How to Approach Patients with Cardiac Implantable Electronic Devices and Bacteremia.

The approach to a patient with a cardiac implantable electronic device (CIED) and bacteremia requires a high index of suspicion. The microorganism and duration of bacteremia affect the pretest probability of CIED infection. When transesophageal echocardiography findings are equivocal, fluorodeoxyglucose-PET/computed tomography can increase the sensitivity and specificity for CIED infection. Confirmed CIED infection warrants complete system extraction. In patients with persistent gram-positive bacteremia despite antimicrobial therapy and unclear involvement of the CIED, the device is sometimes empirically extracted. Long-term effects of extraction (such as risk of suboptimal/failed cardiac resynchronization therapy reimplant) should be factored into decisions regarding empiric CIED extraction.