What should be done for a red Automated Implantable Cardioverter-Defibrillator (AICD) site?

Management of a Red AICD Site

For a red Automated Implantable Cardioverter-Defibrillator (AICD) site, complete device removal is recommended as the definitive treatment, as this likely represents a device infection.

Initial Evaluation

• Evaluate for signs of infection including erythema, warmth, tenderness, swelling, or drainage at the generator pocket site 1
• Obtain blood cultures before starting antibiotics to identify potential bloodstream infection 1
• Avoid percutaneous aspiration of the generator pocket as part of diagnostic evaluation as this is contraindicated 1
• Consider transesophageal echocardiography (TEE) to evaluate for lead vegetations or valvular involvement if systemic symptoms are present 1

Management Algorithm

For Localized Pocket Infection:

• Complete removal of all hardware (generator and leads) is necessary even if infection appears limited to the pocket 1
• Empiric antibiotic therapy should be initiated with vancomycin to cover staphylococcal species (including MRSA) until culture results are available 1
• Switch to a more targeted antibiotic based on culture results and susceptibility testing 1
• For pocket site infection without systemic involvement:
  • 10-14 days of antimicrobial treatment is recommended 1
  • If presentation is device erosion without inflammatory changes, 7-10 days may be sufficient 1

For Systemic Infection:

• Complete device removal is still mandatory 1
• At least 2 weeks of parenteral antibiotic therapy is recommended after extraction for patients with bloodstream infection 1
• Extend to 4 weeks of parenteral therapy for patients with sustained positive blood cultures despite device removal 1
• Obtain repeat blood cultures after device removal to confirm clearance of infection 1

Reimplantation Considerations

• Delay reimplantation until blood cultures are negative for at least 72 hours 1
• The contralateral side is preferred for new device placement when required 1
• Consider temporary pacing if necessary during the treatment period 1

Common Pitfalls and Caveats

• Failure to remove the entire system (including leads) significantly increases risk of relapse 1
• Erosion of any part of the AICD implies contamination of the entire system and requires complete removal 1
• Attempting to treat with antibiotics alone without device removal is inadequate and leads to treatment failure 1
• Delaying device removal increases risk of systemic complications and mortality 1

Follow-up Care

• Monitor for resolution of infection and ensure appropriate device function if reimplantation occurs 1
• Regular device interrogation after reimplantation to ensure proper functioning 1
• Patient education regarding signs of recurrent infection and importance of follow-up 1

By following this systematic approach to management, patients with red AICD sites can be appropriately treated to minimize complications and optimize outcomes.