Synopsis
Recognise infection involving prosthetic valves or cardiac electronic devices, preserve microbiological evidence, define hardware involvement and coordinate complete source control with prolonged directed antimicrobial therapy.
- Establish exactly what was implanted, when, why and whether any revision, haematoma, wound problem or recent bloodstream infection occurred.
- In a stable adult obtain three peripheral blood-culture sets before antibiotics; in shock collect rapidly without delaying resuscitation.
- Start with TTE but use TOE early because prosthetic shadowing and lead position reduce transthoracic sensitivity.
- Cardiac CT and FDG PET-CT can clarify peri-prosthetic extension or metabolically active hardware when specialist interpretation is available.
- Pocket erosion, exposed hardware or purulent drainage needs complete system extraction rather than antibiotics or superficial wound care alone.
- Definite lead infection generally requires removal of generator and all leads, with reimplantation delayed and moved to a clean site if still needed.
- Prosthetic-valve infection frequently needs early surgery for heart failure, dehiscence, abscess, uncontrolled infection or difficult organisms.
- Empirical and directed combinations differ by organism, implant age, resistance, renal function and operative plan; use an endocarditis service protocol.
Key red flags
New prosthetic-valve regurgitation, rocking or dehiscence with heart failure requires emergency cardiac-surgical assessment.
An exposed generator, draining sinus or pocket erosion constitutes cardiac-device infection even when fever and blood cultures are absent.
Staphylococcus aureus bacteraemia in a patient with intracardiac material requires urgent evaluation for lead or valve infection.
Persistent positive cultures despite active therapy suggest retained infected material, abscess or another uncontrolled metastatic focus.
New PR prolongation or atrioventricular block can signal peri-annular extension around an aortic prosthesis.
Haemoptysis, pleuritic pain or hypoxaemia with an infected right-sided lead may reflect septic pulmonary embolisation.
Fever, malaise, new regurgitant murmur, heart failure or embolus in anyone with a replacement valve should trigger endocarditis assessment.
Pain, warmth, erythema, swelling, fluctuance, discharge, threatened skin or generator exposure indicates local device infection; manipulation risks deeper spread.
Persistent or recurrent staphylococcal, enterococcal or unexplained bacteraemia may be the only evidence of colonised valve or lead material.
Fever with cough, pleuritic pain, haemoptysis or peripheral pulmonary nodules suggests right-sided lead vegetation and septic pulmonary embolisation.
Investigation priorities
Identify bloodstream organisms before antimicrobial exposure and distinguish sustained infection from contamination.
Management branches
There is shock, pulmonary oedema, severe prosthetic dysfunction, dehiscence or conduction deterioration.
- Use ABCDE, obtain several blood-culture sets rapidly, measure lactate and support oxygenation and circulation without excessive fluid in valve failure.
- Start the locally approved empirical prosthetic-endocarditis regimen after cultures, adjusted for implant timing, allergy, renal function and healthcare resistance.
- Arrange urgent TTE and TOE, ECG surveillance and cardiac CT where it will not delay definitive intervention.
- Activate cardiac surgery and critical care immediately because antimicrobial improvement does not remove a mechanical indication.