cardiac implantable electronic devices infection: insight from traditional bacterial culture.
        J Am Heart Assoc. 2021; 10
        • Blomstrom-Lundqvist C.
        • Ostrowska B.
        Prevention of cardiac implantable electronic device infections: guidelines and conventional prophylaxis.
        EP Eur. 2021; 23 (iv11–9)
        • Sørensen L.T.
        Wound healing and infection in surgery.
        Ann Surg. 2012; 255: 1069-1079
        • Saad T.F.
        • Hentschel D.M.
        • Koplan B.
        • Wasse H.
        • Asif A.
        • Patel D.V.
        • et al.
        Cardiovascular implantable electronic device leads in CKD and ESRD patients: review and recommendations for practice.
        Semin Dial. 2013; 26: 114-123
        • A Griffin K.
        • Pothugunta K.
        • Polichnowski A.J.
        • Bidani A.K.
        The role of systemic blood pressure in the progression of chronic kidney disease.
        Curr Cardiovasc Risk Rep. 2015; 9
        • Krajewski M.L.
        • Raghunathan K.
        • Paluszkiewicz S.M.
        • Schermer C.R.
        • Shaw A.D.
        Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation.
        Br J Surg. 2015; 102: 24-36
        • de Vries F.E.E.
        • Gans S.L.
        • Solomkin J.S.
        • Allegranzi B.
        • Egger M.
        • Dellinger E.P.
        • et al.
        Meta-analysis of lower perioperative blood glucose target levels for reduction of surgical-site infection.
        Br J Surg. 2017; 104: e95-e105
        • Kutinsky I.B.
        • Jarandilla R.
        • Jewett M.
        • Haines D.E.
        Risk of hematoma complications after device implant in the clopidogrel era.
        Circ Arrhythmia Electrophysiol. 2010; 3: 312-318
        • Birnie D.H.
        • Healey J.S.
        • Wells G.A.
        • Ayala-Paredes F.
        • Coutu B.
        • Sumner G.L.
        • et al.
        Continued vs. interrupted direct oral anticoagulants at the time of device surgery, in patients with moderate to high risk of arterial thrombo-embolic events (BRUISE CONTROL-2).
        Eur Heart J. 2018; 39: 3973-3979
        • Bongiorni M.G.
        • Della Tommasina V.
        • Barletta V.
        • Di Cori A.
        • Rogani S.
        • Viani S.
        • et al.
        Feasibility and long-term effectiveness of a non-apical Micra pacemaker implantation in a referral centre for lead extraction.
        Europace. 2019; 21: 114-120
        • El-Chami M.F.
        • Clementy N.
        • Garweg C.
        • Omar R.
        • Duray G.Z.
        • Gornick C.C.
        • et al.
        Leadless pacemaker implantation in hemodialysis patients: experience with the Micra transcatheter pacemaker.
        JACC Clin Electrophysiol [Internet]. 2019; 5: 162-170https://doi.org/10.1016/j.jacep.2018.12.008
        • El-Chami M.F.
        • Johansen J.B.
        • Zaidi A.
        • Faerestrand S.
        • Reynolds D.
        • Garcia-Seara J.
        • et al.
        Leadless pacemaker implant in patients with pre-existing infections: results from the Micra postapproval registry.
        J Cardiovasc Electrophysiol [Internet]. 2019; 30: 569-574https://doi.org/10.1111/jce.13851
        • Kumar D.S.
        • Tompkins C.M.
        • Veenhuyzen G.D.
        • Henrikson C.A.
        Significance of leukocytosis prior to cardiac device implantation.
        Pacing Clin Electrophysiol. 2018; 41: 1197-1200
        • Madadi S.
        • Kafi M.
        • Kheirkhah J.
        • Azhari A.
        • Kiarsi M.
        • Mehryar A.
        • et al.
        Postoperative antibiotic prophylaxis in the prevention of cardiac implantable electronic device infection.
        Pacing Clin Electrophysiol. 2019; 42: 161-165
        • Mittal S.
        • Wilkoff B.L.
        • Kennergren C.
        • Poole J.E.
        • Corey R.
        • Bracke F.A.
        • et al.
        The World-wide Randomized Antibiotic Envelope Infection Prevention (WRAP-IT) trial: long-term follow-up.
        Heart Rhythm [Internet]. 2020; 17: 1115-1122https://doi.org/10.1016/j.hrthm.2020.02.011
        • Wilkoff B.L.
        • Boriani G.
        • Mittal S.
        • Poole J.E.
        • Kennergren C.
        • Corey G.R.
        • et al.
        Cost-effectiveness of an antibacterial envelope for cardiac implantable electronic device infection prevention in the US healthcare system from the WRAP-IT Trial.
        Circ Arrhythmia Electrophysiol, 2020: 1073-1082
        • Sohail M.R.
        • Esquer Garrigos Z.
        • Elayi C.S.
        • Xiang K.
        • Catanzaro J.N.
        Preclinical evaluation of efficacy and pharmacokinetics of gentamicin containing extracellular-matrix envelope.
        Pacing Clin Electrophysiol. 2020; 43: 341-349
        • Deering T.F.
        • Chang C.
        • Snyder C.
        • Natarajan S.K.
        • Matheny R.
        Enhanced antimicrobial effects of decellularized extracellular matrix (CorMatrix) with added vancomycin and gentamicin for device implant protection.
        Pacing Clin Electrophysiol. 2017; 40: 615-623
        • Beton O.
        • Saricam E.
        • Kaya H.
        • Yucel H.
        • Dogdu O.
        • Turgut O.O.
        • et al.
        Bleeding complications during cardiac electronic device implantation in patients receiving antithrombotic therapy: is there any value of local tranexamic acid?.
        BMC Cardiovasc Disord [Internet]. 2016; 16: 1-10https://doi.org/10.1186/s12872-016-0251-1
        • Reynbakh O.
        • Akhrass P.
        • Souvaliotis N.
        • Pamidimukala C.K.
        • Nahar H.
        • Bastawrose J.
        • et al.
        Use of MPH hemostatic powder for electrophysiology device implantation reduces postoperative rates of pocket hematoma and infection.
        Curr Med Res Opin [Internet]. 2018; 34: 1861-1867https://doi.org/10.1080/03007995.2018.1476847
        • Ohlow M.A.
        • Lauer B.
        • Buchter B.
        • Schreiber M.
        • Geller J.C.
        Pocket related complications in 163 patients receiving anticoagulation or dual antiplatelet therapy: D-Stat HemostatTM versus standard of care.
        Int J Cardiol [Internet]. 2012; 159: 177-180https://doi.org/10.1016/j.ijcard.2011.02.042
        • Asif A.
        • Carrillo R.
        • Garisto J.D.
        • Lopera G.
        • Ladino M.
        • Barakat U.
        • et al.
        Epicardial cardiac rhythm devices for dialysis patients: minimizing the risk of infection and preserving central veins.
        Semin Dial. 2012; 25: 88-94
        • Boersma L.
        • Barr C.
        • Knops R.
        • Theuns D.
        • Eckardt L.
        • Neuzil P.
        • et al.
        Implant and Midterm Outcomes of the Subcutaneous Implantable Cardioverter-Defibrillator Registry: The EFFORTLESS Study.
        J Am Coll Cardiol. 2017; 70: 830-841
        • Brouwer T.F.
        • Yilmaz D.
        • Lindeboom R.
        • Buiten M.S.
        • Olde Nordkamp L.R.A.
        • Schalij M.J.
        • et al.
        Long-term clinical outcomes of subcutaneous versus transvenous implantable defibrillator therapy.
        J Am Coll Cardiol. 2016; 68: 2047-2055
        • Knops R.E.
        • Olde Nordkamp L.R.A.
        • Delnoy P.-P.H.M.
        • Boersma L.V.A.
        • Kuschyk J.
        • El-Chami M.F.
        • et al.
        Subcutaneous or transvenous defibrillator therapy.
        N Engl J Med. 2020; 383: 526-536
        • Tjong F.V.Y.
        • Koop B.E.
        The modular cardiac rhythm management system: the EMPOWER leadless pacemaker and the EMBLEM subcutaneous ICD.
        Herzschrittmachertherapie und Elektrophysiologie. 2018; 29: 355-361