*2.2.2 CIED infection risk factors*

Patients with chronic kidney disease, long-term corticosteroid use, presence of more than 2 pacing leads, diabetes mellitus, heart failure and oral anticoagulation are at higher risk for CIED infection [25, 26]. Use of preprocedural temporary pacing, fever within 24 hours prior to implantation, blood stream infections, and early reintervention were also associated with higher risk of CIED infection [25]. Lower rates of CIED infection was associated with antibiotic perioperative prophylaxis new device placement, use of pectoral approach rather than abdominal or transthoracic approach, and device placement by a high-volume physician [25].

#### *2.2.3 Pathogenesis and microbiology*

Source of microorganisms often originate from the skin during the implantation of the electrical agent in the subcutaneous tissue, from the pocket in which the electrical agent is placed, the tunnel that forms around the lead before its point of entry into the blood vessel or from bacteria unrelated to the CIED, which may be present in the form of a foreign body placed on or in contact with the endocardial tissue, or that applies pressure to the endocardial tissue and tricuspid valve [23, 27]. Alternatively, contamination of the CIED can occur at different stages or from various causes. This includes but is not limited to manufacturing or packaging, infection prior to or during implantation, secondary to surgical site infection or via hematogenous seeding from a distant site or after erosion through the skin [24, 25, 27].

Physical and chemical properties such as electrostatic charge, surface tension and hydrophobicity of each device plays an important role in the interaction with bacteria and development of bacterial attachment and biofilm formation [23]. More hydrophobic surfaces such as polyvinyl chloride, polyethylene, silicone, latex and stainless steel are associated with higher microbial adherence [24]. Pathogens are more likely to adhere to irregular surfaces and may also adhere to the patient's matrix proteins (fibrinogen, fibronectin and collagen) that coat the surface of an implanted device [25]. CIED infections are more likely to occur due to gram positive bacteremia than gram negative bacteremia [25]. Staphylococci species, especially coagulase negative staph, have a knack for adhesion to CIEDs via host matrix proteins and to each other thus forming biofilms [24, 25]. Coagulase negative staphylococci comprise 42% of all PPM and ICD infections, followed by oxacillin sensitive *S. aureus* (25%), oxacillin resistant *S. aureus* (4%), with the remaining causative organisms being other gram positive cocci (4%), gram negative bacilli (9%), fungal (2%), polymicrobial (7%), and unidentified/culture negative (7%) [28].

#### *2.2.4 The role of biofilm*

Biofilm is a group of one or more microbial species firmly attached to a device surface and each other and covered by extracellular polymeric matrix [24, 25]. This matrix provides a protective barrier and results in antibiotic resistance and extreme difficult of bacterial irradiation that frequently requires device explanation [24, 25]. Some bacteria are more adept to adhering to non-biological materials such as staphylococci.

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thrombus, emboli or vegetation.

*Contemporary and Evolving Treatment of Tricuspid Endocarditis*

rate with hardware removal in addition to antibiotic therapy [30].

**3. Evolving percutaneous options for treatment**

Antibiotics are generally empirically initiated after obtaining at least three sets of blood cultures. These usually consists of broad-spectrum intravenous antibiotics covering both gram-positive and gram-negative bacteria, including methicillin/oxacillin-resistant *Staphylococcus aureus* [29]. Antibiotic therapy alone without device removal, however, is associated with a 7 times increase in 30-day mortality [28]. Treatment of CIDE as recommended per the 2017 HRS Consensus Document include complete device and lead removal in addition to antibiotics [29]. Immediate system removal is associated with a 3 times decrease in 1-year mortality as compared to preliminary antibiotic treatment and delayed system removal [30]. Mortality rates in patients with endocarditis who had systems removed and antimicrobial therapy are 18% or less compared with up to 66% on antibiotic therapy alone [27]. Multiple clinical studies have now demonstrated a 97.7% clinical success

The start of antibiotic therapy duration is counted from the first day of negative blood cultures, therefore it is reasonable to obtain blood cultures every 24 to 48 hours until they are negative [31]. If the patient requires surgery and the surgical cultures are negative, then the duration of therapy is still counted from the first day of negative blood cultures [31]. If surgical cultures are positive, then the start of antibiotic therapy duration occurs the next day, after the achievement of source control [31]. This applies to post device removal as well as some authors recommend obtaining new blood cultures 48–72 hours post device removal [26]. If the need for CIED remains in patients treated for bacteremia, negative blood cultures should be documented at least 72 hours prior to new device implantation [29]. Duration of treatment usually consists of 4–6 weeks of IV antibiotics, in addition to removal of

Given that 10–15% of patients fail medical therapy, percutaneous treatment

options as an adjunct to medical therapy have now started to become mainstream. Specifically, the use of AngioVac device (AngioDynamics, Latham, New York) has begun to get traction because of its ease of use, low risk profile and ability to debulk the vegetation and prevent septic pulmonary emboli. The AngioVac system is a veno-venous extracorporeal system. The most common configuration is as a bilateral femoral venous platform or via the right internal jugular and femoral platform. The system mainly consists of a cannula and a circuit along with a trap, which captures the undesirable material. AngioVac is currently used in the setting of thromboembolic disease, particularly in the vena cava or the right atrium. Both the cannula and circuit are indicated for use in procedures requiring extracorporeal circulatory support for periods up to six hours for removal of fresh, soft thrombi or emboli. The cannula and circuit are designed to be used with off shelf pump, filter and reinfusion cannula. The device itself leverages the use of blood flow through a centrifugal pump to create negative pressure in order to extirpate undesirable intravascular material, such as

*DOI: http://dx.doi.org/10.5772/intechopen.95434*

*2.2.5 Treatment and prognosis*

*2.2.6 Duration of treatment*

CIED [29].
