40. Chesdachai S, Baddour LM, Sohail MR, et al. Evaluation of European Heart Rhythm Association consensus in patients with cardiovascular implantable electronic devices and Staphylococcus aureus bacteremia. Heart Rhythm 2022; 19:570. 41. Nakajima I, Narui R, Tokutake K, et al. Staphylococcus bacteremia without evidence of cardiac implantable electronic device infection. Heart Rhythm 2021; 18:752. 42. Berge A, Arkel L, Nilson B, Rasmussen M. Enterococcus faecalis bacteremia, cardiac implantable electronic device, extraction, and the risk of recurrence. Infection 2022; 50:1517. 43. Oh TS, Le K, Baddour LM, et al. Cardiovascular implantable electronic device infections due to enterococcal species: Clinical features, management, and outcomes. Pacing Clin Electrophysiol 2019; 42:1331. 44. Uslan DZ, Sohail MR, Friedman PA, et al. Frequency of permanent pacemaker or implantable cardioverter-defibrillator infection in patients with gram-negative bacteremia. Clin Infect Dis 2006; 43:731. 45. Chesdachai S, Baddour LM, Sohail MR, et al. Risk of Cardiovascular Implantable Electronic Device Infection in Patients Presenting With Gram-Negative Bacteremia. Open Forum Infect Dis 2022; 9:ofac444. 46. Camus C, Leport C, Raffi F, et al. Sustained bacteremia in 26 patients with a permanent endocardial pacemaker: assessment of wire removal. Clin Infect Dis 1993; 17:46. 47. Baman JR, Medhekar AN, Jain SK, et al. Management of systemic fungal infections in the presence of a cardiac implantable electronic device: A systematic review. Pacing Clin Electrophysiol 2021; 44:159. 48. Nakamura T, Narui R, Holmes B, et al. Candidemia in patients with cardiovascular implantable electronic devices. J Interv Card Electrophysiol 2021; 60:69. 49. Da Costa A, Leli vre H, Kirkorian G, et al. Role of the preaxillary flora in pacemaker infections: a prospective study. Circulation 1998; 97:1791. 50. Chua JD, Wilkoff BL, Lee I, et al. Diagnosis and management of infections involving implantable electrophysiologic cardiac devices. Ann Intern Med 2000; 133:604. 51. Esquer Garrigos Z, George MP, Khalil S, et al. Predictors of Bloodstream Infection in Patients Presenting With Cardiovascular Implantable Electronic Device Pocket Infection. Open Forum Infect Dis 2019; 6:ofz084. 52. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010; 121:458. https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 24/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up 53. Nagpal A, Patel R, Greenwood-Quaintance KE, et al. Usefulness of sonication of cardiovascular implantable electronic devices to enhance microbial detection. Am J Cardiol 2015; 115:912. 54. Esquer Garrigos Z, Sohail MR, Greenwood-Quaintance KE, et al. Molecular Approach to Diagnosis of Cardiovascular Implantable Electronic Device Infection. Clin Infect Dis 2020; 70:898. 55. Downey BC, Juselius WE, Pandian NG, et al. Incidence and significance of pacemaker and implantable cardioverter-defibrillator lead masses discovered during transesophageal echocardiography. Pacing Clin Electrophysiol 2011; 34:679. 56. Patel NJ, Singleton MJ, Brunetti R, et al. Evaluation of lead-based echodensities on transesophageal echocardiogram in patients with cardiac implantable electronic devices. J Cardiovasc Electrophysiol 2023; 34:7. 57. Cox JN. Pathology of cardiac pacemakers and central catheters. Curr Top Pathol 1994; 86:199. 58. Spittell PC, Hayes DL. Venous complications after insertion of a transvenous pacemaker. Mayo Clin Proc 1992; 67:258. 59. Sohail MR, Uslan DZ, Khan AH, et al. Infective endocarditis complicating permanent pacemaker and implantable cardioverter-defibrillator infection. Mayo Clin Proc 2008; 83:46. 60. Huang XM, Fu HX, Zhong L, et al. Outcomes of Transvenous Lead Extraction for Cardiovascular Implantable Electronic Device Infections in Patients With Prosthetic Heart Valves. Circ Arrhythm Electrophysiol 2016; 9. 61. Voet JG, Vandekerckhove YR, Muyldermans LL, et al. Pacemaker lead infection: report of three cases and review of the literature. Heart 1999; 81:88. 62. Schulze MR, Ostermaier R, Franke Y, et al. Images in cardiovascular medicine. Aortic endocarditis caused by inadvertent left ventricular pacemaker lead placement. Circulation 2005; 112:e361. 63. Victor F, De Place C, Camus C, et al. Pacemaker lead infection: echocardiographic features, management, and outcome. Heart 1999; 81:82. 64. George MP, Esquer Garrigos Z, Vijayvargiya P, et al. Discriminative Ability and Reliability of Transesophageal Echocardiography in Characterizing Cases of Cardiac Device Lead Vegetations Versus Noninfectious Echodensities. Clin Infect Dis 2021; 72:1938. 65. Sohns JM, Bavendiek U, Ross TL, Bengel FM. Targeting Cardiovascular Implant Infection: Multimodality and Molecular Imaging. Circ Cardiovasc Imaging 2017; 10. https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 25/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up 66. Erba PA, Sollini M, Conti U, et al. Radiolabeled WBC scintigraphy in the diagnostic workup of patients with suspected device-related infections. JACC Cardiovasc Imaging 2013; 6:1075. 67. Ahmed FZ, James J, Memmott MJ, Arumugam P. Radionuclide Imaging of Cardiovascular Infection. Cardiol Clin 2016; 34:149. 68. Chen W, Sajadi MM, Dilsizian V. Merits of FDG PET/CT and Functional Molecular Imaging Over Anatomic Imaging With Echocardiography and CT Angiography for the Diagnosis of Cardiac Device Infections. JACC Cardiovasc Imaging 2018; 11:1679. 69. Sarrazin JF, Philippon F, Tessier M, et al. Usefulness of fluorine-18 positron emission tomography/computed tomography for identification of cardiovascular implantable electronic device infections. J Am Coll Cardiol 2012; 59:1616. 70. Brinker J. Imaging for infected cardiac implantable electronic devices: a new trick for your pet. J Am Coll Cardiol 2012; 59:1626. 71. Pizzi MN, Roque A, Fern ndez-Hidalgo N, et al. Improving the Diagnosis of Infective Endocarditis in Prosthetic Valves and Intracardiac Devices With 18F-Fluordeoxyglucose Positron Emission Tomography/Computed Tomography Angiography: Initial Results at an Infective Endocarditis Referral Center. Circulation 2015; 132:1113. 72. Calais J, Touati A, Grall N, et al. Diagnostic Impact of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography and White Blood Cell SPECT/Computed Tomography in Patients With Suspected Cardiac Implantable Electronic Device Chronic Infection. Circ Cardiovasc Imaging 2019; 12:e007188. 73. Juneau D, Golfam M, Hazra S, et al. Positron Emission Tomography and Single-Photon Emission Computed Tomography Imaging in the Diagnosis of Cardiac Implantable Electronic Device Infection: A Systematic Review and Meta-Analysis. Circ Cardiovasc Imaging 2017; 10. 74. Galea N, Bandera F, Lauri C, et al. Multimodality Imaging in the Diagnostic Work-Up of Endocarditis and Cardiac Implantable Electronic Device (CIED) Infection. J Clin Med 2020; 9. 75. Jer nimo A, Olmos C, Vilacosta I, et al. Accuracy of 18F-FDG PET/CT in patients with the suspicion of cardiac implantable electronic device infections. J Nucl Cardiol 2022; 29:594. 76. Mahmood M, Kendi AT, Farid S, et al. Role of 18F-FDG PET/CT in the diagnosis of cardiovascular implantable electronic device infections: A meta-analysis. J Nucl Cardiol 2019; 26:958. Topic 2146 Version 44.0 https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 26/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up GRAPHICS Microbiology of cardiac implantable electronic device (CIED) infections Pacemaker All CIED infections (pocket endocarditis and bloodstream) Organism Number of patients Number of pathogens [1] [2] (percent) (percent) Coagulase-negative staphylococci 99 (61) 183 (44) Staphylococcus aureus 49 (30) 148 (36) Enterobacteriaceae 8 (5) 18 (4) Streptococci 7 (4) 12 (3) Pseudomonas 6 (4) 12 (3) Other gram-negative bacteria 8 (2) Candida 3 (2) 2 (<1) Enterococci 3 (2) 20 (5) Corynebacterium 2 (1) 2 (<1) Cutibacterium (formerly Propionibacterium) acnes 1 (<1) 1 (<1) Listeria 1 (<1) Anaerobes 5 (1) Micrococci 1 (<1) Mycobacterium spp 2 (<1) Apergillus 1 (<1) Polymicrobial infection occurred in 11 percent of cases. References: 1. Arber N, Pras E, Copperman Y, et al. Medicine (Baltimore) 1994; 73:299; Duval X, Selton-Suty C, Alla F, et al. Clin Infect Dis 2004; 39:68; Klug D, Lacroix D, Savoye C, et al. Circulation 1997; 95:2098; and Cacoub P, Leprince P, Nataf P, et al. Am J Cardiol 1998; 82:480. 2. Tarakji KG, Chan EJ, Cantillon DJ, et al. Cardiac implantable electronic device infections: Presentation, management, and patient outcomes. Heart Rhythm 2010; 7:1043. Graphic 55942 Version 5.0 https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 27/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up Transvenous cardiac implantable electronic device (CIED) lead and pulse generator Transvenous CIED demonstrating the pulse generator in the left pectoral region with three transvenous leads in the right atrium, right ventricle, and coronary sinus/left ventricle as would be seen in a patient receiving cardiac resynchronization therapy. Used with permission of Mayo Foundation for Medical Education and Research. All rights reserved. https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 28/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up Graphic 118356 Version 2.0 https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 29/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up Pacemaker pocket erosion The pacemaker generator, implanted several years prior to presentation, is clearly visible beneath the skin and is on the verge of complete erosion (arrow). The patient was asymptomatic. The device and leads were easily removed. Although purulent material was present, cultures of the pocket obtained at the time of explant were negative. A new pacing system was placed on the contralateral side. Courtesy of Margaret Lloyd, MD. Graphic 74725 Version 3.0 https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 30/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up Approach to evaluation and management of suspected infection limited to cardiac implantable electronic device (CIED) pocket in adults https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 31/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up TEE: transesophageal echocardiogram; FDG PET/CT: fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography; SPECT/CT: radiolabeled autologous white blood cell single-photon emission computed tomography with computed tomography; MRSA: methicillin- resistant Staphylococcus aureus. Refer to separate UpToDate algorithm for approach to patients with systemic symptoms, positive blood cultures, and/or vegetation on TEE. FDG PET/CT may be useful to distinguish between CIED pocket infection and superficial site infection in some circumstances; refer to the 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 Linezolid 600 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 We favor initial therapy with vancomycin (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. Graphic 117258 Version 5.0 https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 32/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up Approach to evaluation and management of suspected infection of a cardiac implantable electronic device (CIED) in adults TTE: transthoracic echocardiogram; TEE: transesophageal echocardiogram. Signs and symptoms of an isolated CIED pocket infection include pocket erythema, discomfort, swelling, incision dehiscence, deformation, and erosion. Signs and symptoms of endocarditis include new murmur, new regurgitation, vegetation, paravalvular leak, evidence of pulmonary or systemic emboli, and immune phenomena. https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 33/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up Vancomycin dosing consists of 15 to 20 mg/kg/dose intravenously every 8 to 12 hours (not to exceed 2 g per dose); in patients presenting with severe sepsis, broadening of parenteral therapy to include gram-negative bacteria is appropriate. Refer to UpToDate text for further discussion. The choice of antibiotic regimen is guided by blood culture results (refer to UpToDate text). The duration of antibiotic therapy (4 to 6 weeks) should be counted from the day of device explantation, if warranted. Graphic 117257 Version 7.0 https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 34/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up Approach to management of adults with suspected CIED infection and negative UpToDate algorithm for approach to initial diagnostic evaluation) CIED: cardiac implantable electronic device; TEE: transesophageal echocardiogram; FDG PET/CT: fluorine-18 f tomography/computed tomography; SPECT/CT: single photon emission computed tomography/computed to High-grade bacteremia is defined as multiple (2 or more) separate blood cultures positive for the same org for coagulase-negative staphylococci or Cutibacterium species may represent skin contamination. In such cas grade bacteremia. If repeat cultures are confounded by antibiotic therapy and clinical suspicion for CIED infe PET/CT) if available; further management should be guided by consultation with infectious disease expertise Clinical suspicion is increased for organisms that commonly cause endocarditis. FDG PET/CT may be useful to establish a diagnosis of CIED infection in some circumstances. Other potentia https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 35/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up The choice and duration of antibiotic therapy is based on regimens for treatment of endocarditis caused by implicated (refer to UpToDate text and related topics). The duration of antibiotic therapy (usually 4 to 6 weeks warranted. The choice of antibiotic therapy is guided by culture results. Graphic 131691 Version 2.0 https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 36/37 7/6/23, 10:53 AM Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis - Up Contributor Disclosures Adolf W Karchmer, MD Equity Ownership/Stock Options: AbbVie [Pharmaceuticals]; Johnson and Johnson [Pharmaceuticals]; Lilly [Pharmaceuticals]; Merck [Pharmaceuticals]; Pfizer [Pharmaceuticals]. Grant/Research/Clinical Trial Support: Karius [Endocarditis]. Consultant/Advisory Boards: Debio International [Antibiotic development]; Pfizer [Rheumatologic diseases, ulcerative colitis]. Other Financial Interest: Board of Directors [Winter Course in Infectious Diseases]. All of the relevant financial relationships listed have been mitigated. Vivian H Chu, MD, MHS No relevant financial relationship(s) with ineligible companies to disclose. Jay A Montgomery, MD No relevant financial relationship(s) with ineligible companies to disclose. Stephen B Calderwood, MD Consultant/Advisory Boards: Day Zero Diagnostics [Whole genome sequencing for microbial identification and determination of antimicrobial susceptibility]. All of the relevant financial relationships listed have been mitigated. Elinor L Baron, MD, DTMH No relevant financial relationship(s) with ineligible companies to disclose. Todd F Dardas, MD, MS No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/infections-involving-cardiac-implantable-electronic-devices-epidemiology-microbiology-clinical-manifestations-an 37/37