Europace (2020) 22, 515–516 EHRA CONSENSUS PAPER doi:10.1093/europace/euz246 European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac Downloaded from https://academic.oup.com/europace/article-abstract/22/4/515/5614580 by guest on 05 August 2020 implantable electronic device infections— endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) Carina Blomstro¨m-Lundqvist (Chair)1*, Vassil Traykov (Co-Chair)2, Paola Anna Erba3, Haran Burri4, Jens Cosedis Nielsen5, Maria Grazia Bongiorni6, Jeanne Poole (HRS representative)7, Giuseppe Boriani8, Roberto Costa (LAHRS representative)9, Jean-Claude Deharo10, Laurence M. Epstein (HRS representative)11, Laszlo Saghy12, Ulrika Snygg-Martin (ESCMID and ISCVID representative)13, Christoph Starck (EACTS representative)14, Carlo Tascini (ESCMID representative)15, and Neil Strathmore (APHRS representative)16 1Department of Medical Science and Cardiology, Uppsala University, Uppsala, Sweden; 2Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria; 3Nuclear Medicine, Department of Translational Research and New Technology in Medicine, University of Pisa, Pisa, Italy, and University of Groningen, University Medical Center Groningen, Medical Imaging Center, Groningen, The Netherlands; 4Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland; 5Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; 6Division of Cardiology and Arrhythmology, CardioThoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy; 7Division of Cardiology, University of Washington, Seattle, WA, USA; 8Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; 9Department of Cardiovascular Surgery, Heart Institute (InCor) of the University of S~ao Paulo, S~ao Paulo, Brazil; 10Department of Cardiology, Aix Marseille Universite´, CHU la Timone, Marseille, France; 11Electrophysiology, Northwell Health, Hofstra/ Northwell School of Medicine, Manhasset, NY, USA; 12Division of Electrophysiology, 2nd Department of Medicine and Cardiology Centre, University of Szeged, Szeged, * Tel: +46 18 611 3113. Corresponding author. E-mail address: [email protected] VC The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] 516 C. Blomstro¨m-Lundqvist et al. Hungary; 13Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 14Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; 15First Division of Infectious Diseases, Cotugno Hospital, Azienda ospedaliera dei Colli, Naples, Italy; and 16Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia Received 1 August 2019; editorial decision 11 August 2019; accepted 19 August 2019; online publish-ahead-of-print 8 November 2019 Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infec- tion, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket anti- Downloaded from https://academic.oup.com/europace/article-abstract/22/4/515/5614580 by guest on 05 August 2020 biotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagno- sis, and treatment of CIED infections. ................................................................................................................................................................................................... Keywords Infection • Endocarditis • Microbiology • Cardiac implantable electronic devices • Implantable cardioverter- defibrillators • Pacemakers • Cardiac resynchronization therapy • Leads • Extraction • Re-implantation • EHRA consensus document Table of contents Re-intervention ............................................ 516i Diagnosis of cardiac implantable electronic device infections Introduction .................................................... 516a andrelatedcomplications........................................ 516i Scopeoftheconsensusdocument............................. 516a Clinicalfindings ............................................... 516i Methodology ................................................. 516a Identification of the causative microorganisms . 516i Backgroundandepidemiology ................................... 516a Imaging....................................................... 516k Pathogenesis and microbiology of cardiac implantable Echocardiography .......................................... 516k electronicdeviceinfections ...................................... 516b Radiolabelled leucocyte scintigraphy, positron emission Risk factors for cardiac implantable electronic device infection . 516c tomography,andcomputerizedtomography ................ 516l Riskstratification.............................................. 516e Management of cardiac implantable electronic device infections: Prevention ...................................................... 516e when,how,andwhere........................................... 516n Pre-proceduralmeasures ..................................... 516e Cardiac implantable electronic device removal . 516n Patientselection............................................ 516e Antimicrobial therapy including long-term suppressive Leadmanagement.......................................... 516e therapy....................................................... 516p Patientfactors.............................................. 516e Preventive strategies after cardiac implantable electronic Anticoagulationandantiplateletdrugs ....................... 516e device implantations, new re-implantations, and Appropriateenvironment .................................. 516e alternativenoveldevices......................................... 516r Stafftraining................................................ 516e Preventive strategies after cardiac implantable electronic Nasal swabs/S. aureus decolonization of patients . 516e deviceimplantations .......................................... 516r Pre-procedureskinpreparation............................. 516h Re-implantations.............................................. 516r Pre-procedureantibiotictherapy............................ 516h Alternativenoveldevices...................................... 516s Peri-proceduralmeasures ..................................... 516h Prognosis, outcomes, and complications of cardiac Patientsurgicalpreparation ................................. 516h implantableelectronicdeviceinfections .......................... 516s Goodsurgicaltechnique.................................... 516h Special considerations to prevent device-related Antibioticenvelope......................................... 516h infections (elderly, paediatrics, adult with congenital Local instillation of antibiotics or antiseptics . 516h heartdisease) ................................................... 516t Capsulectomy.............................................. 516h Minimum quality requirements concerning centres and Closure.................................................... 516h operatorexperienceandvolume................................. 516u Post-proceduralmeasures .................................... 516i Health economics for cardiac implantable electronic Post-procedureantibiotictherapy........................... 516i devicesinfectionsandstrategiestoreducecosts .................. 516v Woundcare ............................................... 516i Divergent recommendations