**2.2 Classification of CIED infections**

	- Definite:
		- a.Symptoms/signs of systemic infection, NO signs of generator pocket infection AND echocardiography consistent with vegetation(s) attached to lead(s) AND presence of major Duke microbiological criteria.
		- b.Symptoms/signs of systemic infection, NO signs of generator pocket infection AND culture, histology or molecular evidence of infection on explanted lead**.**
	- Possible.
		- a.Symptoms/signs of systemic infection AND echocardiography consistent with vegetation(s) attached to lead(s), BUT NO major Duke microbiological criteria present.
		- b.Symptoms/signs of systemic infection AND major Duke microbiological criteria present, BUT NO echocardiographic evidence of lead vegetations.
		- c.Pulmonary emboli are considered supportive evidence of lead infection in the absence of definite evidence of infection.

**121**

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

meet the criteria for endocarditis [2, 7, 10].

for 6.4% of all cases of definite infective endocarditis [11].

tion of case) [7].

**2.3 Risk factors**

patients [7].

• Male sex.

• Diabetes Mellitus.

• Renal insufficiency.

disease (COPD).

• Use of corticosteroids.

• States of immunosuppression.

Factors associated with the procedure

• Neoplasia.

infection on CIED [2, 7, 8, 11–13]:

of valve involvement in a patient with an CIED in situ.

Duke criteria for definite endocarditis satisfied, with echocardiographic evidence

The last two forms are considered by the European Society of Cardiology (ESC) as endocarditis related to CIEDs, and we will now focus on them, not forgetting that they coexist with local infection of the generator pocket in up to 10–50% of cases (although in some recent series, the figure is closer to 10%, which suggests that causative microorganism reached PM leads by haematogenic way in a high propor-

Different epidemiological studies, with follow-up ranging from 6 weeks to 11 years, estimate the incidence of CDI-related infection at 2% [6, 8], although the figures are highly variable depending on the criteria used (0–6% and up to 19% if intra-abdominal devices are included) [9]. Between 10 and 23% of these infections

A study in 7424 patients who underwent a pacemaker and/or ICD device implantation demonstrated an increasing incidence of IE in pacemakers [7]. It represented almost 10% with an increment from 1.25 to 9.32% of all IE between the period 1987–1993 compared to the period 2008–2013. Another prospective cohort study, using data from the International Collaboration on Endocarditis–Prospective Cohort Study (ICE-PCS), conducted from June 2000 through August 2006 in 61 centers in 28 countries, found that cardiac device infective endocarditis accounted

Several studies have identified the following risk factors for the development of

• Age, probably a confounding factor due to the higher number of comorbidities.

• Other comorbidities such as heart failure or (chronic obstructive pulmonary

• Non-first implant: Infection is more frequent in replacement or update procedures (1–4%) than in first implantation (0.5–0.8%) The risk of CIED infection is much greater after generator change or device revision. It has been suggested that this is related to bacterial contamination of the avascular pocket that is formed around the generator, which may impede penetration of

Factors associated with the patient: Several of them coexist in up to 50% of

• CIED -associated native or prosthetic valve endocarditis.

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

*Advanced Concepts in Endocarditis - 2021*

**2.2 Classification of CIED infections**

positive blood cultures).

explanted lead**.**

cal criteria present.

• Lead infection.

○ Definite:

○ Possible.

at 1 per 1000 hospital admissions and 1.5–9.6 cases per 100000 inhabitants [1, 2]. While in countries with limited resources it continues to be closely related to rheumatic valve disease, in developed countries it is fundamentally related to degenerative valve disease, valve prostheses and CIED. The use of implantable cardiac electronic devices (pacemakers [PM], implantable cardioverter-defibrillators [ICD], cardiac re-synchronized therapy [CRT]) has increased by 4.7% annually between 1993 and 2009 with a growth of 96% in the entire period. The number of implanted pacemakers increased by 55.6% (especially bicameral), while that of defibrillators did so by 504% [3, 4]. Such increase is due to a number of factors: the aging of the population, the complexity of their pathologies, the new indications and the advance in implantation techniques. However, the growth of infections associated with these devices has raised disproportionately and is estimated at 210% between 1993 and 2008 [4, 5].

• **Post-operative wound inflammation:** occurs within 30 days of implantation, with wound inflammation or 'stitch abscess', in the absence of definite evidence of infection and not necessarily requiring antimicrobial therapy

• **Uncomplicated generator infection:** cellulitis confined to the generator site, including purulent discharge, abscess, fistula or device erosion in the absence

• **Complicated generator infection**: generator infection plus involvement of any part of the lead or development of systemic involvement (signs or symptoms or

a.Symptoms/signs of systemic infection, NO signs of generator pocket

b.Symptoms/signs of systemic infection, NO signs of generator pocket infection AND culture, histology or molecular evidence of infection on

a.Symptoms/signs of systemic infection AND echocardiography consistent with vegetation(s) attached to lead(s), BUT NO major Duke microbiologi-

b.Symptoms/signs of systemic infection AND major Duke microbiological criteria present, BUT NO echocardiographic evidence of lead vegetations.

c.Pulmonary emboli are considered supportive evidence of lead infection in

the absence of definite evidence of infection.

• CIED -associated native or prosthetic valve endocarditis.

lead(s) AND presence of major Duke microbiological criteria.

infection AND echocardiography consistent with vegetation(s) attached to

(possible skin reaction to dressings, sutures or antiseptics) [6].

of systemic involvement, and negative blood cultures.

**120**

Duke criteria for definite endocarditis satisfied, with echocardiographic evidence of valve involvement in a patient with an CIED in situ.

The last two forms are considered by the European Society of Cardiology (ESC) as endocarditis related to CIEDs, and we will now focus on them, not forgetting that they coexist with local infection of the generator pocket in up to 10–50% of cases (although in some recent series, the figure is closer to 10%, which suggests that causative microorganism reached PM leads by haematogenic way in a high proportion of case) [7].

Different epidemiological studies, with follow-up ranging from 6 weeks to 11 years, estimate the incidence of CDI-related infection at 2% [6, 8], although the figures are highly variable depending on the criteria used (0–6% and up to 19% if intra-abdominal devices are included) [9]. Between 10 and 23% of these infections meet the criteria for endocarditis [2, 7, 10].

A study in 7424 patients who underwent a pacemaker and/or ICD device implantation demonstrated an increasing incidence of IE in pacemakers [7]. It represented almost 10% with an increment from 1.25 to 9.32% of all IE between the period 1987–1993 compared to the period 2008–2013. Another prospective cohort study, using data from the International Collaboration on Endocarditis–Prospective Cohort Study (ICE-PCS), conducted from June 2000 through August 2006 in 61 centers in 28 countries, found that cardiac device infective endocarditis accounted for 6.4% of all cases of definite infective endocarditis [11].
