From the Guidelines
For treating a pacemaker site infection, vancomycin should be administered initially as empirical antibiotic coverage until microbiological results are known, with a treatment duration of 10 to 14 days after CIED removal for pocket-site infection, as recommended by the American Heart Association 1.
Key Considerations
- The choice of antimicrobial therapy should be based on the identification and in vitro susceptibility results of the infecting pathogen 1.
- Complete device and lead removal is recommended for all patients with definite CIED infection, as evidenced by valvular and/or lead endocarditis or sepsis 1.
- For patients with pocket-site infection, 7 to 10 days of antibiotic therapy with an oral agent with activity against staphylococci is reasonable if the presentation is device erosion without inflammatory changes; otherwise, 10 to 14 days of antimicrobial treatment is recommended 1.
Antibiotic Selection
- Vancomycin should be administered initially as empirical antibiotic coverage until microbiological results are known 1.
- Patients with infections due to oxacillin-susceptible staphylococcal strains can be given cefazolin or nafcillin alone with discontinuation of vancomycin 1.
- Vancomycin should be continued in patients who are not candidates for β-lactam antibiotic therapy and those with infections due to oxacillin-resistant staphylococci 1.
Treatment Duration
- Treatment duration is typically 10 to 14 days after CIED removal for pocket-site infection 1.
- At least 2 weeks of parenteral therapy is recommended after extraction of an infected device for patients with bloodstream infection 1.
- Patients with sustained (24 hours) positive blood cultures despite CIED removal and appropriate antimicrobial therapy should receive parenteral therapy for at least 4 weeks, even if TEE is negative for valvular vegetations 1.
From the Research
Pacemaker Site Infection Antibiotics
- The recommended antibiotics for treating pacemaker site infections include vancomycin, flucloxacillin, dicloxacillin, or a first-generation cephalosporin 2.
- Vancomycin is suitable as initial antimicrobial therapy as it covers both S. aureus and coagulase-negative staphylococci 2.
- The addition of low-dose gentamicin may improve bacterial killing 2.
- Cefepime in combination with low- and high-dose aminoglycosides has been shown to be effective against methicillin-resistant Staphylococcus aureus (MRSA) 3.
- Nebacetin has been found to have good in vitro antibacterial activity against both Gram-positive and Gram-negative pathogens without impairing human cell vitality, making it a potential candidate for pacemaker impregnation 4.
- Staphylococcus epidermidis is the most frequently isolated bacterial strain in pacemaker and implantable cardioverter defibrillator infections, followed by Gram-positive flora, Staphylococcus aureus, and other strains 5.
- The most effective antibiotics for treating these infections include teicoplanin/vancomycin, doxicyclin, amikacin, and piperacillin-tazobactam, with retained sensitivity reported in 100%, 96%, 94%, and 58% of cases, respectively 5.