Internal and Emergency Medicine

, Volume 8, Issue 6, pp 465–476 | Cite as

Current trends in the management of cardiac implantable electronic device (CIED) infections

  • Emanuele Durante-Mangoni
  • Irene Mattucci
  • Federica Agrusta
  • Marie-Françoise Tripodi
  • Riccardo UtiliEmail author


Cardiac implantable electronic device (CIED) infections are an emerging clinical problem. A growing number of dedicated and high quality clinical studies are currently being generated. We here review the most recent advances in the diagnosis and treatment of patients with CIED infection including intracardiac lead endocarditis. We discuss the current etiology and risk factors, and appraise the major diagnostic issues, describing our center’s therapeutic approach. We also address the management of CIED infection complications.


Infective endocarditis Pacemaker Defibrillator Staphylococcus Echocardiography Antimicrobial therapy 


Conflict of interest

R. Utili is an Advisory Board member for and has received speaker honoraria from Novartis. E. Durante-Mangoni received speaker’s honoraria from Novartis. No other author has any potential conflicts of interest to disclose.


  1. 1.
    Sohail MR, Henrikson CA, Braid-Forbes MJ, Forbes KF, Lerner DJ (2011) Mortality and cost associated with cardiovascular implantable electronic device infections. Arch Intern Med 171:1821–1828PubMedCrossRefGoogle Scholar
  2. 2.
    Voigt A, Shalaby A, Saba S (2010) Continued rise in rates of cardiovascular implantable electronic device infections in the United States: temporal trends and causative insights. Pacing Clin Electrophysiol 33:414–419PubMedCrossRefGoogle Scholar
  3. 3.
    Duval X, Selton-Suty C, Alla F, Salvador-Mazenq M, Bernard Y, Weber M, Lacassin F, Nazeyrolas P, Chidiac C, Hoen B, Leport C; Association pour l’Etude et la Prevention de l’Endocardite Infectieuse (2004) Endocarditis in patients with a permanent pacemaker: a 1-year epidemiological survey on infective endocarditis due to valvular and/or pacemaker infection. Clin Infect Dis 39:68–74Google Scholar
  4. 4.
    Uslan DZ, Sohail MR, St. Sauver JL, Friedman PA, Hayes DL, Stoner SM, Wilson WR, Steckelberg JM, Baddour LM (2007) Permanent pacemaker and implantable cardioverter defibrillator infection: a population-based study. Arch Intern Med 167:669–675Google Scholar
  5. 5.
    Mattucci I, Casillo R, Caianiello C, Pinto D, Agrusta F, Malgeri U, Andini R, Senese A, Albisinni R, Ragone E, Utili R, Durante-Mangoni E (2011) Current clinical features of infective endocarditis on cardiac implantable electronic devices: a prospective cohort study. Intern Emerg Med 6(Suppl 2):S151–S152Google Scholar
  6. 6.
    Greenspon AJ, Prutkin JM, Sohail MR, Vikram HR, Baddour LM, Danik SB, Peacock J, Falces C, Miro JM, Blank E, Naber C, Carrillo RG, Tseng CH, Uslan DZ (2012) Timing of the most recent device procedure influences the clinical outcome of lead-associated endocarditis results of the MEDIC (Multicenter Electrophysiologic Device Infection Cohort). J Am Coll Cardiol 59:681–687PubMedCrossRefGoogle Scholar
  7. 7.
    Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB, Masoudi FA, Okum EJ, Wilson WR, Beerman LB, Bolger AF, Estes NA 3rd, Gewitz M, Newburger JW, Schron EB, Taubert KA, American Heart Association (2010) Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 121:458–477PubMedCrossRefGoogle Scholar
  8. 8.
    Klug D, Balde M, Pavin D, Hidden-Lucet F, Clementy J, Sadoul N, Rey JL, Lande G, Lazarus A, Victor J, Barnay C, Grandbastien B, Kacet S, PEOPLE Study Group (2007) Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study. Circulation 116:1349–1355PubMedCrossRefGoogle Scholar
  9. 9.
    Poole JE, Gleva MJ, Mela T, Chung MK, Uslan DZ, Borge R, Gottipaty V, Shinn T, Dan D, Feldman LA, Seide H, Winston SA, Gallagher JJ, Langberg JJ, Mitchell K, Holcomb R, REPLACE Registry Investigators (2010) Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry. Circulation 122:1553–1561PubMedCrossRefGoogle Scholar
  10. 10.
    Nery PB, Fernandes R, Nair GM, Sumner GL, Ribas CS, Menon SM, Wang X, Krahn AD, Morillo CA, Connolly SJ, Healey JS (2010) Device-related infection among patients with pacemakers and implantable defibrillators: incidence, risk factors, and consequences. J Cardiovasc Electrophysiol 21:786–790PubMedGoogle Scholar
  11. 11.
    de Oliveira JC, Martinelli M, D’Orio Nishioka SA, Varejão T, Uipe D, Andrade Pedrosa AA, Costa R, Danik SB (2009) Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter defibrillators: results of a large, prospective, randomized, double blinded, placebo-controlled trial. Circ Arrhythm Electrophysiol 2:29–34PubMedCrossRefGoogle Scholar
  12. 12.
    Uslan DZ, Gleva MJ, Warren DK, Mela T, Chung MK, Gottipaty V, Borge R, Dan D, Shinn T, Mitchell K, Holcomb RG, Poole JE (2012) Cardiovascular implantable electronic device replacement infections and prevention: results from the REPLACE Registry. Pacing Clin Electrophysiol 35:81–87PubMedCrossRefGoogle Scholar
  13. 13.
    Ghanbari H, Feldman D, Schmidt M, Ottino J, Machado C, Akoum N, Wall TS, Daccarett M (2010) Cardiac resynchronization therapy device implantation in patients with therapeutic international normalized ratios. Pacing Clin Electrophysiol 33:400–406PubMedCrossRefGoogle Scholar
  14. 14.
    Sohail MR, Uslan DZ, Khan AH, Friedman PA, Hayes DL, Wilson WR, Steckelberg JM, Stoner S, Baddour LM (2007) Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol 49:1851–1859PubMedCrossRefGoogle Scholar
  15. 15.
    Bongiorni MG, Tascini C, Tagliaferri E, Di Cori A, Soldati E, Leonildi A, Zucchelli G, Ciullo I, Menichetti F (2012) Microbiology of cardiac implantable electronic device infections. Europace. doi: 10.1093/europace/eus044
  16. 16.
    von Eiff C, Peters G, Heilmann C (2002) Pathogenesis of infections due to coagulase-negative staphylococci. Lancet Infect Dis 2:677–685CrossRefGoogle Scholar
  17. 17.
    Otto M (2012) Molecular basis of Staphylococcus epidermidis infections. Semin Immunopathol 34:201–214PubMedCrossRefGoogle Scholar
  18. 18.
    Pan A, Fracassi F, Ravasio V, Carnevale G, Carosi G, Chinello P, Durante Mangoni E, Magri S, Lorenzotti S, Petrosillo N, Pirelli S, Rizzi M, Soavi L, Stellini R, Utili R, Suter F, per il gruppo SEI (2008) Endocardite su filo di pace maker (PM) o defibrillatore impiantabile (ICD): analisi della casistica dello studio endocarditi italiano-SEI. 7° Congresso Nazionale SIMIT, Bergamo, 19-22/11/2008 – Atti, p.74, abs #CO IV-4Google Scholar
  19. 19.
    Sohail MR, Gray AL, Baddour LM, Tleyjeh IM, Virk A (2009) Infective endocarditis due to Propionibacterium species. Clin Microbiol Infect 15:387–394PubMedCrossRefGoogle Scholar
  20. 20.
    Towns ML, Jarvis WR, Hsueh PR (2010) Guidelines on blood cultures. J Microbiol Immunol Infect 43:347–349PubMedCrossRefGoogle Scholar
  21. 21.
    Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP, Raad II, Rijnders BJ, Sherertz RJ, Warren DK (2009) Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 49:1–45PubMedCrossRefGoogle Scholar
  22. 22.
    Dy Chua J, Abdul-Karim A, Mawhorter S, Procop GW, Tchou P, Niebauer M, Saliba W, Schweikert R, Wilkoff BL (2005) The role of swab and tissue culture in the diagnosis of implantable cardiac device infection. Pacing Clin Electrophysiol 28:1276–1281PubMedCrossRefGoogle Scholar
  23. 23.
    Golzio PG, Vinci M, Anselmino M, Comoglio C, Rinaldi M, Trevi GP, Bongiorni MG (2009) Accuracy of swabs, tissue specimens, and lead samples in diagnosis of cardiac rhythm management device infections. Pacing Clin Electrophysiol 32(Suppl 1):S76–S80PubMedCrossRefGoogle Scholar
  24. 24.
    Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH 3rd, Epstein LM, Friedman RA, Kennergren CE, Mitkowski P, Schaerf RH, Wazni OM; Heart Rhythm Society; American Heart Association (2009) Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management. Heart Rhythm 6:1085–1104Google Scholar
  25. 25.
    Habib G, Badano L, Tribouilloy C, Vilacosta I, Zamorano JL, Galderisi M, Voigt JU, Sicari R, Cosyns B, Fox K, Aakhus S, European Association of Echocardiography (2010) Recommendations for the practice of echocardiography in infective endocarditis. Eur J Echocardiogr 11:202–219PubMedCrossRefGoogle Scholar
  26. 26.
    Jacob S, Tong AT (2002) Role of echocardiography in the diagnosis and management of infective endocarditis. Curr Opin Cardiol 17:478–485PubMedCrossRefGoogle Scholar
  27. 27.
    Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, Moreillon P, de Antunes Jesus M, Thilen U, Lekakis J, Lengyel M, Müller L, Naber CK, Nihoyannopoulos P, Moritz A, Zamorano JL, ESC Committee for Practice Guidelines (2009) Guidelines on the prevention, diagnosis, and treatment of infective endocarditis. Eur Heart J 30:2369–2413PubMedCrossRefGoogle Scholar
  28. 28.
    Kojodjojo P, John RM, Epstein LM (2011) Disseminated malignancies masquerading as cardiovascular implantable electronic devices infections. Europace 13:821–824PubMedCrossRefGoogle Scholar
  29. 29.
    Van Riet J, Hill EE, Gheysens O, Dymarkowski S, Herregods MC, Herijgers P, Peetermans WE, Mortelmans L (2010) (18)F-FDG PET/CT for early detection of embolism and metastatic infection in patients with infective endocarditis. Eur J Nucl Med Mol Imag 37:1189–1197CrossRefGoogle Scholar
  30. 30.
    Bongiorni MG, Di Cori A, Soldati E, Zucchelli G, Arena G, Segreti L, De Lucia R, Marzilli M (2008) Intracardiac echocardiography in patients with pacing and defibrillating leads: a feasibility study. Echocardiography 25:632–638PubMedCrossRefGoogle Scholar
  31. 31.
    Falcone M, Barzaghi N, Carosi G, Grossi P, Minoli L, Ravasio V, Rizzi M, Suter F, Utili R, Viscoli C, Venditti M, Italian Study on Endocarditis (2009) Candida infective endocarditis: report of 15 cases from a prospective multicenter study. Medicine (Baltimore) 88:160–168CrossRefGoogle Scholar
  32. 32.
    Pea F, Viale P (2009) Bench-to-bedside review: appropriate antibiotic therapy in severe sepsis and septic shock—does the dose matter? Crit Care 13:214PubMedCrossRefGoogle Scholar
  33. 33.
    Rybak MJ, Lomaestro BM, Rotschafer JC, Moellering RC, Craig WA, Billeter M, Dalovisio JR, Levine DP (2009) Vancomycin therapeutic guidelines: a summary of consensus recommendations from the infectious diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis 49:325–327PubMedCrossRefGoogle Scholar
  34. 34.
    Hidayat LK, Hsu DI, Quist R, Shriner KA, Wong-Beringer A (2006) High-dose vancomycin therapy for methicillin-resistant Staphylococcus aureus infections: efficacy and toxicity. Arch Intern Med 166:2138–2144PubMedCrossRefGoogle Scholar
  35. 35.
    Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, Rybak M, Talan DA, Chambers HF (2011) Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis 52:285–292PubMedCrossRefGoogle Scholar
  36. 36.
    Svetitsky S, Leibovici L, Paul M (2009) Comparative efficacy and safety of vancomycin versus teicoplanin: systematic review and meta-analysis. Antimicrob Agents Chemother 53:4069–4079PubMedCrossRefGoogle Scholar
  37. 37.
    Harding I, MacGowan AP, White LO, Darley ES, Reed V (2000) Teicoplanin therapy for Staphylococcus aureus septicaemia: relationship between pre-dose serum concentrations and outcome. J Antimicrob Chemother 45:835–841PubMedCrossRefGoogle Scholar
  38. 38.
    Fowler VG, Boucher HW, Corey GR et al (2006) Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus. N Engl J Med 355:653–665PubMedCrossRefGoogle Scholar
  39. 39.
    Raad I, Hanna H, Jiang Y et al (2007) Comparative activities of daptomycin, linezolid, and tigecycline against catheter-related methicillin-resistant Staphylococcus bacteremic isolates embedded in biofilm. Antimicrob Agents Chemother 51:1656–1660PubMedCrossRefGoogle Scholar
  40. 40.
    Stewart PS, Davison WM, Steenbergen JN (2009) Daptomycin rapidly penetrates a Staphylococcus epidermidis biofilm. Antimicrob Agents Chemother 53:3505–3507PubMedCrossRefGoogle Scholar
  41. 41.
    Tascini C, Bongiorni MG, Doria R, Polidori M, Iapoce R, Fondelli S, Tagliaferri E, Soldati E, Di Paolo A, Leonildi A, Menichetti F (2011) Linezolid for endocarditis: a case series of 14 patients. J Antimicrob Chemother 66:679–682PubMedCrossRefGoogle Scholar
  42. 42.
    Durante-Mangoni E, Casillo R, Bernardo M, Caianiello C, Mattucci I, Pinto D, Agrusta F, Caprioli R, Albisinni R, Ragone E, Utili R (2012) High-dose daptomycin for cardiac implantable electronic device-related infective endocarditis. Clin Infect Dis 54:347–354PubMedCrossRefGoogle Scholar
  43. 43.
    Soriano A, Marco F, Martínez JA, Pisos E, Almela M, Dimova VP, Alamo D, Ortega M, Lopez J, Mensa J (2008) Influence of vancomycin minimum inhibitory concentration on the treatment of methicillin-resistant Staphylococcus aureus bacteremia. Clin Infect Dis 46:193–200PubMedCrossRefGoogle Scholar
  44. 44.
    Gould IM, Cauda R, Esposito S, Gudiol F, Mazzei T, Garau J (2011) Management of serious methicillin-resistant Staphylococcus aureus infections: what are the limits? Int J Antimicrob Agents 37:202–209PubMedCrossRefGoogle Scholar
  45. 45.
    Cosgrove SE, Fowler VG Jr (2008) Management of methicillin-resistant Staphylococcus aureus bacteremia. Clin Infect Dis 46(Suppl 5):S386–S393PubMedCrossRefGoogle Scholar
  46. 46.
    Gould FK, Denning DW, Elliott TS, Foweraker J, Perry JD, Prendergast BD, Sandoe JA, Spry MJ, Watkin RW (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 67:269–289PubMedCrossRefGoogle Scholar
  47. 47.
    Uslan DZ, Dowsley TF, Sohail MR, Hayes DL, Friedman PA, Wilson WR, Steckelberg JM, Baddour LM (2010) Cardiovascular implantable electronic device infection in patients with Staphylococcus aureus bacteremia. Pacing Clin Electrophysiol 33:407–413PubMedCrossRefGoogle Scholar
  48. 48.
    Dumont E, Camus C, Victor F, de Place C, Pavin D, Alonso C, Mabo P, Daubert JC (2003) Suspected pacemaker or defibrillator transvenous lead infection. Prospective assessment of a TEE-guided therapeutic strategy. Eur Heart J 24:1779–1787PubMedCrossRefGoogle Scholar
  49. 49.
    Bongiorni MG, Soldati E, Zucchelli G, Di Cori A, Segreti L, De Lucia R, Solarino G, Balbarini A, Marzilli M, Mariani M (2008) Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads. Eur Heart J 29:2886–2893PubMedCrossRefGoogle Scholar
  50. 50.
    Grammes JA, Schulze CM, Al-Bataineh M, Yesenosky GA, Saari CS, Vrabel MJ, Horrow J, Chowdhury M, Fontaine JM, Kutalek SP (2010) Percutaneous pacemaker and implantable cardioverter-defibrillator lead extraction in 100 patients with intracardiac vegetations defined by transesophageal echocardiogram. J Am Coll Cardiol 55:886–894PubMedCrossRefGoogle Scholar
  51. 51.
    del Río A, Anguera I, Miró JM, Mont L, Fowler VG Jr, Azqueta M, Mestres CA; Hospital Clínic Endocarditis Study Group (2003) Surgical treatment of pacemaker and defibrillator lead endocarditis: the impact of electrode lead extraction on outcome. Chest 124:1451–1459Google Scholar
  52. 52.
    Rundstrom H, Kennergren C, Andersson R, Alestig K, Hogevik H (2004) Pacemaker endocarditis during 18 years in Goteborg. Scand J Infect Dis 36:674–679PubMedCrossRefGoogle Scholar
  53. 53.
    Sohail MR, Sultan OW, Raza SS (2010) Contemporary management of cardiovascular implantable electronic device infections. Expert Rev Anti Infect Ther 8:831–839PubMedCrossRefGoogle Scholar
  54. 54.
    Utili R, Durante-Mangoni E, Tripodi MF (2007) Infection of intravascular prostheses: how to treat other than surgery. Int J Antimicrob Agents 30(Suppl 1):S42–S50PubMedCrossRefGoogle Scholar
  55. 55.
    Nandyala R, Parsonnet V (2006) One stage side-to-side replacement of infected pulse generators and leads. Pacing Clin Electrophysiol 29:393–396PubMedCrossRefGoogle Scholar
  56. 56.
    Anavekar NS, Tleyjeh IM, Anavekar NS, Mirzoyev Z, Steckelberg JM, Haddad C, Khandaker MH, Wilson WR, Chandrasekaran K, Baddour LM (2007) Impact of prior antiplatelet therapy on risk of embolism in infective endocarditis. Clin Infect Dis 44:1180–1186PubMedCrossRefGoogle Scholar
  57. 57.
    Santangelo L, Russo V, Ammendola E, De Crescenzo I, Pagano C, Savarese C, Caruso A, Utili R, Calabrò R (2006) Superior vena cava thrombosis after intravascular AICD lead extraction: a case report. J Vasc Access 7:90–93PubMedGoogle Scholar
  58. 58.
    Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schünemann HJ, for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel (2012) Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 41(Suppl):7S–47SGoogle Scholar

Copyright information

© SIMI 2012

Authors and Affiliations

  • Emanuele Durante-Mangoni
    • 1
    • 2
  • Irene Mattucci
    • 1
    • 2
  • Federica Agrusta
    • 1
    • 2
  • Marie-Françoise Tripodi
    • 1
    • 2
    • 3
  • Riccardo Utili
    • 1
    • 2
    • 4
    Email author
  1. 1.Internal Medicine Section, Department of Cardiothoracic SciencesUniversity of Naples S.U.NNaplesItaly
  2. 2.Unit of Infectious and Transplant MedicineAORN dei Colli-MonaldiNaplesItaly
  3. 3.Medical SchoolUniversity of SalernoSalernoItaly
  4. 4.Cattedra di Medicina Interna, U.O.C. Medicina Infettivologica e dei Trapianti, Ospedale MonaldiII Università di NapoliNaplesItaly

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