Cardiac device-related infections/endocarditis (CDRIE)

[Europ Heart J 2020;41:2012-32, Heart Rhythm 2017;14:e503-51]

- CDRIE must be suspected if unexplained fever in a patient with a cardiac device, e.g. pacemaker or implantable cardioverter defibrillator.

Diagnosis

• Cultures of blood, wound, drive line, device pocket, +/- pump prior to antibiotic therapy

• Imaging:

  • echocardiogram

  • PET/CT or WBC SPECT/CT

  • cardiac CT

• Clinical factors/signs/symptoms:

  • predisposing heart condition or injection drug use

  • temperature > 38°C

  • vascular phenomena – major arterial or septic pulmonary emboli, mycotic aneurysm, intracranial or conjunctival hemorrhage, Janeway’s lesions

Management

- Infectious Diseases consult recommended.

- Complete device and lead removal is usually indicated, unless early superficial site infection.

- If bacteremia in a patient with a cardiac device but no evidence of CDRIE, the following is recommended:

• S. aureus, coagulase negative Staph, Cutibacterium, or yeast - cardiac device removal with treatment of bacteremia or fungemia as per organism.
• Viridans group streptococci, β-hemolytic streptococci, or enterococci - cardiac device removal with treatment of bacteremia as per organism, or observation with treatment if patient stable and all repeat blood cultures negative. If persistent or recurrent bacteremia, remove cardiac device.
• Gram negative (excluding Pseudomonas and Serratia), or S. pneumoniae – Observation with treatment if patient stable and all repeat blood cultures negative.  If persistent or recurrent bacteremia, remove cardiac device.

- When indicated, and where possible, device re-implantation should be postponed until 72 hours from first negative blood culture, or 14 days from device removal if valvular infection.

- For culture-directed therapy of endocarditis, see Culture-Directed Infections, Endocarditis.

- Long term suppressive therapy should be considered if complete device removal not possible.

- Tailor antibiotic therapy to C&S results. β-lactams superior to vancomycin so preferred if susceptible.

Coagulase negative Staphylococcus
S. aureus/MRSA

Others:

Enterococcus spp
Enterobacterales
P. aeruginosa
Yeast

Pocket infection with negative blood cultures and no systemic symptoms

Pocket infection with negative blood cultures and with systemic symptoms

Lead infection/endocarditis