*2.7.2 Antibiotic prophylaxis*

*Advanced Concepts in Endocarditis - 2021*

**2.7 Prevention and prophylaxis**

infectious complications.

operating room [6].

implant room [6, 30].

hemostasis [18, 26].

in the past 48 hours [6, 11, 18].

*Pulmonary infectious involvement in IE-CIED. TC.*

an experienced supervisor [6, 11, 26, 30].

[6, 18, 27–29].

*2.7.1 General measures*

or infectious pulmonary involvement (**Figure 8**).

the pulmonary parenchyma as there may be images suggestive of septic embolism

Before addressing the treatment of IE-CIED we will discuss how to prevent

Any implant procedure must be performed following the usual aseptic surgical standards. Additionally, it is recommended to adhere to the following guidelines:

• Carry out the procedure in an appropriate place, with adequate ventilation. The air requirements specified for cardiac catheterization laboratories (15 air changes/hour) are less than the 25 air changes/hour recommended for the

• Do not shave the skin with blades. When trimming hair, shave with a single-use electric head or with depilatory cream, before the procedure and outside the

• Prepare the skin with an alcoholic solution of chlorhexidine (minimum 2%) or as an alternative for allergic individuals, use povidone iodine in alcohol

• Avoid unnecessarily long procedures, best if performed by a first operator or

• Do not perform procedures in patients with suspected active infection or fever

• Carry out a correct hemostasis to avoid the formation of hematoma. In the case of anticoagulated patients in whom anticoagulation should not be interrupted, do not use bridging therapy with heparin and look for an INR close to 2. Individualize treatment in the rest of antiplatelet or anticoagulated patients. Local thrombin solutions can be considered to facilitate

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**Figure 8.**

Antimicrobial prophylaxis should be administered on time to ensure, at the time of incision and throughout the procedure, that the tissue and plasma concentrations exceed the MIC for the microorganisms commonly associated with infection. This would normally be within 1 h for intravenous drugs given as a bolus or short infusion, but for some longer infusions that are given over 30 minutes or more, they may need to be started earlier to ensure that the infusion is completed at least 20 minutes before incision (e.g. vancomycin and fluoroquinolones) [6, 18, 19, 26–30].

Currently, the use of a dose of cefazolin (2 gr) or another first-generation cephalosporin or flucloxacillin (1–2 g) is recommended, one hour prior to the procedure. In patients allergic to Beta lactams or when the local incidence of MR Staphylococci is very high, vancomycin is recommended (vancomycin requires a mg/kg iv slower rate of infusion to prevent systemic vasodilatation and erythema within 2 hours before incision) or teicoplanin as an alternative regimen. If a glycopeptide is to be used, teicoplanin has some practical advantages over vancomycin in terms of administration as it can be given as a bolus (400 mg iv 5 minutes) rather than a long infusion. Teicoplanin resistance is more frequent than vancomycin resistance among Staphylococci (including CoNS), but both are uncommon. In case of allergy to both, assess linezolid/daptomycin.

In very prolonged procedures or in case of heavy bleeding, a second dose of intraprocedural antibiotic can be considered [12].

For elective procedures, *S. aureus* colonization can be detected by nasal swabs. Nasal treatment with mupirocin and chlorhexidine skin washing can reduce colonization and has been shown in some surgical studies to reduce the risk of infection, but there are no studies relating specifically to CIED interventions [6, 18, 30].

Antibiotic doses after wound closure are not recommended [6, 30]. The use of local antibiotic delivery is not recommended [6, 21, 30] as well.

Antimicrobial 'envelopes' have been developed to deliver antimicrobial agents locally into the generator pocket at the time of implantation or generator replacement. A product that delivers rifampicin and minocycline locally was tested in a randomized, controlled clinical trial WRAP-IT to assess its safety and efficacy in a population of patients who were at increased risk for CIED pocket infection. The envelope was significantly more effective at preventing infection than standard protocols. There is no formal recommendation for the use of these covers but it could be considered in high-risk patients [29, 30].

Antimicrobial prophylaxis is not recommended for dental or other invasive procedures not directly related to device manipulation to prevent CIED infection, except in case of infected tissue manipulation [26].

#### **2.8 IE-CIED treatment**

Treatment is based on two pillars: the removal of the device and antimicrobial therapy.

#### *2.8.1 The removal of the device*

Complete removal of the device, electrodes, or abandoned remains, is indicated in patients with any CIED infection, with the exception of superficial infections

related to the incision and provided that they do not occur with exteriorization of the device or erosion of the skin [24, 30–32].

Explantation is indicated in case of:


The device should also be removed in CIED carriers in case of [21, 30]:


The device must be completely removed as early as possible. Percutaneous removal is indicated as first choice when possible. Surgical approach is indicated when there is an indication for surgery associated with endocarditis in another location or after incomplete percutaneous removal. For large vegetations, greater than 20 mm, surgery may be considered the first option from the outset, due to a hypothetical higher risk of pulmonary embolism, although this cut-off point is arbitrary. The aspiration of large vegetations is reported before the percutaneous extraction of the electrodes. Removal of the system percutaneously is usually relatively simple when it is performed early after implantation, since there is less fibrosis around the device elements and implies more difficulty and risk of complications the longer the period after implantation and the complexity of the device.

The extraction should be done in expert centers by interventional cardiologists, electrophysiologists or cardiac surgeons. The percentage of complete removal of the device is high>90% with the techniques and materials currently available (specific stylets, mechanical dissection sheaths, with radiofrequency or laser, ties, etc.) (**Figure 9**). Implant removal requires centers with availability of urgent cardiac surgery, given that, although the percentage of complications is low, they can be serious and lead to vital compromise. The risk of serious complications is 2–4%, the most severe being cardiac avulsion or tear (CA / T) with tamponade and vascular avulsion or tear (VA/T). In the case of surgical extraction, (**Figure 10**) the percentage of complications observed is higher and it seems related to a greater severity of the patients [30–32].

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own refusal [6, 10].

**Figure 10.**

**Figure 9.**

*Materials for percutaneous.*

*2.8.2 The antimicrobial therapy*

*Lead with big vegetation, surgical removal.*

collection and sample processing is so important.

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

In 3–15% of patients with an indication of removal of the device, this will not be carried out for various reasons, especially a very high surgical risk or the patient's

Intravenous (iv) antimicrobial therapy should be guided whenever possible by microbiological documentation and antibiogram; this is the reason why the correct

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

*Advanced Concepts in Endocarditis - 2021*

cultures).

Candida spp.

CIED system.

continued infection is found.

electrodes or valves.

the device or erosion of the skin [24, 30–32]. Explantation is indicated in case of:

related to the incision and provided that they do not occur with exteriorization of

• local pocket infections without data of systemic involvement (negative blood

• infections of the pocket with systemic involvement, without vegetations on the

• infections of the pocket with systemic involvement, with evidence of vegeta-

• bacteremia or fungaemia caused by S Aureus, CoNS, Cutibacterium spp. and

Enterococcus spp. as first-line treatment or as a second step in case of recur-

Pneumococci in case of recurrent/continued bacteremia, in spite of appropriate antibiotic therapy when no other identifiable source for recurrence or

• patients with infective valve endocarditis without definite involvement of the

The device must be completely removed as early as possible. Percutaneous removal is indicated as first choice when possible. Surgical approach is indicated when there is an indication for surgery associated with endocarditis in another location or after incomplete percutaneous removal. For large vegetations, greater than 20 mm, surgery may be considered the first option from the outset, due to a hypothetical higher risk of pulmonary embolism, although this cut-off point is arbitrary. The aspiration of large vegetations is reported before the percutaneous extraction of the electrodes. Removal of the system percutaneously is usually relatively simple when it is performed early after implantation, since there is less fibrosis around the device elements and implies more difficulty and risk of complications the longer the period after implantation and the complexity of

The extraction should be done in expert centers by interventional cardiologists, electrophysiologists or cardiac surgeons. The percentage of complete removal of the device is high>90% with the techniques and materials currently available (specific stylets, mechanical dissection sheaths, with radiofrequency or laser, ties, etc.) (**Figure 9**). Implant removal requires centers with availability of urgent cardiac surgery, given that, although the percentage of complications is low, they can be serious and lead to vital compromise. The risk of serious complications is 2–4%, the most severe being cardiac avulsion or tear (CA / T) with tamponade and vascular avulsion or tear (VA/T). In the case of surgical extraction, (**Figure 10**) the percentage of complications observed is higher and it seems related to a greater severity of

The device should also be removed in CIED carriers in case of [21, 30]:

• bacteremia with Alpha- or Beta-Hemolytic Streptococcus spp. and

rent/continued bacteremia despite appropriate antibiotic therapy.

• bacteremia with non-Pseudomonal/Serratia Gram-negative bacteria or

tions in electrodes and/or valves and/or embolisms.

**132**

the patients [30–32].

the device.

**Figure 9.** *Materials for percutaneous.*

**Figure 10.** *Lead with big vegetation, surgical removal.*

In 3–15% of patients with an indication of removal of the device, this will not be carried out for various reasons, especially a very high surgical risk or the patient's own refusal [6, 10].
