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.