Infection of Cardiac Implantable Electrical Devices: An Emerging Epidemiological Issue

  • Giuseppe BorianiEmail author
  • Marco Vitolo


In the last five decades, the use of cardiac implantable electronic devices (CIEDs), which include permanent pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices, has dramatically increased counting, according to recent data, more than 1,000,000 PM and 300,000 ICDs (new implants and replacements). Despite of the use of antibiotic prophylaxis, rates of device-related infection increased in recent years, and CIED infection is a more and more serious problem with high morbidity and mortality.

The real incidence of CIED’s infection is unknown, but recent data showed that the mean incidence of CIED is 0.1–0.7% for PPM infection and 0.7–1.2% for ICD.

Remarkably, the rate of CIED infections increased faster and disproportionate as compared to the rate of CIED implantations due to the growth in a number of complex procedures such as ICD and CRT implantations and the increase in the prevalence of coexistent comorbidities among CIED recipients that may facilitate the risk of infections.

In view of the epidemiological burden of arrhythmic conditions requiring CIEDs, the importance and clinical implications of CIED infections, the complexity of managing CIED infections, as well as the important financial implications of infections, the ideal approach to this complex topic should be that of health technology assessment (HTA), in order to provide a multidimensional and multidisciplinary approach, putting together inputs from clinicians, clinical guideline groups, epidemiologists, biostatisticians, economists, commissioners, and health policy-makers.


Pacemaker Defibrillator Cost Healthcare Infection Economy 


  1. 1.
    Voigt A, Shalaby A, Saba S. Rising rates of cardiac rhythm management device infections in the United States: 1996 through 2003. J Am Coll Cardiol. 2006;48(3):590–1.PubMedGoogle Scholar
  2. 2.
    Mond HG, Proclemer A. The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar year 2009—a World Society of Arrhythmia’s project. Pacing Clin Electrophysiol. 2011;34(8):1013–27.PubMedGoogle Scholar
  3. 3.
    Valzania C, Torbica A, Tarricone R, Leyva F, Boriani G. Implant rates of cardiac implantable electrical devices in Europe: a systematic literature review. Health Policy. 2016;120(1):1–15.PubMedGoogle Scholar
  4. 4.
    Boriani G, Ziacchi M, Nesti M, Battista A, Placentino F, Malavasi VL, Diemberger I, Padeletti L. Cardiac resynchronization therapy: how did consensus guidelines from Europe and the United States evolve in the last 15 years? Int J Cardiol. 2018;261:119–29.PubMedGoogle Scholar
  5. 5.
    Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, Cleland J, Deharo JC, Delgado V, Elliott PM, Gorenek B, Israel CW, Leclercq C, Linde C, Mont L, Padeletti L, Sutton R, Vardas PE, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Blomstrom-Lundqvist C, Badano LP, Aliyev F, Bansch D, Bsata W, Buser P, Charron P, Daubert JC, Dobreanu D, Faerestrand S, Le Heuzey JY, Mavrakis H, McDonagh T, Merino JL, Nawar MM, Nielsen JC, Pieske B, Poposka L, Ruschitzka F, Van Gelder IC, Wilson CM. ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013;34(29):2281–329.PubMedGoogle Scholar
  6. 6.
    Goldberger Z, Lampert R. Implantable cardioverter-defibrillators: expanding indications and technologies. JAMA. 2006;295(7):809–18.PubMedGoogle 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. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121(3):458–77.PubMedGoogle Scholar
  8. 8.
    Cabell CH, Heidenreich PA, Chu VH, Moore CM, Stryjewski ME, Corey GR, Fowler VG Jr. Increasing rates of cardiac device infections among Medicare beneficiaries: 1990-1999. Am Heart J. 2004;147(4):582–6.PubMedGoogle Scholar
  9. 9.
    Zhan C, Baine WB, Sedrakyan A, Steiner C. Cardiac device implantation in the United States from 1997 through 2004: a population-based analysis. J Gen Intern Med. 2008;23(Suppl 1):13–9.PubMedGoogle Scholar
  10. 10.
    Voigt A, Shalaby A, Saba S. Continued rise in rates of cardiovascular implantable electronic device infections in the United States: temporal trends and causative insights. Pacing Clin Electrophysiol. 2010;33(4):414–9.PubMedGoogle Scholar
  11. 11.
    Kurtz SM, Ochoa JA, Lau E, Shkolnikov Y, Pavri BB, Frisch D, Greenspon AJ. Implantation trends and patient profiles for pacemakers and implantable cardioverter defibrillators in the United States: 1993-2006. Pacing Clin Electrophysiol. 2010;33(6):705–11.PubMedGoogle Scholar
  12. 12.
    Greenspon AJ, Patel JD, Lau E, Ochoa JA, Frisch DR, Ho RT, Pavri BB, Kurtz SM. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol. 2011;58(10):1001–6.PubMedGoogle Scholar
  13. 13.
    Durante-Mangoni E, Mattucci I, Agrusta F, Tripodi MF, Utili R. Current trends in the management of cardiac implantable electronic device (CIED) infections. Intern Emerg Med. 2013;8(6):465–76.PubMedGoogle Scholar
  14. 14.
    He W, Goodkind D, Kowal PR. An aging world: 2015. Washington, DC: United States Census Bureau; 2016.Google Scholar
  15. 15.
    Organization WH. Global report on diabetes. 2016.Google Scholar
  16. 16.
    Chen L, Magliano DJ, Zimmet PZ. The worldwide epidemiology of type 2 diabetes mellitus—present and future perspectives. Nat Rev Endocrinol. 2011;8(4):228–36.PubMedGoogle Scholar
  17. 17.
    Rowley WR, Bezold C, Arikan Y, Byrne E, Krohe S. Diabetes 2030: insights from yesterday, today, and future trends. Popul Health Manag. 2017;20(1):6–12.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Boriani G, Savelieva I, Dan GA, Deharo JC, Ferro C, Israel CW, Lane DA, La Manna G, Morton J, Mitjans AM, Vos MA, Turakhia MP, Lip GY. Chronic kidney disease in patients with cardiac rhythm disturbances or implantable electrical devices: clinical significance and implications for decision making-a position paper of the European Heart Rhythm Association endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. Europace. 2015;17(8):1169–96.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Levey AS, Astor BC, Stevens LA, Coresh J. Chronic kidney disease, diabetes, and hypertension: what’s in a name? Kidney Int. 2010;78(1):19–22.PubMedGoogle Scholar
  20. 20.
    Hoerger TJ, Simpson SA, Yarnoff BO, Pavkov ME, Rios Burrows N, Saydah SH, Williams DE, Zhuo X. The future burden of CKD in the United States: a simulation model for the CDC CKD initiative. Am J Kidney Dis. 2015;65(3):403–11.PubMedGoogle Scholar
  21. 21.
    Polyzos KA, Konstantelias AA, Falagas ME. Risk factors for cardiac implantable electronic device infection: a systematic review and meta-analysis. Europace. 2015;17(5):767–77.PubMedGoogle Scholar
  22. 22.
    de Oliveira JC, Martinelli M, Nishioka SA, Varejao T, Uipe D, Pedrosa AA, Costa R, D’Avila A, Danik SB. 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. 2009;2(1):29–34.PubMedGoogle Scholar
  23. 23.
    Sandoe JA, Barlow G, Chambers JB, Gammage M, Guleri A, Howard P, Olson E, Perry JD, Prendergast BD, Spry MJ, Steeds RP, Tayebjee MH, Watkin R. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE). J Antimicrob Chemother. 2015;70(2):325–59.PubMedGoogle Scholar
  24. 24.
    Tarakji KG, Wilkoff BL. Management of cardiac implantable electronic device infections: the challenges of understanding the scope of the problem and its associated mortality. Expert Rev Cardiovasc Ther. 2013;11(5):607–16.PubMedGoogle Scholar
  25. 25.
    Sohail MR, Henrikson CA, Braid-Forbes MJ, Forbes KF, Lerner DJ. Mortality and cost associated with cardiovascular implantable electronic device infections. Arch Intern Med. 2011;171(20):1821–8.PubMedGoogle Scholar
  26. 26.
    Johansen JB, Jorgensen OD, Moller M, Arnsbo P, Mortensen PT, Nielsen JC. Infection after pacemaker implantation: infection rates and risk factors associated with infection in a population-based cohort study of 46299 consecutive patients. Eur Heart J. 2011;32(8):991–8.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Carrasco F, Anguita M, Ruiz M, Castillo JC, Delgado M, Mesa D, Romo E, Pan M, Suárez de Lezo J. Clinical features and changes in epidemiology of infective endocarditis on pacemaker devices over a 27-year period (1987-2013). Europace. 2016;18(6):836–41.PubMedGoogle Scholar
  28. 28.
    Uslan DZ, Sohail MR, St Sauver JL, Friedman PA, Hayes DL, Stoner SM, Wilson WR, Steckelberg JM, Baddour LM. Permanent pacemaker and implantable cardioverter defibrillator infection: a population-based study. Arch Intern Med. 2007;167(7):669–75.PubMedGoogle Scholar
  29. 29.
    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. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study. Circulation. 2007;116(12):1349–55.PubMedGoogle Scholar
  30. 30.
    Korantzopoulos P, Sideris S, Dilaveris P, Gatzoulis K, Goudevenos JA. Infection control in implantation of cardiac implantable electronic devices: current evidence, controversial points, and unresolved issues. Europace. 2016;18(4):473–8.PubMedGoogle Scholar
  31. 31.
    Bongiorni MG, Marinskis G, Lip GY, Svendsen JH, Dobreanu D, Blomstrom-Lundqvist C. How European centres diagnose, treat, and prevent CIED infections: results of an European Heart Rhythm Association survey. Europace. 2012;14(11):1666–9.PubMedGoogle Scholar
  32. 32.
    Tarakji KG, Wilkoff BL. Cardiac implantable electronic device infections: facts, current practice, and the unanswered questions. Curr Infect Dis Rep. 2014;16(9):425.PubMedGoogle Scholar
  33. 33.
    Prutkin JM, Reynolds MR, Bao H, Curtis JP, Al-Khatib SM, Aggarwal S, Uslan DZ. Rates of and factors associated with infection in 200 909 Medicare implantable cardioverter-defibrillator implants: results from the National Cardiovascular Data Registry. Circulation. 2014;130(13):1037–43.PubMedGoogle Scholar
  34. 34.
    Baddour LM, Cha YM, Wilson WR. Clinical practice. Infections of cardiovascular implantable electronic devices. N Engl J Med. 2012;367(9):842–9.PubMedGoogle Scholar
  35. 35.
    Nielsen JC, Gerdes JC, Varma N. Infected cardiac-implantable electronic devices: prevention, diagnosis, and treatment. Eur Heart J. 2015;36(37):2484–90.PubMedGoogle Scholar
  36. 36.
    Sadeghi H, Alizadehdiz A, Fazelifar A, Emkanjoo Z, Haghjoo M. New insights into predictors of cardiac implantable electronic device infection. Tex Heart Inst J. 2018;45(3):128–35.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Rizwan Sohail M, Henrikson CA, Jo Braid-Forbes M, Forbes KF, Lerner DJ. Increased long-term mortality in patients with cardiovascular implantable electronic device infections. Pacing Clin Electrophysiol. 2015;38(2):231–9.PubMedGoogle Scholar
  38. 38.
    Greenspon AJ, Eby EL, Petrilla AA, Sohail MR. Treatment patterns, costs, and mortality among Medicare beneficiaries with CIED infection. Pacing Clin Electrophysiol. 2018;41(5):495–503.PubMedGoogle Scholar
  39. 39.
    Ahmed FZ, Fullwood C, Zaman M, Qamruddin A, Cunnington C, Mamas MA, Sandoe J, Motwani M, Zaidi A. Cardiac implantable electronic device (CIED) infections are expensive and associated with prolonged hospitalisation: UK Retrospective Observational Study. PLoS One. 2019;14(1):e0206611.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Ludwig S, Theis C, Brown B, Witthohn A, Lux W, Goette A. Incidence and costs of cardiac device infections: retrospective analysis using German health claims data. J Compar Effective Res. 2018;7(5):483–92.Google Scholar
  41. 41.
    Kay G, Eby EL, Brown B, Lyon J, Eggington S, Kumar G, Fenwick E, Sohail MR, Wright DJ. Cost-effectiveness of TYRX absorbable antibacterial envelope for prevention of cardiovascular implantable electronic device infection. J Med Econ. 2018;21(3):294–300.PubMedGoogle Scholar
  42. 42.
    Ludwig S, Theis C, Brown B, Witthohn A, Lux W, Goette A. Incidence and costs of cardiac device infections: retrospective analysis using German health claims data. J Comp Eff Res. 2018;7(5):483–92.PubMedGoogle Scholar
  43. 43.
    Ahsan SY, Saberwal B, Lambiase PD, Koo CY, Lee S, Gopalamurugan AB, Rogers DP, Lowe MD, Chow AW. A simple infection-control protocol to reduce serious cardiac device infections. Europace. 2014;16(10):1482–9.PubMedGoogle Scholar
  44. 44.
    Egea M, Urra FG, Bellver A, Alvarez M, Waweru C, Quesada A. Economic impact associated with complications of cardiac implantable electronic devices in Spain. In: Poster Presentation EHRA Congress 2018; 2018.Google Scholar
  45. 45.
    Clementy N, Carion PL, Leotoing L, Lamarsalle L, Wilquin-Bequet F, Brown B, Verhees KJP, Fernandes J, Deharo JC. Infections and associated costs following cardiovascular implantable electronic device implantations: a nationwide cohort study. Europace. 2018;20(12):1974–80.PubMedGoogle Scholar
  46. 46.
    Boriani G, Maniadakis N, Auricchio A, Muller-Riemenschneider F, Fattore G, Leyva F, Mantovani L, Siebert M, Willich SN, Vardas P, Kirchhof P. Health technology assessment in interventional electrophysiology and device therapy: a position paper of the European Heart Rhythm Association. Eur Heart J. 2013;34(25):1869–74.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Cardiology Division, Department of Biomedical, Metabolic and Neural SciencesUniversity of Modena and Reggio Emilia, Policlinico di ModenaModenaItaly

Personalised recommendations