Suspected CIED systemic infection in adults: Approach to management in setting of positive blood cultures but TEE negative for vegetation (refer to separate algorithm for initial evaluation)

CIED: cardiac implantable electronic device; CTA: CT angiography; FDG PET/CT: fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography; SPECT/CT: single photon emission computed tomography/computed tomography; TEE: transesophageal echocardiogram.

* High-grade bacteremia is defined as multiple (2 or more) separate blood cultures positive for the same organism, ideally drawn ≥1 hour apart. A single positive blood culture for coagulase-negative staphylococci or Cutibacterium species may represent skin contamination. In such cases, blood cultures should be repeated to evaluate for high-grade bacteremia. If repeat cultures are confounded by antibiotic therapy and clinical suspicion for CIED infection persists, consider pursuing further imaging (FDG PET/CT) if available; further management should be guided by consultation with infectious disease expertise.

¶ FDG PET/CT may be useful to establish a diagnosis of CIED infection in some circumstances. Other potentially useful imaging modalities include SPECT/CT or CTA.

Δ The choice and duration of antibiotic therapy is based on regimens for treatment of endocarditis caused by the organism isolated from blood cultures or otherwise implicated (refer to UpToDate text and related topics). The duration of antibiotic therapy (usually 4 to 6 weeks) should be counted from the day of device explanation, if warranted.