Experts Suggest Ways to Prevent, Treat Heart-Device Infections

By Will Boggs MD

March 20, 2020

NEW YORK (Reuters Health) - A new international consensus document from the European Heart Rhythm Association (EHRA) suggests steps to minimize the risk of cardiac implantable electronic device (CIED) infection and manage existing disease.

"Many risk factors can be identified and prevented," Dr. Carina Blomstroem-Lundqvist of Uppsala University, in Sweden, who chaired the collaboration, told Reuters Health by email. "Record and assess your own CIED infection rates in a quality registry regularly. Implement recommendations in your center. Follow preventive measures according to recommendations."

The consensus statement, along with useful flowcharts, appears in the European Heart Journal.

Dr. Blomstroem-Lundqvist and colleagues from 11 countries on four continents developed their recommendations after a detailed literature review and consideration of systematic reviews of published evidence related to CIED topics.

Device-related infections can be minimized by targeting modifiable risk factors related to the patient (fever, oral anticoagulants, etc.), the procedure (prolonged procedure, inexperienced implanter, etc.), and the device lead, but practitioners also need to be aware of nonmodifiable risk factors.

"An antibacterial envelope reduces CIED infections in patients with risk factors for device-related infections and is recommended in high-risk patients," Dr. Blomstroem-Lundqvist said.

The diagnosis of suspected CIED infection relies on blood culture and culture of the device pocket. In most cases, transthoracic and transesophageal echocardiography will also be indicated. Patients with definite or possible CIED infection should be referred to a center with expertise in CIED infections.

Management of CIED infection depends on specific features. An isolated pocket infection with negative blood cultures can be managed with removal/extraction plus 10-14 days' antibiotic therapy.

Systemic infection without vegetation on leads or valves requires removal/extraction of the device and four weeks' antibiotic therapy (two weeks if blood cultures are negative), whereas systemic infection with CIED endocarditis requires removal/extraction of the device, four to six weeks' antibiotic therapy, and oral antibiotic therapy follow-up if there is a secondary infection focus.

"The timing of an extraction procedure should be without time delay after diagnosis of CIED infection, since if performed within 3 days after hospitalization it results in significantly lower in-hospital mortality and shortens hospitalizations," Dr. Blomstroem-Lundqvist said.

The consensus statement recommends that operators with less than approximately 100 CIED procedures should work under close supervision of more experienced operators and recommends an annual minimum operator volume of approximately 50 CIED procedures for all operators.

"It may be difficult for some centers to accept that low implantation volumes are associated with higher risk of complications and thereby infections," Dr. Blomstroem-Lundqvist said.

She added, "Prudent large national/international non-voluntary, user-friendly, quality registries of device implantations and its complications with regular monitoring is important. It is also important to state national requirements of minimal annual operator/center device volumes which affect complication and infection rates substantially."

The statement is endorsed by the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, the Latin American Heart Rhythm Society, International Society for Cardiovascular Infectious Diseases and the European Society of Clinical Microbiology and Infectious Diseases in collaboration with the European Association for Cardio-Thoracic Surgery.

SOURCE: European Heart Journal, online February 26, 2020.