Table 1

ICED infection definitions, treatment and empirical antibiotic regimens

DefinitionTreatmentEmpirical antibiotics*
Early postimplantation inflammationErythema affecting the box implantation incision site, without purulent exudate, dehiscence, fluctuance or systemic signs of infection and occurring within 30 days of implantation. Includes a small, localised area (<1 cm) of erythema and/or purulence associated with a suture (‘stitch abscess’)Close observation. ICED can initially be left in situ. Role of antimicrobials unclearConsider 7–10 days of treatment with flucloxacillin 0.5–1 g oral four times a day (penicillin allergy or MRSA colonisation—doxycycline 100 mg oral twice daily OR linezolid 600 mg oral twice daily OR clindamycin 450 mg oral four times a day)
Uncomplicated generator pocket infectionAny one of:
  1. Spreading cellulitis affecting the generator site

  2. Incision site purulent exudate (excluding simple stitch abscess)

  3. Wound dehiscence

  4. Erosion through skin with exposure of the generator or leads

  5. Fluctuance (abscess) or fistula formation

AND no systemic symptoms or signs of infection AND negative blood cultures
Complete removal of the ICED system (generator and all leads) as soon as possible (<2 weeks from diagnosis) followed by antimicrobial treatment for skin and soft tissue infection (see guidelines for preferred agents)Vancomycin 1 g intravenous twice dailyOR daptomycin 4 mg/kg intravenous once daily
OR teicoplanin 6 mg/kg to a maximum of 1 g given at 0, 12 and 24 h and then 24 h
Complicated generator pocket infectionAs for uncomplicated generator pocket infection but with any one of:
  1. Evidence of lead or endocardial involvement

  2. Systemic signs or symptoms of infection

  3. Positive blood cultures

 
Complete removal of the ICED system. Antimicrobial treatment options and duration of antimicrobial therapy depend on echo findings; if no native valve involvement, treat as uncomplicated generator pocket infectionVancomycin 1 g intravenous twice daily
AND meropenem 1 g intravenous three times a day
OR
daptomycin 8–10 mg/kg intravenous once daily
AND meropenem 1 g intravenous three times a day
Note: gentamicin or other anti-Gram-negative agents may be appropriate depending on local epidemiology.
Choice of vancomycin or daptomycin depends on risk of acute kidney injury
ICED-lead infection (ICED-LI)Symptoms and signs of systemic infection without signs of generator pocket infection, but with:Definite ICED-LI—either:
  1. Echocardiography consistent with vegetation(s) attached to lead(s) and major modified Duke microbiological criteria or

  2. Culture, histology or molecular evidence of infection on explanted lead

Possible ICED-LI—either:
  1. Echocardiography consistent with vegetation(s) attached to lead(s) but no major modified Duke microbiological criteria or

  2. Major modified Duke microbiological criteria but no echocardiographic evidence of lead vegetation(s)

 
ICED-associated infective endocarditis (ICED-IE)All of:
  1. ICED in situ

  2. Modified Duke criteria for definite infective endocarditis

  3. Echocardiographic evidence of valve involvement

 
  • *Doses should be checked/revised in patients with renal/hepatic impairment; drug interactions and allergies considered.

  • ICED, implantable cardiac electronic device; ICED-IE; MRSA methicillin-resistant S. aureus