ampk activator Despite these recommendations diagnosing CIED

Despite these recommendations, diagnosing CIED infection could be challenging. Early after implantation procedure it is important to differentiate CIED pocket infection from incisional erythema or superficial wound infection or stitch abscess. These cases usually resolve with local measures and sometimes short course of oral ampk activator directed against staph species. Close follow up is important to avoid missing the diagnosis of CIED pocket infection. Patients with CIED pocket infections can present acutely or subacutely after device implant or replacement procedure, but sometimes it could be months or even years before the infection becomes manifest [7]. CIED endocarditis patients can have atypical presentations which could delay the diagnosis compared to patients with native or prosthetic valve endocarditis [18].
Management
Reimplant The management plan for treating CIED infection should take into consideration the need for reimplant as this might affect our approach in CIED removal as discussed earlier. Reimplant should not be an automatic decision, but rather CIED removal should be an opportunity to reassess the need for the device. In our experience, almost one third of the patients undergoing CIED removal for infection did not require immediate reimplant [7]. Patients who had an ICD implanted for primary prevention for impaired left ventricular function might not need it if they have never had ICD therapies and the ventricular function has now recovered with medical therapy. Patients who underwent pacemaker implant for possible sinus node dysfunction might not need it (at least not immediately) if the data from the prior device showed minimal need for pacing. The emergence of new and advanced medical conditions that would affect survival or quality of life like would make us avoid reimplanting an ICD for primary prevention. When reimplant is needed, it should be performed on the opposite side of the chest. Other alternative approaches include abdominal device with transiliac lead implantation or epicardial lead surgical implantation. There are no randomized trials to guide the timing of reimplant, but this usually depends on several factors including the type of infection, the presence of positive blood cultures, and the pathogen involved. Patients with positive blood cultures and no evidence of endocarditis (no valve vegetation) can be reimplanted if the repeat blood cultures after CIED removal remain negative for 72h.
Outcomes and economic burden CIED infections carry significant morbidity and mortality [7,15]. In-hospital mortality among patients admitted with CIED infection ranges between 4% and 10% [7,10,17–19] and 1-year mortality ranges between 15% and 20% [7,17,18,20]. Mortality is higher among patients with endovascular infection (especially with endocarditis) compared to patients with pocket infection [7,18]. Contrary to common belief, only a small proportion of the in-hospital mortality is directly related to the extraction procedure itself, [7] reflecting the serious significance of CIED infection itself and the comorbidities among these patients. The high morbidity and mortality, along with prolonged hospital stay, antimicrobial therapy, added to the cost of extraction and potential reimplantation of a new device, all result in significant financial burden that has been increasing over the last two decades [5,21,22].
Prevention The best strategy to address CIED infection is to prevent its occurrence. This process starts with the decision of implanting a CIED. Thorough evaluation of the recipient of the device is invaluable and the following questions should always be addressed. Is the device indicated? Is the timing appropriate? Is the patient ready? CIED should not be implanted if there is any documented fever or concern for an active infection. Temporary pacemaker should be avoided if possible prior to implanting a new device. Patients who are found to be colonized with methicillin resistant Staphylococcus aureus can benefit from decolonization using nasal application of Bactroban ointment [23]. All efforts should be made to minimize the risk of bleeding and hematoma including holding the use of anticoagulants if possible. In our experience, if anticoagulation cannot be interrupted, we find that performing the implantation on coumadin (with INR equal or less than 2.5) carries less risk of hematoma than bridging with heparin. Recommendations for CIED implantation while using newer oral anticoagulants require further studies. The use of low molecular weight heparin should be avoided around the time of implantation. Strict surgical techniques should be applied at time of implantation, these include antiseptic skin preparation, washing the pocket with saline or antibiotic solution and perioperative antibiotic use [24–26]. Many centers use first generation cephalosporin, however, the increasing proportion of methicillin resistance among Staph species have led many centers, including our own institution, to use vancomycin for perioperative prophylaxis [2,7]. Future advancement in minimizing CIED infection include the use or antibacterial envelope [27]. Rechargeable batteries in the future would hopefully minimize the need for CIED change procedures which carry a high risk for infection.