Cardiology and Angiology: An International Journal

Background: Infective endocarditis (IE) associated with implantable cardiac devices (ICDs): pacemakers, automatic defibrillators, and cardiac resynchronisation therapy devices, is a rare but serious complication with a high mortality rate despite therapeutic advances. The steady increase in the number of implantations worldwide is accompanied by a parallel rise in infection cases, even exceeding the expected growth in the implantation rate.

Aim: The objective of this study was to describe the epidemiological, clinical, microbiological, therapeutic, and prognostic characteristics of IE associated with ICDs in a Moroccan university hospital in Marrakech.

Materials and Methods: We conducted a retrospective descriptive study in the cardiac electrophysiology department of the university hospital Mohammed VI in Marrakech, covering the period from January 2022 to December 2025. All patients hospitalised for infective endocarditis associated with a pacemaker or implantable cardioverter-defibrillator, meeting the modified Duke criteria, were included. Epidemiological, clinical, paraclinical, therapeutic, and outcome data were collected from medical records and hospitalisation registers and then analysed using an Excel spreadsheet.

Results: Of the 200 patients who underwent endocarditis implantable cardioverter-defibrillator (ECID) implantation in our department during the study period, 19 patients (9.5%) developed a device-related infection, including 16 implanted at our centre and 3 outside the hospital. The mean age of infected patients was 66 years (range 45–80 years), with a marked male predominance (male-to-female ratio 2:1). The most frequently observed cardiovascular risk factors were hypertension (7 patients), diabetes (4 patients), dyslipidemia (3 patients), and chronic smoking (5 patients). The time between implantation and the onset of endocarditis was less than three months in 8 patients (early infection) and more than three months in the remaining 11 (late infection). Local signs of infection (erythema, warmth, fluctuation, swelling, or skin dehiscence) were present in 63% of patients, while fever was absent in 77% of cases. Blood cultures were positive in 12 patients (58.3%), with a clear predominance of staphylococci: coagulase-negative Staphylococcus (6 cases), methicillin-resistant Staphylococcus aureus (3 cases), and, less frequently, Klebsiella pneumoniae, Pseudomonas, and Streptococcus sobrius. Transesophageal echocardiography revealed vegetations in only 10% of patients, highlighting the diagnostic difficulty of this condition. All patients received initial empirical antibiotic therapy with amoxicillin-clavulanic acid and gentamicin due to the local unavailability of antibiotics recommended by learned societies. This was followed by tailored antibiotic therapy: dual therapy (flucloxacillin plus gentamicin) in 15 patients (70%) and triple therapy (vancomycin, rifampicin, and gentamicin) in 4 patients (20%). Infected material was removed by simple mechanical traction in 10 patients and by excimer laser in the remaining 9, with temporary stimulation via the right jugular vein in 9 patients awaiting reimplantation. Contralateral definitive reimplantation was performed in 17 patients after negative blood cultures. The outcome was favourable in 83% of cases (15 patients), while two patients died from refractory septic and cardiogenic shock.

Conclusion: Infective endocarditis associated with implantable cardiac devices primarily affects middle-aged men, often diabetic, and typically presents with local symptoms without fever. Diagnosis relies on blood cultures and transesophageal echocardiography. Complete removal of the material, preferably by laser, combined with prolonged antibiotic therapy, is the standard treatment. Prevention depends on strict aseptic technique during implantation.