Hello, my name is Vassil Traykov. I come from Sofia, Bulgaria, working as an electrophysiologist there, and I'm here to discuss the most important topics on antimicrobial strategies in the management of CIED infections.

What are the unmet needs of patients with CIED infections in 2025?

Well, the unmet needs in the field are just a few but very important ones. Firstly, I would mention the need for better recognition of those infections, better diagnosis among the general physicians, not only by cardiologists or device specialists. It is very important that we raise awareness on these infections among the medical community as a whole, to be able to get those recognized early and managed early, because this means better survival, better outcomes in these situations.

On the other hand, regarding specifically CIED antimicrobial therapy, we need more new agents. There are some already available, but we need more and we need more studies to demonstrate their efficacy in this patient population.

What do you see as the biggest challenges in antimicrobial management of CIED infections?

The biggest challenges in the antimicrobial therapy of CIED infections is the fact that it should go along with the surgical treatment of those infections. So antimicrobial therapy goes hand in hand with surgical intervention to remove the CIED system, because this is the only way to cure the patient. And this is extremely important to note again for the medical community as a whole. In general, these patients should be referred early for the intervention.

On the hand, regarding the challenges, there are a couple of challenges. We are facing increasing rates of microbial resistance, so we need to work there. We need new medications, new molecules on the field, which we already have to some extent, but we need to test them, how they work, especially in the setting of complicated CIED infections. And I think this represents a significant challenge as we need data, which is we don't have enough data at this very point.

What do the current guidelines say about antimicrobial treatment for CIED-related infections?

We have two major papers issued by the European Heart Rhythm Association and the European Society of Cardiology dealing with CIED infections. One of them is the EHRA Consensus Document published in 2020. The other one is the ESC 2023 Effective Endocrine Guidelines which recommend different regimens for different scenarios in CIED infections. They have been well established and easy to find, and these documents are widely available. They can be readily accessed on the internet. So a very good handbook, a very good recommendations for these type of infections.

They say that we need to follow specifically determined regimens before, and then we need to also do that, as I said already, together with surgical intervention to remove the system in cases of CIED infections.

What improvements in antimicrobial strategies for CIED infections do you anticipate in the near future?

We are looking forward to new developments in the field, mainly regarding new molecules, as I mentioned already new regiments as well. And what's more important, now the guidelines do recommend something which is really, I would say, challenging the prevailing dogma up to now, and it is the outpatient antibiotic therapy.

Now, the guidelines recommend that some patients who are stable, who have effective endocarditis, can be treated as outpatients and is expected to reduce the costs without changing the outcomes. So it's a promising new strategy, and for that we need new regimens, we need new molecules that can be given, for example once per week, as we already have such drugs, and we also need more studies to establish and to confirm the efficacy of those strategies involving outpatient antimicrobial therapy.

What educational initiatives do you think would most improve compliance with best practices for CIED infection management?

In terms of educational activities, I think we as a community do have lots of work to do because studies show that the guidelines and the recommendations are not followed everywhere, and there is great heterogeneity of the way those people are treated, the CIED infection patients are managed. And therefore, we need a huge strategy, global strategy, to start educating more and more physicians from the general medical community to recognize and refer those patients for early management at specialized centres. I think this is where we should really focus.
The other thing is to raise awareness among the patients themselves, to be able to be aware, to be able to recognize those dangerous conditions and seek medical help on time to avoid any further complications and avoid fatal outcomes which are not infrequent in this population.