Cardiac Implantable Electronic Devices (CIEDs), like pacemakers and defibrillators, have become an essential part of modern cardiac care—especially as our population ages. While these devices are lifesaving, occasionally they can become infected, and may be difficult to manage.

CIED infections are uncommon; and one of the main challenges is that when patients present to primary care clinics or emergency departments, the first line clinicians may not have experience with such infections, possibly resulting in diagnostic delay or inappropriate treatment. This is particularly difficult in remote parts of the province, where timely access to imaging and specialist evaluation is more difficult.

Management of confirmed CIED infection includes complete removal of the device and its leads, usually by laser lead extraction—a complex procedure, which in British Columbia is only performed at St. Paul’s Hospital (SPH) in Vancouver and the Royal Jubilee Hospital (RJH) in Victoria. The laser lead extraction team at SPH has seen various patients from all regions of BC with delays in referral and optimal management resulting in prolonged hospital stay, increased mortality, and increased healthcare costs.  Realizing the need for a more effective strategy with greater awareness and communication, Dr. Jamil Bashir (Head, Division of Cardiac Surgery for UBC) and Dr. Peter Phillips (Division of Infectious Diseases, SPH) launched an initiative through the Department of Medicine Innovation Platform. Their mission: to enhance early detection, simplify the referral process, and ensure patients receive timely and appropriate care. This effort united a province-wide team of clinicians to tackle these issues, including publishing a clinical review of CIED infection management in CJC Open.  A summary of these guidelines is provided below:

5 Key Points for Managing CIED Infections

1. Clinical Presentations Can Be Subtle and Misleading

CIED infections are often hard to detect. They may present with minor or hidden changes at the pocket site—like a small scab that conceals a draining sinus. About two-thirds of infections are limited to the pocket, while others involve bloodstream infections, sometimes including endocarditis. Up to 25% of patients may show no symptoms or signs at the pocket site and instead report non-specific symptoms such as fever, malaise, night sweats, or even respiratory symptoms from septic pulmonary emboli.

2. Diagnostic Evaluation

When infection is suspected, always collect two sets of blood cultures before starting antibiotics, regardless of whether or not there are documented or symptomatic fevers. Echocardiography is often needed to assess for endocarditis. Needle aspiration of a fluid collection at the device pocket site is not recommended due to concern related to possible inadvertent contamination of the device.

3. Use of Empiric Antibiotic Therapy—Or Withholding Antibiotics in Stable Patients

The empiric antibiotic (typically vancomycin) should target common culprits like Staphylococcus aureus and coagulase-negative staphylococci. In patients who are stable and not showing systemic signs (i.e., no SIRS), it’s reasonable to withhold antibiotics until the time of device removal in order to improve the yield of cultures collected from the surgical site. If bacteremia is suspected, initial antibiotic therapy should also include gram-negative antibacterial coverage, pending culture results.

4. Complete Removal of the Device and Leads Is Essential

CIED infections persist unless the entire device and all associated leads are removed. Indefinite longterm antibiotic therapy without removal of the device and leads may suppress infection, but should be reserved for those who are considered to have unacceptably high surgical risk. In B.C., device and laser sheath lead removal are only available at SPH (Vancouver) and RJH (Victoria). For confirmed or strongly suspected cases, early referral to the on-call cardiologist at either of these centers is critical.

5. Prevent Infection When the Device Is Implanted

Preventative steps include using pre-operative antibiotic prophylaxis and managing anticoagulation carefully to avoid surgical site hematomas. Notably, anticoagulant therapy bridging with low-molecular-weight heparin (LMWH) is associated with a higher risk of pocket hematomas and should be avoided.

As the number of people living with CIEDs in B.C. continues to grow, especially with an aging population, building awareness and improving coordination of care is key.