Recommendations for prevention and treatment of infections preimplant and postimplant
Recommendations   Class   Level   References
Infection prevention prior to LT-MCS implant
If time and clinical status permit, removal or exchange of all central venous catheters, pulmonary vein catheters and urine catheter prior to LT-MCS device implantation is recommended.  I  C  [474, 482–484]
If time and clinical status permit, a dental assessment and therapy if required prior to LT-MCS device implantation, are recommended.  I  C  [485]
A nasal and groin screen for methicillin-resistant Staphylococcus aureus and, if positive, treatment with topical antibiotics prior to LT-MCS device implantation, are recommended.  I  C  [486, 487]
Antibiotic prophylaxis
Preoperative antimicrobial prophylaxis targeted at Staphylococcus sp. and methicillin-resistant S. aureus (in patients with positive test results) is recommended.  I  C  [478–480]
The inclusion of antifungal treatment in routine preoperative antimicrobial prophylaxis is not recommended.  III  C  [488, 489]
It is recommended that antibiotic prophylaxis be administered within 60 min of the first incision, remain in the therapeutic range throughout its use and not be extended beyond 24 h after surgery.  I  C  [479, 490]
Managing active infection preimplant
In patients with active infections prior to LT-MCS device implantation, antibiotic therapy as directed by an infectious disease expert is recommended.  I  C  [363]
Infective endocarditis treatment preimplant
Documented clearance (negative blood culture results) of patients who have had bacteraemia prior to LT-MCS device implantation is recommended.  I  C
In patients with bacteraemia, antimicrobial therapy for at least 7 days prior to implantation of a mechanical circulatory support device is recommended.  I  C
In patients with bloodstream infections not related to infective endocarditis, removal of sources (if known) and antimicrobial treatment are recommended.  I  C
LT-MCS implantation in patients with untreated acute infective endocarditis with active bacteraemia is not recommended.  III  C
Preventing infection postimplant
It is recommended that the velour part of the driveline not exit the body.  I  C  [259]
Stabilization of the driveline immediately after the device is implanted and continuing throughout the duration of support is recommended.  I  C  [491]
A dressing change protocol initiated immediately postoperatively is recommended.  I  B  [491, 492]
Secondary antibiotic prophylaxis for the prevention of infectious events during routine procedures and dental work due to the risk of bacteraemia should be considered.  IIa  C  [71, 493, 494]
Evaluation of patients with mechanical circulatory support with a suspected infection
In all patients, a complete blood count, chest radiographic images and blood cultures are recommended.  I  C  [363]
It is recommended to draw at least 3 sets of blood cultures over 24 h, with at least 1 culture from any indwelling central venous catheter.  I  C  [363]
For those with a suspected pump cannula or driveline infection, obtaining a sample for gram stain, the KOH test and routine bacterial and fungal cultures are recommended.  I  C  [363]
When clinically indicated, an aspirate from other potential sources, as dictated by presenting symptoms and examination, is recommended.  I  C  [363]
Directed radiographic studies based on presenting symptoms and examination are recommended.  I  C  [363]
Erythrocyte sedimentation rate or serial C-reactive protein should be considered.  IIa  C  [363]
Routine computed tomography of the chest, abdomen and pelvis is not recommended.  III  C  [363]
Leucocyte radiolabelled scintigraphy may be considered to identify deep infections but by itself lacks anatomical specificity.  IIb  C  [495]
Combining single positron emission tomography/computed tomography scans with radiolabelled leucocytes has increased the sensitivity for detection of infection and retained the specificity for anatomical location of the MCS infection; it can also identify distal foci if infected emboli are present and should be considered.  IIa  C  [496, 497]
Treatment of patients with mechanical circulatory support with a suspected infection of the driveline exit site or the driveline itself
A full evaluation as outlined above should be performed in all patients prior to treatment before commencing antimicrobial treatment even if only superficial infection is suspected.  I  C  [363]
In patients with a superficial driveline exit site infection but without a BSI or systemic illness, it is recommended that antibiotic therapy be deferred until culture results are known.  I  C  [71, 498, 499]
In patients with clinical signs of driveline exit site infection but with negative culture results, initiation of empirical oral antibiotic therapy and evaluation based on clinical response are recommended.  I  C
In the presence of systemic illness and/or sepsis, initiation of empirical intravenous antibacterial therapy always covering Staphylococcus, Pseudomonas and Enterobacteriaceae species, also taking local institutional epidemiology and colonization (e.g. methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci) into consideration, is recommended.  I  C
Rifampicin should usually be avoided due to its significant impact on the international normalized ratio, but it may be considered in rare cases.  IIb  C  [500]
It is recommended that the duration of antimicrobial treatment be guided by the clinical response, type of infection, pathogen(s), transplant status and the opinion of an infectious disease expert.  I  C
It is recommended that the treatment of a superficial infection without an associated BSI last at least 2 weeks.  I  C
For deep infections, treatment for at least 6 weeks, depending on the pathogen, time to clearance of the BSI, the clinical response and the expert opinion of an infection disease expert, are recommended.  I  C  [26]
Single positron emission tomography/computed tomography combined with radiolabelled leucocytes for the detection of location of infection and infected emboli should be considered.  IIa  C  [496, 497]
Leucocyte radiolabelled scintigraphy for identification of deep infection may be considered.  IIb  C  [495]
If the infection is not eradicated despite debridement and 6 weeks of systemic intravenous antibiotic treatment, specific surgical treatment of the infections should be considered, including driveline relocation, pump exchange, prolonged treatment of the ventricular assist device, wrapping driveline with omentum and a heart transplant.  IIa  C
Lifelong antibiotic treatment for complicated S. aureus infection should be considered unless there is an option to remove the device.  IIa  C
Treatment of patients with mechanical circulatory support with a suspected infection of the pump
In all patients with mechanical circulatory support, a full evaluation for any suspected infection as outlined above should be performed before commencing antimicrobial treatment.  I  C  [26, 363]
In the case of a persistent bloodstream infection, pump seeding or endovascular infection should be suspected. It is recommended that intravenous antimicrobial therapy be initiated after microbiological samples have been taken.  I  C
For infection in patients with mechanical circulatory support at the time of device exchange or heart transplant, it is recommended that antimicrobial therapy be continued for at least 6 weeks, depending on the pathogen and the clinical course, to minimize the risk of relapse.  I  C  [26]
After failure of eradication of infection with debridement and 6 weeks of systemic intravenous antibiotic treatment, specific surgical treatment of infections including pump exchange and a heart transplant should be considered.  IIa  C
LT-MCS: long-term mechanical circulatory support; BSI: bloodstream infection.