II. Epidemiology

  1. Device infections increased nearly 4 fold since 1990 as of 2006
    1. Implants on older patients with comorbidities with more frequent revisions
  2. Nearly 31,000 device infections per year in United States
    1. Nearly two thirds are under-treated without device extraction, with a higher mortality and endocarditis risk (see below)
  3. Risk of infection based on device status
    1. Replacement device infection rate: 3%
    2. New device implant infection rate: 1%
    3. Existing device, late infection rate: 0.8%

III. Precautions

  1. Pacemakers must be removed for either early or late infections
  2. Do not aspirate or incise and drain the pocket
  3. Assume endocarditis (associated with high mortality) in febrile Pacemaker patients
  4. Pocket infections have mortality rate as high as 20%
  5. Biofilm infections are more common and with higher rates of Antibiotic Resistance

IV. Risk Factors: Occult Implant Infection as source of Staphylococcus aureus Bacteremia

  1. Relapsing bacteremia after appropriate antibiotics
  2. No identified source for bacteremia
  3. Bacteremia persists >24 hours
  4. ICD Implant
  5. Prosthetic Cardiac Valve present
  6. Bacteremia within 3 months of device placement
  7. (2010) PACE 33(4): 407-13 [PubMed]

V. Pathophysiology: Organisms

  1. Staphylococcus aureus (most common)
  2. Other Gram Positive infections
    1. Coagulase negative Staphylococcus
    2. Enterococcus species
    3. Assorted Streptococcus species (Beta hemolytic strep, pneumococcus, Strep viridans)
  3. Gram Negative Bacteria
    1. E. coli (45%)
    2. Klebsiella (20%)
    3. Pseudomonas (16%)
  4. References
    1. (2010) Circ Arrhythm Electrophysiol 3:639-45 [PubMed]

VI. Types

  1. Early infection
    1. Presents with localized erythema, swelling, purulent discharge within weeks of Pacemaker placement
    2. Infections occur more often in Diabetes Mellitus, post-placement hematoma or with Defibrillator placement
  2. Late infection
    1. Most infections occur with one year of implantation
      1. Typically Staphylococcus infections (50% MRSA)
      2. Gram Negative Bacteria and fungal infections are less common
    2. Presents with insidious, slowly developing infection; may only demonstrate an overlying Skin Erosion
    3. Infections occur more often after Pacemaker manipulations (with 1-3% risk with each manipulation)
    4. Endocarditis should be assumed (Blood Cultures are positive in 70% of cases, see below)

VII. Evaluation

  1. Palpate the Pacemaker pocket for tenderness, fluctuance suggestive of infection
  2. Bedside Ultrasound can detect Pacemaker pocker fluid collection

VIII. Labs

  1. Obtain Blood Cultures (3 sets)

IX. Diagnostics

  1. Echocardiogram
    1. Evaluate for valvular vegetation
  2. PET Scan
    1. Can highlight pocket infections

X. Management

  1. Consult cardiology, infectious disease and surgery
    1. Device removal recommended in all cases
    2. Diagnosis may be unclear in early cases (pocket hematoma or inflammation versus infection)
      1. Some may opt for early empiric doxycyline course under close interval observation
      2. Device removal if recurrent symptoms or signs after antibiotic course
    3. Conservative management of infection (without immediate device removal) is associated with increased mortality
      1. Thirty day mortality is increased 7 fold over early device removal
      2. One year mortality is increased 3 fold over early device removal
      3. (2011) Heart Rhythm 8:1678-85 [PubMed]
  2. Start empiric antibiotics after Blood Cultures (adult dosing shown)
    1. Antibiotic course
      1. Pocket infection: 10-14 days
      2. Lead associated endocarditis: 4-6 weeks (organism specific recommendations exist)
    2. MRSA
      1. Vancomycin 15-20 mg/kg IV q8-12 hours (or Daptomycin 8-10 mg/kg q24 h) AND
      2. Rifampin 300 mg orally twice daily
    3. MSSA
      1. Nafcillin 2 g IV every 4 hours OR
      2. Cefazolin 2 g IV every 8 hours
    4. References
      1. (2016) Sanford Guide, accessed 3/7/2016

XI. Prevention

  1. Prophylactic antibiotics are not currently recommended at the time of device implantation
    1. Baddour (2010) Circulation [PubMed]

XII. References

  1. (2018) Cardiac Arrhythmia Conference, UMN, Minneapolis
  2. Jones and Orman in Majoewsky (2012) EM:Rap 12(5): 4-6
  3. Mallemat, Swaminathan and Egan in Herbert (2014) EM:Rap 14(10): 5-7
  4. Vanlandingham (2015) Crit Dec Emerg Med 29(10): 2-14

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