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Guidelines for the diagnosis, management and prevention of implantable cardiac electronic device infection
  1. James L Harrison1,
  2. Bernard D Prendergast2,
  3. Jonathan A T Sandoe3
  1. 1Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
  2. 2Oxford University Hospitals NHS Trust, Oxford, UK
  3. 3Department of Microbiology, University of Leeds and Leeds Teaching Hospital NHS Trust, Leeds, UK
  1. Correspondence to Dr Jonathan A T Sandoe, Department of Microbiology, University of Leeds and Leeds Teaching Hospital NHS Trust, Leeds LS1 3EX, UK; j.sandoe{at}leeds.ac.uk

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Introduction

Implantable cardiac electronic devices (ICEDs) comprise permanent pacemakers (PPMs), implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy (CRT). Implantation rates in the UK are increasing1 and are set to rise further in the wake of recent guidelines that significantly widen eligibility criteria.2 However, an unfortunate consequence is the associated increase in ICED infections with attendant morbidity and mortality. The incidence of ICED infections is increasing in the USA3 and a similar increase in the UK seems inevitable.

ICED infections can be extremely challenging to diagnose and manage, and can involve any combination of the generator pocket, device leads and endocardial structures, the last associated with particularly high mortality. Device extraction has a significant risk of serious complications and mortality.4 Multiple and long hospital attendances are common and attempts to salvage infected devices are frequently unsuccessful.5

Strategies for preventing and managing ICED infections vary widely and the evidence to guide practice is limited. Until now, the only published guidelines in this difficult area were from the American Heart Association in 2010.6 Recent joint guidelines from the British Society for Antimicrobial Chemotherapy, British Heart Rhythm Society, British Cardiovascular Society, British Heart Valve Society and British Society of Echocardiography promote a standardised approach to this important and increasing clinical problem.7 In this article, we summarise their key messages.

Epidemiology

The UK incidence of ICED infection is unknown and extrapolating international estimates may be inappropriate due to varying case definitions and measures of incidence. Acknowledging variable follow-up periods, the international literature suggests an overall incidence of infection of 0.5%–2.2% of implants with higher incidence for ICD/CRT compared with PPM and redo procedures compared with primary implants. An increasing number of patients receiving ICED have renal impairment, heart failure and diabetes mellitus, which increase the risk of subsequent infection. …

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