Suspected infection limited to cardiac implantable electronic device (CIED) pocket in adults: Approach to evaluation and management

CIED: cardiac implantable electronic device; FDG PET/CT: fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography; MRSA: methicillin-resistant Staphylococcus aureus; SPECT/CT: radiolabeled autologous white blood cell single-photon emission computed tomography with computed tomography; TEE: transesophageal echocardiogram.

* Blood cultures should be obtained prior to antibiotic administration. Blood cultures obtained following antibiotic administration may be falsely negative; refer to UpToDate text for further discussion.

¶ Noninfectious causes of erythema or other skin/soft tissue abnormalities at the CIED pocket site include local bleeding, reaction to a wound dressing or skin preparation, retained suture, or allergy to device components.

Δ If available, FDG PET/CT may be useful to distinguish between CIED pocket infection and superficial site infection in some circumstances; refer to UpToDate topic on diagnosis of CIED infection for further discussion.

◊ Oral antibiotic dosing as follows:

• Cephalexin 500 mg orally 4 times daily
• Clindamycin 300 to 450 mg orally 4 times daily (use higher dose for patients with weight >120 kg)
• Dicloxacillin 500 mg orally 4 times daily
• Doxycycline 100 mg orally twice daily
• Minocycline 200 mg orally once, then 100 mg orally every 12 hours
• Trimethoprim-sulfamethoxazole 1 to 2 double-strength tablets orally every 12 hours

§ Vancomycin dosing: 15 to 20 mg/kg/dose intravenously every 8 to 12 hours (not to exceed 2 g per dose); refer to UpToDate text for discussion of alternative agents.

¥ TEE demonstrating vegetation is consistent with CIED systemic infection; such patients should receive antibiotic therapy according to approach for endocarditis. Refer to UpToDate text for further discussion.

‡ Swabs and tissue from the pocket should be sent for culture, in addition to lead tips.

† For fungal CIED pocket infection, the duration of antifungal therapy is four weeks following device removal. Refer to UpToDate text for further discussion of treatment for CIED infection.