Should all patients with a CIED receive antimicrobial prophylaxis prior to invasive dental, urologic, or endoscopic procedures?
No. Merely having a CIED is not considered an indication for antimicrobial prophylaxis.2
Back to the case
Two sets of blood cultures are drawn, and vancomycin is started as empiric therapy. The culture results show CoNS species, and antimicrobial resistance testing shows oxacillin-resistance.
TEE shows a vegetation on one of the leads but no vegetation on any of the heart valves. Cardiac electrophysiology is consulted and performs a percutaneous extraction of the entire device (generator and leads). Starting on the day of extraction, the patient undergoes two weeks of intravenous antimicrobial therapy with vancomycin. The patient, his family, and the electrophysiology team discuss the patient’s wishes, indications, and potential burdens related to device replacement.
He ultimately decides to have a replacement device installed. An infectious disease specialist is consulted to help define appropriate timing of the new device installation procedure.
Bottom line
The patient clearly had a CIED infection which required TEE, extraction of his CIED, and prolonged antimicrobial therapy.
Dr. Davisson is a primary care physician at Community Health Network in Indianapolis, Ind. Dr. Lockwood is a hospitalist at the Lexington VA Medical Center. Dr. Sweigart is a hospitalist at the University of Kentucky, Lexington, and the Lexington VA Medical Center.
References
1. Baddour LM, Epstein AE, Erickson CC, et al. Update on Cardiovascular Implantable Electronic Device Infections and Their Management: A Scientific Statement From the American Heart Association. Circulation. 2010;121(3):458-77.
2. Baddour LM, Cha YM, Wilson WR. Infections of Cardiovascular Implantable Electronic Devices. N Engl J Med. 2012;367(9):842-9.
3. Uslan DZ, Sohail MR, St. Sauver JL, et al. Permanent Pacemaker and Implantable Cardioverter Defibrillator Infection: A Population-Based Study. Arch Intern Med. 2007;167(7):669-75.
4. Bongiorni MG, Tascini C, Tagliaferri E, et al. Microbiology of Cardiac Implantable Electronic Device Infections. Europace. 2012;14(9):1334-9.
