*2.8.2 The antimicrobial therapy*

Intravenous (iv) antimicrobial therapy should be guided whenever possible by microbiological documentation and antibiogram; this is the reason why the correct collection and sample processing is so important.

The empirical antibiotic regimens recommended by a consensus of various scientific societies, European Heart Rhythm Association (EHRA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious

Diseases (ISCVID), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), European Association for Cardio-Thoracic Surgery (EACTS)] [30] are listed in **Table 1**. The duration of the treatment will continue once the device is removed as follows:


4 weeks (2 weeks if negative blood culture after extraction with total treatment duration not shorter than 4 weeks).

• Systemic infection: IE-CIED with vegetation on leads and/or valves + embolism: 4–6 weeks + oral antibiotic therapy follow-up if indicated by secondary infectious focus.

Long-term suppressive therapy with iv antibiotic, according to the recommendations in prosthetic valve endocarditis for 4–6 weeks, is reasonable for patients in whom the device cannot be totally or partially removed, due to the high rates of failure, relapse or reinfection [33].

#### **2.9 New device implant**

After the removal of a CIED, the indication for a new implant must be reconsidered. This must be done critically and individually [19, 26, 30].

It is estimated that, in about 30% of patients, implantation of a new device is not indicated. The reason may be that there is no longer any indication, that the explanted device was not correctly indicated, or that the patient himself rejects a new implant. In the case of a new reimplantation, it will be necessary to assess whether a similar device is indicated, or whether it should be different, generally of less complexity or "downgrade" [31, 34].

If the indication for a new implant is confirmed, it should be deferred until the infection is controlled, if possible after obtaining negative blood cultures for at least 72 hours after the explant. In patients dependent on cardiac stimulation, who require temporary stimulation, an electrode ipsilateral to the explant will be used, through a venous access different from that used by the previous one. To prevent manipulations due to instability of the electrode, with a greater risk of contamination, the use of an active fixation electrode connected to an external battery and fixed to the skin is recommended, until it is safe to implant the definitive device [6, 34].

If a device with electrodes (RTC, bicameral pacing) is indicated, it should be implanted initially on the contralateral side. If not, implantation of an epicardial pacemaker or a MicraTM Transcatheter Pacing System (TPS; Medtronic, Minneapolis, MN, USA) femoral leadless pacemaker may be considered. The leadfree pacemaker avoids the possibility of a primary infection of the generator pocket and thanks to its smaller overall surface area and the progressive encapsulation once implanted (**Figure 11**), it would theoretically present less risk of secondary infection in the presence of systemic infection [35].

In the case of patients with an indication for defibrillator reimplantation, without the need for permanent pacing, resynchronization or anti-tachycardia therapy, the implantation of a subcutaneous defibrillator should be considered (the infection rate requiring removal of the device is 2.4% after 3 years of follow up) (**Figure 12**) [36].

**135**

\*

**Table 1.**

*Endocarditis and Cardiac Device Infections DOI: http://dx.doi.org/10.5772/intechopen.96909*

**-Systemic symptoms**

**valves +/-pocket infection**

**+/-pocket infection**

**guidelines 2015**

adapt to local resistance

Directed at MR \*

**Isolated pocket infection** 10–14 days post-extraction

**(Empirical treatment/ - blood cultures)** -Cephalosporin: standard dose

**After culture result** Flucloxacillin: 8 g/d iv in 4 doses

**+ Systemic symptoms** +/−

**Systemic infections without vegetation on leads or** 

**Systemic infections with vegetation on leads or valves** 

**Adjust to culture result according to ESC endocarditis** 

*IE-CIED Empirical antibiotic regimens recommended.*

\*\*adjust according to kidney function od: once day

**Empirical treatment/ - blood cultures** -Vancomycin: 30–60 mg/kg/d iv in 2–3 doses

For additional Gram- coverage -Alternative: Gentamicin\*\* 5–7 mg/kg iv od

If sensitive Staphylococcus Alternative: 1st generation cephalosporin

**Empirical treatment/ - blood cultures** Vancomycin: 30–60 mg/kg/d iv in 2–3 doses Directed at MR Staphylococci and Gram- bacteria Alternative: Daptomycin 8–10 mg/kg od

**After culture result** Flucloxacillin: 8 g/d iv in 4 doses

If sensitive Staphylococcus Alternative: 1st generation cephalosporin

**Empirical treatment/ - blood cultures** Vancomycin:30–60 mg/kg/d iv in 2–3 doses

**If prosthetic valve and staphylococcal infection:** Add Rifampicin after 5–7 days: 900–1200

CoNS and S Aureus -Alternative: Daptomycin 8–10 mg/kg iv od

standard dose


standard dose

post-extraction

post-extraction

+

+

Partial oral treatment often used

Cephalosporin: standard dose iv

Alternative: Gentamicin 5–7 mg/kg iv o d

Lead vegetation: 2 weeks post-extraction

Prosthetic valve vegetation: (4-) 6 weeks

Alternative: Daptomycin 8–10 mg/kg od

Alternative: Gentamicin 5–7 mg/kg iv od

Cephalosporin: standard dose

mg/day orally (or iv) in 2 doses

(total 4w except S Aureus) Native valve vegetation: 4 weeks

4 weeks post-extraction\_(consider 2w if

### *Endocarditis and Cardiac Device Infections DOI: http://dx.doi.org/10.5772/intechopen.96909*

*Advanced Concepts in Endocarditis - 2021*

device is removed as follows:

duration not shorter than 4 weeks).

infection:

infectious focus.

**2.9 New device implant**

tive device [6, 34].

up) (**Figure 12**) [36].

failure, relapse or reinfection [33].

less complexity or "downgrade" [31, 34].

tion in the presence of systemic infection [35].

Diseases (ISCVID), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), European Association for Cardio-Thoracic Surgery (EACTS)] [30] are listed in **Table 1**. The duration of the treatment will continue once the

• Systemic infection without vegetation on leads or valves +/− pocket

4 weeks (2 weeks if negative blood culture after extraction with total treatment

• Systemic infection: IE-CIED with vegetation on leads and/or valves + embolism: 4–6 weeks + oral antibiotic therapy follow-up if indicated by secondary

Long-term suppressive therapy with iv antibiotic, according to the recommendations in prosthetic valve endocarditis for 4–6 weeks, is reasonable for patients in whom the device cannot be totally or partially removed, due to the high rates of

After the removal of a CIED, the indication for a new implant must be reconsid-

It is estimated that, in about 30% of patients, implantation of a new device is not indicated. The reason may be that there is no longer any indication, that the explanted device was not correctly indicated, or that the patient himself rejects a new implant. In the case of a new reimplantation, it will be necessary to assess whether a similar device is indicated, or whether it should be different, generally of

If the indication for a new implant is confirmed, it should be deferred until the infection is controlled, if possible after obtaining negative blood cultures for at least 72 hours after the explant. In patients dependent on cardiac stimulation, who require temporary stimulation, an electrode ipsilateral to the explant will be used, through a venous access different from that used by the previous one. To prevent manipulations due to instability of the electrode, with a greater risk of contamination, the use of an active fixation electrode connected to an external battery and fixed to the skin is recommended, until it is safe to implant the defini-

If a device with electrodes (RTC, bicameral pacing) is indicated, it should be implanted initially on the contralateral side. If not, implantation of an epicardial pacemaker or a MicraTM Transcatheter Pacing System (TPS; Medtronic, Minneapolis, MN, USA) femoral leadless pacemaker may be considered. The leadfree pacemaker avoids the possibility of a primary infection of the generator pocket and thanks to its smaller overall surface area and the progressive encapsulation once implanted (**Figure 11**), it would theoretically present less risk of secondary infec-

In the case of patients with an indication for defibrillator reimplantation, without the need for permanent pacing, resynchronization or anti-tachycardia therapy, the implantation of a subcutaneous defibrillator should be considered (the infection rate requiring removal of the device is 2.4% after 3 years of follow

ered. This must be done critically and individually [19, 26, 30].

• Isolated pocket infection (negative blood culture): 10–14 days.

**134**


**Table 1.**

*IE-CIED Empirical antibiotic regimens recommended.*

**Figure 11.** *MICRA.*

**Figure 12.** *Subcutaneous defibrillator.*
