Implantable Cardiac Electronic Device Infection Guidelines
Implantable Cardiac Electronic Device Infection Guidelines
The guidelines categorise ICED infections as early postimplantation inflammation, uncomplicated and complicated generator pocket infections, ICED-infective endocarditis (ICED-IE) and ICED-lead infections (ICED-LIs) (Table 1). Pocket infections are characterised by localised cellulitis, swelling, discharge, dehiscence or pain. Wound inflammation occurring soon after implantation ('superficial cellulitis') can be an early sign of pocket infection, but can also be caused by non-infective conditions. The device should be considered infected once the skin is breached due to erosion. Pocket infections frequently coexist with ICED-IE/ICED-LI and often present insidiously with fevers, rigors, night sweats, malaise and anorexia—the presence of an ICED is all too often disregarded. Patients with ICED-IE/ICED-LI may also present with secondary spinal or pulmonary infection—fewer than 10% present with septic shock. While the modified Duke criteria for IE are unproven in this setting, the guidelines recommend their use as an objective tool.
Echocardiography should be performed as soon as possible (<24 h) once a diagnosis of ICED infection has been considered and in all patients with generator pocket infections and signs/symptoms of systemic infection or positive blood cultures. Echocardiography should also be repeated after ICED removal to identify persisting vegetations.
Transthoracic and transoesophageal echocardiography (TOE) are complementary techniques, although TOE has higher diagnostic sensitivity in ICED-IE/ICED-LI. An oscillating or sessile mass attached to a lead suggests vegetation although masses can be seen on non-infected leads and false negatives are common.
Culture samples should include blood, distal and proximal lead fragments, lead vegetations, generator pocket tissue and pus from the pocket wound, as appropriate. Meticulous technique is needed to prevent contamination—coagulase-negative staphylococci are a common contaminant as well as a frequent cause of ICED infection. Lead fragments can be easily contaminated if there is pocket infection.
Three sets of blood cultures should be taken from peripheral sites at least 6 h apart prior to starting antibiotics unless there is severe sepsis and suspected ICED infection when two sets at different times within an hour will suffice. Blood cultures should be repeated 48–72 h after ICED removal.
In a patient with an ICED, a single positive blood culture for Staphylococcus aureus or multiple positive cultures for another organism necessitate active exclusion of ICED infection.
Diagnosis
The guidelines categorise ICED infections as early postimplantation inflammation, uncomplicated and complicated generator pocket infections, ICED-infective endocarditis (ICED-IE) and ICED-lead infections (ICED-LIs) (Table 1). Pocket infections are characterised by localised cellulitis, swelling, discharge, dehiscence or pain. Wound inflammation occurring soon after implantation ('superficial cellulitis') can be an early sign of pocket infection, but can also be caused by non-infective conditions. The device should be considered infected once the skin is breached due to erosion. Pocket infections frequently coexist with ICED-IE/ICED-LI and often present insidiously with fevers, rigors, night sweats, malaise and anorexia—the presence of an ICED is all too often disregarded. Patients with ICED-IE/ICED-LI may also present with secondary spinal or pulmonary infection—fewer than 10% present with septic shock. While the modified Duke criteria for IE are unproven in this setting, the guidelines recommend their use as an objective tool.
Echocardiography
Echocardiography should be performed as soon as possible (<24 h) once a diagnosis of ICED infection has been considered and in all patients with generator pocket infections and signs/symptoms of systemic infection or positive blood cultures. Echocardiography should also be repeated after ICED removal to identify persisting vegetations.
Transthoracic and transoesophageal echocardiography (TOE) are complementary techniques, although TOE has higher diagnostic sensitivity in ICED-IE/ICED-LI. An oscillating or sessile mass attached to a lead suggests vegetation although masses can be seen on non-infected leads and false negatives are common.
Microbiological Sampling
Culture samples should include blood, distal and proximal lead fragments, lead vegetations, generator pocket tissue and pus from the pocket wound, as appropriate. Meticulous technique is needed to prevent contamination—coagulase-negative staphylococci are a common contaminant as well as a frequent cause of ICED infection. Lead fragments can be easily contaminated if there is pocket infection.
Three sets of blood cultures should be taken from peripheral sites at least 6 h apart prior to starting antibiotics unless there is severe sepsis and suspected ICED infection when two sets at different times within an hour will suffice. Blood cultures should be repeated 48–72 h after ICED removal.
In a patient with an ICED, a single positive blood culture for Staphylococcus aureus or multiple positive cultures for another organism necessitate active exclusion of ICED infection.
