Cardiac Implantable electronic devices

Increasingly common management process for chronic heart disease.

Estimate is that one and a half million patients receive cardiac implantable electronics devices worldwide every year.

Exponential growth in device implantation in the United States.

Infection is a recognized complication of such device implantation and there has been a marked increase in infections.

Infection necessitates complete device removal and pathogen directed antimicrobial drug therapy.

Cardiac implantable electronic device infections can occur at the device pocket site, the leafs, and/or the endocardial surfaces.

Infections of CIEDs can result in increased mortality ranging between 12 and 22%.

Increased risk of infections associated with age, coexisting diabetes, device revision, heart failure, corticosteroid use and use of anticoagulant at the time of implantation with high rates of pocket hematomas.

Managing infections are costly with an estimated cumulative infection management cost as high as $279,000 for initial implants at 362,000 for replacements.

Device infections are associated with significant in-hospital and long-term mortality.

Fever within 24 hours preceding the device implantation, utilization of a temporary transient space maker, need to remove pocket hematoma, wound dehiscence, and failure to use at a biotic prophylaxis all increase risk of infection.

Increase in device lead number and longer implant times may also be associated with increased risk of infections, and physician procedure volume experience is inversely correlated with risk of infection.

Device variations may be associated with increased bacterial seeding.

CIED infection has worse outcomes for staphylococcal infections.

Most CIED infections are caused by Gram positive organisms, particularly staphylococcal bacteria.

Diagnosis relies on blood culture and echocardiography.

Transesophageal echocardiography has a higher sensitive for detecting lead and valvular vegetations compared with transthoracic echocardiography.

PET/CT can help in diagnosing cardiac implantable electronic device infections.

Gram negative bacteria represent about 10% of device infections.

Gram negative bacteria CIED infections are usually present with a localized pocket infection.

Untreated gram-negative CIED pocket infections may progress to blood systemic infection by hematogenous spread, but is rare.

After explantation, oral Antibiotic drug management is a reasonable choice for pocket infections due to Gram negative bacteria.

Adjunctive use of an antibacterial envelope results in a 40% lower incidence of major CIED infection and standard of care infection-prevention strategies alone (WRAP-IT investigators).

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