- Hello, dear ladies and gentlemen, the audience. Welcome to this podcast on device infection. My name is Dan Atar, Professor of Cardiology at Oslo University Hospital in Norway. And throughout the episodes in this podcast series, we learned that when a patient has a device infection, early device removal is mandatory. Now, you might be asking yourself, what can we actually do to prevent device infections? For that, I will speak to Professor Carina Blomstrom-Lundqvist at the Universities of Uppsala and Orebro in Sweden. And she's actually the lead author of the "European Devices Infection Guidelines". Welcome, Carina.

- Hi, Dan. Nice to see you.

- So, let's start with the general question, what are the key steps to prevent device infection?

- Well, Dan, the prevention of infection starts with preventive actions while referring the patient for a device implantation. For example, is the patient in his/her most optimal condition? The second step is the prevention starts with preventive measures at the time of implantation and continues with good clinical practice for lab procedures and cleanliness. The third step is the secondary bacteremia, seeding after the procedure, that is the infection can occur many years after the implantation. And here is of course, the most important message is to detect and not to miss this infection, because it's difficult to prevent.

- Yes, exactly. This is already giving us a very concise overview. And let us go into depth with regard to the chronologic situation of a device patient, namely starting with the pre-implantation. What should one consider to take action on at the referral of a patient? How can the referrals reduce the risk of infection?

- Yeah, this is an important issue to optimise the condition of the patient, to optimise the treatment of comorbidities such as diabetes and heart failure of the patient. It's also important to, of course, to treat temporary conditions such as skin infection or any intercurrent infections, fever, illness, that may result in a slight delay of the implantation procedure. But of course, it's more important to postpone a procedure than to risk an infection. If possible, you should also consider to temporarily discontinue medications that may increase the risk for hematoma like antiplatelets and anticoagulation therapy.

- I think you're raising really important and excellent points and I recognise of course the dilemma, nobody is happy to postpone an elective, a scheduled procedure, but in order to optimise the outcome and the safety, it is really sometimes the best choice. What about other infections? Like a simple tooth infection?

- Yeah, I agree with you. Tooth infection should of course be managed before implantation, but that relates to all infections. All infections should be managed before implantation to reduce the risk for a device infection.

- Absolutely. This is understood. Do you have any other clear advices regarding steps that are being taken just before the procedure?

- Well, we know from randomised trials that preoperative antibiotics given as an infusion one hour before the procedure reduces the risk for infection dramatically. So, that is a standard procedure to give preoperative antibiotics. Also, if possible, to remove temporary pacing wire or intravenous lines, which also reduces the risk for infection.

- Absolutely, that makes sense. So, that brings us actually to the very procedure. During implantation, what could physicians and staff, healthcare professionals at the hospital setting take action?

- Yeah, this is an important part as well. First of all, you should minimise the number of people in the operating room and you should use a room with surgical facilities. But I think most important is to have an experienced implanter, because you know that a prolonged procedure or a reoperation dramatically increases the risk of infection. So, if an experienced implanter will reduce the risk for infection, good surgical techniques is also a factor that is important. It reduces the risk for bleeding and thereby it prevents pocket hematoma. And pocket hematoma increases the risk for infection 8 to 10 times. So, that is important. Another measure is to use an antibacterial envelope in high risk patients. And of course, you know the high risk patients are, for example, CRT-D patients, so that should be considered. Or patients coming for a reimplantation. In some cases, you may choose to use a leadless device such as a leadless pacemaker or even a subcutaneous ICD in very high risk patients.

- Yes, these are excellent points. It's really important to have these in mind for the entire operative scenario. And that brings us actually to the post-operative setting. Are there any considerations that the follow up physician should take, you believe?

- Well, I think that if you have a patient with an hematoma, a pocket hematoma, do not puncture the hematoma, because that really increases the risk for infection. That is one of the most important messages.

- Yes, very important. That's an important learning point as well. We actually discussed in previous podcast versions that infection can occur even years after an implantation. Is there anything that can be done to prevent that type of infection?

- Well, this is a very important issue. We should indeed be aware that infection can occur at any time. For example, after dental procedure or renal infection. So, message continues to be, be alert about these patients. It's difficult to prevent, but do not miss a device infection.

- Wonderful. I think that gave us a great overview over what can be done and the safety of device patients is really of highest importance. Thank you very much, Carina, for sharing these insights. Again, I have learned very interesting ways to better help device patients. With this, I'd like to close our podcast and you at the audience, you can find more information on deviceinfection.com. Thank you for following.

- Thank you.