Introduction:
As the clinical indications for cardiac implantable electronic devices
(CIED) have expanded, especially in patient populations with significant
co-morbid conditions, the prevalence of CIED infections has increased.
CIED related infections present in many forms, that may or may not lead
to sepsis, ranging from isolated pocket infection to CIED endocarditis
with lead involvement. The morbidity and mortality associated with CIED
infection is considerable. While the extraction procedure itself has
significant morbidity and considerable mortality, even when performed
with success [1], the morbidity and mortality of delayed CIED system
extraction may be significantly higher [2]. Therefore, the Heart
Rhythm Society expert consensus recommends complete CIED system removal,
including any previously retained hardware, in patients with a device
pocket infection, bloodstream infection, and/or valvular endocarditis
with or without lead involvement.
There are no randomized control trials defining the minimum duration for
antibiotic therapy; however, the following durations are recommended: 10
days for pocket erosion; 2 weeks for closed pocket infection; 2 weeks
for bloodstream infection, with the antibiotic course extended to 4
weeks for Staphylococcus aureus ; 2-4 weeks for lead vegetation,
depending on pathogen; 4 weeks for native valvular endocarditis; and 6
weeks for prosthetic valve or staphylococcal valvular
endocarditis[1].
There are also no prospective trial data on the timing of new device
replacement and risk for recurrent infection. Patients should be
evaluated on an individual basis for their ongoing CIED indication and
device reimplantation should be tailored to a given patient’s situation.
Attention should be paid to evidence of ongoing infection and especially
bacteremia. Currently accepted waiting periods for new device
reimplantation range from 72 hours in pocket and bloodstream infections
to two weeks in cases of valvular endocarditis. For pacemaker-dependent
patients, temporary pacing is required as a bridge to reimplanting a
permanent device. A commonly adopted alternative is temporary pacing
using a permanent pacing lead connected to an external re-used pulse
generator, sometimes called a “temporary-permanent pacemaker”. While
this provides the freedom of patient mobility, not all patients are good
candidates for discharge with this device. Likewise, the majority of
long-term care facilities and rehabilitation hospitals will not accept
such a patient.