Management of systemic fungal infections in the presence of a cardiac implantable electronic device: A systematic review

Abstract

Evidence to inform the management of systemic fungal infections in the setting of a cardiac implantable electronic devices (CIED), such as a permanent pacemaker or implantable cardioverter‐defibrillator, is scant and limited to case reports and series. The available literature suggests high morbidity and mortality. To better characterize the shared experience of these cases and their outcomes, we performed a systematic review. We investigated all published reports of systemic fungal infections—fungemia and fungal vegetative disease—in the context of CIED, drawing from PubMed, EMBASE, and the Cochrane database of systematic reviews, inclusive of patients who received treatment between January 2000 and May 2020. Exclusion criteria included presence of ventricular assist device and concurrent bacteremia, bacterial endocarditis, bacterial vegetative infection, or viremia. Among 6261 screened articles, 48 cases from 41 individual studies were identified. Candida and Aspergillus species were the most commonly isolated fungi. There was significant heterogeneity in antifungal medication selection and duration. CIED extraction—either transvenous or surgical—was associated with increased survival to hospital discharge (92%) and clinical recovery at latest follow‐up (81%), compared to cases where CIED extraction was deferred (56% and 40%, respectively). Importantly, there were no prospective data, and the data were limited to individual case reports and one small case series. In summary, CIED extraction is associated with improved fungal clearance and patient survival. Reported antifungal regimens are heterogeneous and nonuniform. Prospective studies are needed to verify these results and define optimal antifungal regimens.

ESC guidelines 2023 on the management of endocarditis

“…Complete device extraction should be considered even in the absence of vegetations in the setting of persistent or relapsing Gram-positive bacteraemia or fungaemia after a course of appropriate antibiotic therapy, if there is no other identified source (see Figure 13). 681 In all instances of lead extraction, procedural risk should be carefully evaluated taking into account lead dwell time, pacemaker dependency, patient frailty, and other co-morbidities within the process of shared decision-making. 703 Lead extraction should be performed, without delay (i.e.…”

Pharmacological options for Candida albicans Endocarditis at the roadblock with irrecoverable prosthetics and drug interactions: a case report and review of literature

“…A recent study by Meena et al (2022), which retrospectively reviewed the literature for 250 cases of fungal endocarditis, highlighted improved survival outcomes in patients with surgical intervention (Hazard ratio 0.20, 95% confidence interval 0.09–0.42; p-value < 0.001) [ 3 ]. Improvement in patient survival parameters and clearance of blood cultures after extraction of cardiac implant electronic devices was reported in a retrospective study by Baman et al [ 9 ]. While the statistics reiterate the brighter outcomes with valve replacements and device extractions, real-life clinical cases get complicated.…”

Pacemaker-relatedCandida parapsilosisfungaemia in an immunosuppressed renal transplant recipient

“…A recent systematic review found that in cases of fungaemia in the presence of implantable cardiac devices, extraction of the devices was associated with both increased survival to discharge and increased clinical recovery or cure. 12 In the case of native valve endocarditis, the IDSA recommends the use of lipid formulation amphotericin B with the addition of flucytosine in certain cases, or treatment with high dose echinocandins, such as caspofungin. Amphotericin B is a polyene antifungal with a broad spectrum of activity that has been associated with nephrotoxicity 13 and other side effects in up to 50% of cases.…”