Characteristics, practice patterns of removal, and relapse bacteraemia in patients with a cardiac implantable electronic device (CIED) and bacteraemia: a nationwide study
A Alhakak, L Ostergaard, N E Bruun, A C Ruwald, M V Le, K H Bengtsen, M Vinther, P G Jorgensen, E Havers-Borgersen, J A Povlsen, J C Nielsen, J B Johansen, H Bundgaard, L Kober, E L FosbolAbstract
Background
International guidelines provide heterogeneous recommendations regarding CIED removal in possible CIED-related IE with bloodstream infection (BSI). While some guidelines, including EHRA and to some extent ESC, recommend removal, the available evidence is limited (level C), calling for further unselected longitudinal data.
Purpose
To examine characteristics and relapse of BSI in patients with a CIED and first-time BSI according to CIED removal status.
Methods
Patients aged ≥18 years with a CIED and first-time BSI (≥1 positive blood culture) caused by IE-relevant pathogens (staphylococci, streptococci [except Streptococcus pneumoniae], and Enterococcus faecalis) were identified using Danish nationwide registries (2010–2023). Patients with IE or death during index admission were excluded. CIED removal during index admission was assessed. Cumulative incidences of relapse BSI within six months after discharge were estimated with death as a competing risk, stratified by removal status.
Results
A total of 1,511 patients with a CIED and first-time BSI were identified; 262 (17.3%) were excluded due to IE and 354 (23.4%) due to death during index admission. CIED removal was performed in 94 (35.9%) of excluded patients with IE. The remaining 895 patients comprised the study population. Median age was 80.1 years, 300 (33.5%) were female, and 40 (4.5%) had prior IE. In total, 32 patients (3.6%) underwent CIED removal. The removal group was younger and less frail than the non-removal group (76.0 vs. 80.3 years). Comorbidities were similar between groups, except for higher prevalence of chronic heart failure and renal disease in the non-removal group.
The most common pathogens were coagulase-negative staphylococci (CoNS) 348 (38.9%), followed by Staphylococcus aureus 243 (27.2%), Streptococcus spp. 184 (20.6%), and Enterococcus faecalis 120 (13.4%). Staphylococcus aureus was more frequent in the removal group than in the non-removal group (25/32, 78.1% vs. 218/863, 25.3%). Among patients with Staphylococcus aureus BSI, 25/243 (10.3%) underwent CIED removal, whereas no patients with CoNS BSI underwent removal. The six-month cumulative incidence of relapse BSI was 0% vs. 3.4% (95% CI 2.3–4.8) in the removal and non-removal groups (Figure). The most common relapse pathogens in the non-removal group were Staphylococcus aureus 15/29 (51.7%) and CoNS 9/29 (31.0%).
Conclusions
In this nationwide cohort of patients with a CIED and first-time BSI without IE, device removal was performed in a minority of patients, most of whom had Staphylococcus aureus infection. Patients who underwent removal were younger and less frail than those without removal. Relapse BSI occurred rarely and only in patients without removal. However, the low number of removals limits firm conclusions. These findings highlight persistent uncertainty regarding optimal treatment and underscore the need for randomized clinical trials.