European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Abstract

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

Keywords: Cardiac implantable electronic devices; Cardiac resynchronization therapy; EHRA consensus document; Endocarditis; Extraction; Implantable cardioverter-defibrillators; Infection; Leads; Microbiology; Pacemakers; Re-implantation.

Figure 1

A flowchart indicating how device-related infections can be minimized by targeting modifiable risk factors on various levels. Risk factors ranked in order of strength from top to bottom. CIED, cardiac implantable electronic device; COPD, chronic obstructive pulmonary disease; CRT, cardiac resynchronization therapy; ICD, implantable cardiac defibrillator; NYHA, New York Heart Association; OAC, oral anticoagulation; w, week.

Figure 2

Diagnostic algorithm for diagnosis of suspected CIED infections. *, ensure sufficient number of blood cultures collected and absence of confounding antibiotic therapy prior to cultures. CIED, cardiac implantable electronic device; [¹⁸F]FDG PET/CT, fluorodeoxyglucose positron emission tomography—computed tomography; ICE, Intracardiac echocardiography; IE, infective endocarditis, TEE, transoesophageal echocardiography; TTE, transthoracic echocardiography; WBC SPECT/CT, white blood cell single-photon emission computed tomography—computed tomography.

Figure 3

Therapeutic strategies for patients with CIED infections. CIED, cardiac implantable electronic device; FU, follow-up; IE, infective endocarditis.