On the basis of findings from 1 investigation,27 CIED infection is unlikely in patients with Gram-negative bactere- mia and no other evidence of device infection; thus, CIED removal is not recommended in this setting. In contrast, patients who have Gram-negative bacteremia that has re- lapsed despite administration of appropriate antibiotic ther- apy and with no other defined focus of infection should undergo CIED removal. CIED removal should also be per- formed in patients with sustained or persistent Gram-negative bacteremia despite administration of appropriate antibiotic therapy and no other defined source of infection. The likelihood of CIED infection in patients with bactere- mia or fungemia due to organisms other than S aureus or Gram-negative bacilli that more commonly cause blood- stream infection (coagulase-negative staphylococci, strepto- cocci, enterococci, and Candida species) and no other evi- Figure 2. A, Approach to management of adults with CIED infection. AHA indicates American Heart Association. Modified from Sohail et al38 with permission. *A history, physical examination, chest radiograph, electrocardiogram, and device interrogation are standard baseline procedures before CIED removal. Duration of antibiotics should be counted from the day of device explantation. Treatment can be extended to 4 or more weeks if there are metastatic septic complications (ie, osteomyelitis, organ or deep abscess, etc) or sus- tained bloodstream infection despite CIED removal. B, Approach to implantation of a new device in patients after removal of an infected CIED. Modified from Sohail et al38 with permission. Baddour et al Cardiovascular Device Infections 465 dence of CIED infection has received limited attention. Results of 2 relatively small case series33,76 suggest that the risk of CIED infection in these patients is low; however, more data are clearly needed in this clinical setting to permit recommendations on whether device removal is warranted. 