What is your approach to management of CIED in a patient with community-acquired Staph aureus bacteremia who clears blood cultures quickly with negative follow up blood cultures within 72 hours of antimicrobial therapy and negative TEE?

The recent 2023 guidelines on AHS CIEDI defined definite CIED infection as 2 or more sets of blood cultures positive for staph aureus or CoNS + (positive TEE and/Or positive PET/CT). The guidelines stated that the organism isolated from blood cultures determines the likelihood of CIEDI, and coagulase-negative staphylococci and S aureus are the most common organisms identified in endovascular CIEDI cases. The isolation of either of these organisms from blood is consequently considered a criterion...

This is, unfortunately, a not uncommon scenario in clinical practice for which we don't have great data. It is very difficult to convince a cardiologist to take out a CIED with negative repeat blood cultures and negative TEE. PET-CT is often not available. If this is the first episode, the blood clears up quickly, and TEE is negative, I typically treat for 4-6 weeks. However, I recommend close follow-up, and of course, if the same organism ever grows again, the device has to come out.

Sometimes these things cannot come out for various patient-related reasons. When they cannot come out, I leave the patient on a suppressive regimen and monitor him/her.

This often depends on the institution and its available resources. I work at a university hospital that has the capability to remove cardiac implantable electronic devices (CIEDs) and perform inpatient PET scans. Please keep this in mind as context for my response. In these situations, I routinely discuss cases with electrophysiology (EP) colleagues—every case warrants a thorough discussion. One key factor to consider is the age of the CIED. Older devices are more difficult and riskier to remove...