A Roadmap for Reducing Cardiac Device Infections: a Review of Epidemiology, Pathogenesis, and Actionable Risk Factors to Guide the Development of an Infection Prevention Program for the Electrophysiology Laboratory


Purpose of Review

Cardiovascular implantable electronic device (CIED) infections are highly morbid, common, and costly, and rates are increasing (Sohail et al. Arch Intern Med 171(20):1821–8 2011; Voigt et al. J Am Coll Cardiol 48(3):590–1 2006). Factors that contribute to the development of CIED infections include patient factors (comorbid conditions, self-care, microbiome), procedural details (repeat procedure, contamination during procedure, appropriate pre-procedural prep, and antimicrobial use), environmental and organizational factors (patient safety culture, facility barriers, such as lack of space to store essential supplies, quality of environmental cleaning), and microbial factors (type of organism, virulence of organism). Each of these can be specifically targeted with infection prevention interventions.

Recent Findings

Basic prevention practices, such as administration of systemic antimicrobials prior to incision and delaying the procedure in the setting of fever or elevated INR, are helpful for day-to-day prevention of cardiac device infections. Small single-center studies provide proof-of-concept that bundled prevention interventions can reduce infections, particularly in outbreak settings. However, data regarding which prevention strategies are the most important is limited as are data regarding the optimal prevention program for day-to-day prevention (Borer et al. Infect Control Hosp Epidemiol 25(6):492–7 2004; Ahsan et al. Europace 16(10):1482–9 2014).


Evolution of infection prevention programs to include ambulatory and procedural areas is crucial as healthcare delivery is increasingly provided outside of hospitals and operating rooms. The focus on traditional operating rooms and inpatient care leaves the vast majority of healthcare delivery—including cardiac device implantations in the electrophysiology laboratory—uncovered.

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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    JP N, Thompson A, Mahajan A. Managing cardiovascular implantable devices during perioperative care. The Anesthesia Patient Safety Foundation [Internet]. 2013. Available from: http://www.apsf.org/newsletters/html/2013/fall/01_cieds.htm.

  2. 2.

    Greenspon AJ, Patel JD, Lau E, Ochoa JA, Frisch DR, Ho RT, et al. Trends in permanent pacemaker implantation in the United States from 1993 to 2009: increasing complexity of patients and procedures. J Am Coll Cardiol. 2012;60(16):1540–5.

    Article  PubMed  Google Scholar 

  3. 3.

    •• Bradshaw PJ, Stobie P, Knuiman MW, Briffa TG, Hobbs MS. Trends in the incidence and prevalence of cardiac pacemaker insertions in an ageing population. Open Heart. 2014;1(1):e000177. This article discusses the changing epidemiology of cardiac device infections.

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Zhan C, Baine WB, Sedrakyan A, Steiner C. Cardiac device implantation in the United States from 1997 through 2004: a population-based analysis. J Gen Intern Med. 2008;23(Suppl 1):13–9.

    Article  PubMed  Google Scholar 

  5. 5.

    Podoleanu C, Deharo JC. Management of cardiac implantable electronic device infection. Arrhythm Electrophysiol Rev. 2014;3(3):184–9.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Voigt A, Shalaby A, Saba S. Rising rates of cardiac rhythm management device infections in the United States: 1996 through 2003. J Am Coll Cardiol. 2006;48(3):590–1.

    Article  PubMed  Google Scholar 

  7. 7.

    Rahman R, Saba S, Bazaz R, Gupta V, Pokrywka M, Shutt K, et al. Infection and readmission rate of cardiac implantable electronic device insertions: an observational single center study. Am J Infect Control. 2016;44(3):278–82.

    Article  PubMed  Google Scholar 

  8. 8.

    Margey R, McCann H, Blake G, Keelan E, Galvin J, Lynch M, et al. Contemporary management of and outcomes from cardiac device related infections. Europace. 2010;12(1):64–70.

    Article  PubMed  Google Scholar 

  9. 9.

    Baman TS, Gupta SK, Valle JA, Yamada E. Risk factors for mortality in patients with cardiac device-related infection. Circ Arrhythm Electrophysiol. 2009;2(2):129–34.

    Article  PubMed  Google Scholar 

  10. 10.

    Rizwan Sohail M, Henrikson CA, Jo Braid-Forbes M, Forbes KF, Lerner DJ. Increased long-term mortality in patients with cardiovascular implantable electronic device infections. Pacing Clin Electrophysiol. 2015;38(2):231–9.

    Article  PubMed  Google Scholar 

  11. 11.

    Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121(3):458–77.

    Article  PubMed  Google Scholar 

  12. 12.

    •• Sohail MR, Henrikson CA, Braid-Forbes MJ, Forbes KF, Lerner DJ. Mortality and cost associated with cardiovascular implantable electronic device infections. Arch Intern Med. 2011;171(20):1821–8. This article outlines the high morbidity, mortality, and healthcare costs associated with cardiac device infections.

    Article  PubMed  Google Scholar 

  13. 13.

    Schweizer ML, Cullen JJ, Perencevich EN, Vaughan Sarrazin MS. Costs associated with surgical site infections in Veterans Affairs Hospitals. JAMA surgery. 2014;149(6):575-81. doi:10.1001/jamasurg.2013.4663.

  14. 14.

    • Nagpal A, Baddour LM, Sohail MR. Microbiology and pathogenesis of cardiovascular implantable electronic device infections. Circ Arrhythm Electrophysiol. 2012;5(2):433–41. This article discusses the microbiology of cardiac device infections.

    Article  PubMed  Google Scholar 

  15. 15.

    Schneider P, Katz DF, Pellegrini CN, Heidenreich PA, Aleong RA, Keung E, et al., editors. Rates and association of risk factors with device infection in veterans undergoing cardioverter-defibrillator implantation enrolled in the OVID Registry. Annual Meeting of the American Heart Association; 2013; Dallas, TX.

  16. 16.

    •• Polyzos KA, Konstantelias AA, Falagas ME. Risk factors for cardiac implantable electronic device infection: a systematic review and meta-analysis. Europace. 2015;17(5):767–77. This article discusses patient and procedural risk factors associated with cardiac device infections.

    Article  PubMed  Google Scholar 

  17. 17.

    • Turagam MK, Nagarajan DV, Bartus K, Makkar A, Swarup V. Use of a pocket compression device for the prevention and treatment of pocket hematoma after pacemaker and defibrillator implantation (STOP-HEMATOMA-I). J Interv Card Electrophysiol. 2017;49(2):197-204. doi:10.1007/s10840-017-0235-9. This article evaluates the impact of a compression device for reducing post-procedural hematomas. Hematomas are a risk factor for cardiac device infections, so this intervention can be used as an infection prevention intervention

  18. 18.

    Qintar M, Zardkoohi O, Hammadah M, Hsu A, Wazni O, Wilkoff BL, et al. The impact of changing antiseptic skin preparation agent used for cardiac implantable electronic device (CIED) procedures on the risk of infection. Pacing Clin Electrophysiol. 2015;38(2):240–6.

    Article  PubMed  Google Scholar 

  19. 19.

    Khalighi K, Aung TT, Elmi F. The role of prophylaxis topical antibiotics in cardiac device implantation. Pacing Clin Electrophysiol. 2014;37(3):304–11.

    Article  PubMed  Google Scholar 

  20. 20.

    Finkelstein R, Rabino G, Mashiach T, Bar-El Y, Adler Z, Kertzman V, et al. Effect of preoperative antibiotic prophylaxis on surgical site infections complicating cardiac surgery. Infect Control Hosp Epidemiol. 2014;35(1):69–74.

    Article  PubMed  Google Scholar 

  21. 21.

    Darouiche R, Mosier M, Voigt J. Antibiotics and antiseptics to prevent infection in cardiac rhythm management device implantation surgery. Pacing Clin Electrophysiol. 2012;35(11):1348–60.

    Article  PubMed  Google Scholar 

  22. 22.

    •• de Oliveira JC, Martinelli M, Nishioka SA, Varejao T, Uipe D, Pedrosa AA, et al. Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter-defibrillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial. Circ Arrhythm Electrophysiol. 2009;2(1):29–34. This sentinel paper highlights the importance of antimicrobial prophylaxis for preventing cardiac device infections.

    Article  PubMed  Google Scholar 

  23. 23.

    Bongiorni MG, Marinskis G, Lip GY, Svendsen JH, Dobreanu D, Blomstrom-Lundqvist C, et al. How European centres diagnose, treat, and prevent CIED infections: results of an European Heart Rhythm Association survey. Europace. 2012;14(11):1666–9.

    Article  PubMed  Google Scholar 

  24. 24.

    Mehrotra P, Gupta K, Strymish J, Kramer DB, Lambert-Kerzner A, Ho PM, Branch-Elliam W. Implementation of Infection Prevention and Antimicrobial Stewardship in Cardiac Electrophysiology Laboratories: results from the SHEA Research Network. Infect Control Hosp Epidemiol. 2017:38(4):496-98. doi:10.1017/ice.2016.309.

  25. 25.

    Branch-Elliman W, Stanislawski M, Strymish J, Baron AE, Gupta K, Varosy PD, et al. Cardiac electrophysiology laboratories: a potential target for antimicrobial stewardship and quality improvement? Infect Control Hosp Epidemiol. 2016;37(9):1005–11.

    Article  PubMed  Google Scholar 

  26. 26.

    Regimbeau JM, Fuks D, Pautrat K, Mauvais F, Haccart V, Msika S, et al. Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis: a randomized clinical trial. JAMA. 2014;312(2):145–54.

    Article  PubMed  Google Scholar 

  27. 27.

    Townley WA, Baluch N, Bagher S, Maass SW, O'Neill A, Zhong T, et al. A single pre-operative antibiotic dose is as effective as continued antibiotic prophylaxis in implant-based breast reconstruction: a matched cohort study. J Plast Reconstr Aesthet Surg. 2015;68(5):673–8.

    Article  PubMed  Google Scholar 

  28. 28.

    Harbarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation. 2000;101(25):2916–21.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review. Aust N Z J Surg. 1998;68(6):388–96.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Santana RS, Viana Ade C, Santiago Jda S, Menezes MS, Lobo IM, Marcellini PS. The cost of excessive postoperative use of antimicrobials: the context of a public hospital. Rev Col Bras Cir. 2014;41(3):149–54.

    Article  PubMed  Google Scholar 

  31. 31.

    Carignan A, Allard C, Pepin J, Cossette B, Nault V, Valiquette L. Risk of Clostridium difficile infection after perioperative antibacterial prophylaxis before and during an outbreak of infection due to a hypervirulent strain. Clin Infect Dis. 2008;46(12):1838–43.

    Article  PubMed  Google Scholar 

  32. 32.

    Lakshmanadoss U, Nuanez B, Kutinsky I, Khalid R, Haines DE, Wong WS. Incidence of pocket infection postcardiac device implantation using antibiotic versus saline solution for pocket irrigation. Pacing Clin Electrophysiol. 2016;39(9):978–84.

    Article  PubMed  Google Scholar 

  33. 33.

    Kolek MJ, Dresen WF, Wells QS, Ellis CR. Use of an antibacterial envelope is associated with reduced cardiac implantable electronic device infections in high-risk patients. Pacing Clin Electrophysiol. 2013;36(3):354–61.

    Article  PubMed  Google Scholar 

  34. 34.

    Shariff N, Eby E, Adelstein E, Jain S, Shalaby A, Saba S, et al. Health and economic outcomes associated with use of an antimicrobial envelope as a standard of care for cardiac implantable electronic device implantation. J Cardiovasc Electrophysiol. 2015;26(7):783–9.

    Article  PubMed  Google Scholar 

  35. 35.

    Mittal S, Shaw RE, Michel K, Palekar R, Arshad A, Musat D, et al. Cardiac implantable electronic device infections: incidence, risk factors, and the effect of the AigisRx antibacterial envelope. Heart Rhythm. 2014;11(4):595–601.

    Article  PubMed  Google Scholar 

  36. 36.

    Shariff N, Akthar T, Razak E, Segerson N, Schwartzman D. Cardiovascular implantable electronic device infections: risk scoring and role of antibiotic envelope in prevention. Recent Adv Cardiovasc Drug Discov. 2015;10(1):70–6.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Tang HJ, Lin HL, Lin YH, Leung PO, Chuang YC, Lai CC. The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infect Dis. 2014;14:356.

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH, Hyzy RC, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;32(4):305–14.

    Article  PubMed  Google Scholar 

  39. 39.

    de Vries EN, Dijkstra L, Smorenburg SM, Meijer RP, Boermeester MA. The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg. 2010;4(1):6.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Sparkes D, Rylah B. The World Health Organization Surgical Safety Checklist. Br J Hosp Med (Lond). 2010;71(5):276–80.

    Article  Google Scholar 

  41. 41.

    Bergs J, Hellings J, Cleemput I, Zurel O, De Troyer V, Van Hiel M, et al. Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg. 2014;101(3):150–8.

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Lepanluoma M, Rahi M, Takala R, Loyttyniemi E, Ikonen TS. Analysis of neurosurgical reoperations: use of a surgical checklist and reduction of infection-related and preventable complication-related reoperations. J Neurosurg. 2015:123(1):145-52. doi:10.3171/2014.12.JNS141077.

  43. 43.

    Manolis AS, Melita H. Prevention of cardiac implantable electronic device infections: single operator technique with use of povidone-iodine, double gloving, meticulous aseptic/antiseptic measures and antibiotic prophylaxis. Pacing Clin Electrophysiol. 2017;40(1):26–34.

    Article  PubMed  Google Scholar 

  44. 44.

    Ahsan SY, Saberwal B, Lambiase PD, Koo CY, Lee S, Gopalamurugan AB, et al. A simple infection-control protocol to reduce serious cardiac device infections. Europace. 2014;16(10):1482–9.

    Article  PubMed  Google Scholar 

  45. 45.

    Chen LF, Vander Weg MW, Hofmann DA, Reisinger HS. The Hawthorne effect in infection prevention and epidemiology. Infect Control Hosp Epidemiol. 2015;36(12):1444–50.

    Article  PubMed  Google Scholar 

  46. 46.

    Sykes PK, Brodribb RK, McLaws ML, McGregor A. When continuous surgical site infection surveillance is interrupted: the Royal Hobart Hospital experience. Am J Infect Control. 2005;33(7):422–7.

    Article  PubMed  Google Scholar 

  47. 47.

    Boggan JC, Baker AW, Lewis SS, Dicks KV, Durkin MJ, Moehring RW, et al. An automated surveillance strategy to identify infectious complications after cardiac implantable electronic device procedures. Open Forum Infect Dis. 2015;2(4):ofv128.

    Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Kondo Y, Ueda M, Kobayashi Y, Schwab JO. New horizon for infection prevention technology and implantable device. J Arrhythm. 2016;32(4):297–302.

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Schwartzman D, Pasculle AW, Ceceris KD, Smith JD, Weiss LE, Campbell PG. An off-the-shelf plasma-based material to prevent pacemaker pocket infection. Biomaterials. 2015;60:1–8.

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    Marsch G, Mashaqi B, Burgwitz K, Bisdas T, Knigina L, Stiesch M, et al. Prevention of pacemaker infections with perioperative antimicrobial treatment: an in vitro study. Europace. 2014;16(4):604–11.

    Article  PubMed  Google Scholar 

  51. 51.

    Strymish J, Welch B, Peralta A, Hoffmeister P, Branch-Elliman W, Gupta K. Implementation of a surgical site infection prevention bundle in the cardiac electrophysiology laboratory for management of a cluster of cardiac device infections. In: Open forum infectious diseases. Oxford: Oxford University Press; 2016.

    Google Scholar 

  52. 52.

    Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States. Natl Health Stat Report. 2006;2009(11):1–25.

    Google Scholar 

  53. 53.

    Borer A, Gilad J, Hyam E, Schlaeffer F, Schlaeffer P, Eskira S, et al. Prevention of infections associated with permanent cardiac antiarrhythmic devices by implementation of a comprehensive infection control program. Infect Control Hosp Epidemiol. 2004;25(6):492–7.

    Article  PubMed  Google Scholar 

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Corresponding author

Correspondence to Westyn Branch-Elliman.

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Conflict of Interest

Westyn Branch-Elliman is supported by a Veterans Integrated Service Network (VISN)-1 Career Development Award and is the recipient of an American Heart Association Institute for Precision Cardiovascular Medicine Award no. 17IG33630052.

Dr. Branch-Elliman declares no conflicts of interest.

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This article is part of the Topical Collection on Healthcare Associated Infections

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Branch-Elliman, W. A Roadmap for Reducing Cardiac Device Infections: a Review of Epidemiology, Pathogenesis, and Actionable Risk Factors to Guide the Development of an Infection Prevention Program for the Electrophysiology Laboratory. Curr Infect Dis Rep 19, 34 (2017). https://doi.org/10.1007/s11908-017-0591-8

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  • Cardiac device infection
  • Infection prevention and control
  • Surveillance
  • Quality improvement