II. 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%

III. 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)

IV. Evaluation

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

V. Labs

  1. Obtain Blood Cultures (3 sets)

VI. Diagnostics

  1. Echocardiogram
    1. Evaluate for valvular vegetation

VII. Management

  1. Consult cardiology and surgery
    1. Device removal recommended in all cases
  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

VIII. References

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

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