What is the treatment for a surgical site pacemaker (artificial cardiac pacemaker) infection?

Treatment of Surgical Site Pacemaker Infection

Complete removal of the entire pacemaker system, including all leads and the generator, is essential for successful treatment of pacemaker infections. 1, 2

Diagnosis

• Pacemaker infections present as either local device infection (pocket infection) or cardiac device-related infective endocarditis (CDRIE) involving the leads, valves, or endocardial surface 1
• Local signs of pocket infection include erythema, warmth, fluctuance, wound dehiscence, erosion, tenderness, or purulent drainage 1
• Obtain blood cultures (minimum of three sets) before initiating antimicrobial therapy 1
• Perform transesophageal echocardiography (TEE) to evaluate for lead vegetations and valvular involvement 1

Treatment Algorithm

Step 1: Device Removal

• Complete removal of the entire pacemaker system is indicated for all documented infections of the device or leads 1, 2
• For pacemaker-dependent patients, consider active-fixation temporary leads connected to external devices as a bridge until permanent reimplantation 1

Step 2: Antimicrobial Therapy

• Empiric therapy should target the most common pathogens: Staphylococcus aureus (40-46%) and coagulase-negative staphylococci 3, 1

For uncomplicated pocket infection:

• First-line: Oxacillin, nafcillin, cefazolin (1-2g IV every 8 hours) or cefalexina 3
• If MRSA suspected or beta-lactam allergy: Vancomycin 15-20 mg/kg IV every 12 hours 3
• Alternative agents: Linezolid, clindamycin, daptomycin, or sulfamethoxazol-trimethoprim 3

For complicated infections (endocarditis, sepsis):

• Consider lipid formulations of amphotericin B with flucytosine for suspected fungal infections 2
• Duration: At least 2 weeks for uncomplicated pocket infections after device removal 1
• For endocarditis or bloodstream infection: 4-6 weeks of therapy 2

Step 3: Reimplantation

• Delay new device implantation until blood cultures are negative for at least 72 hours 2
• For valvular infection, delay new transvenous lead placement for at least 14 days after system removal 2
• Place new device on the contralateral side when possible 2, 1
• Consider leadless cardiac pacemakers as an alternative for patients with severe device infection, especially those with blocked venous access or who are pacemaker dependent 4

Special Considerations

• For patients who cannot undergo complete device removal, long-term suppressive antibiotic therapy should be considered, though this is not optimal 2
• Long-term suppressive therapy should not be administered to patients who are candidates for infected device removal 2
• Monitor for complications including chest wall abscess, septic thrombophlebitis, and right-sided heart endocarditis 2
• Obtain cultures of the infection site before starting antibiotics to guide subsequent therapy 3

Common Pitfalls to Avoid

• Attempting to salvage the device with antibiotics alone, as failure rates are extremely high 3, 5
• Delaying device removal, which increases the risk of systemic infection and mortality 1, 5
• Not recognizing that pocket infections can track along leads to cause endocarditis 1
• Inadequate duration of antimicrobial therapy, which can lead to recurrent infection 2, 5

Prevention of Recurrence

• Administer a single dose of a first-generation cephalosporin (cefazolin) 1 hour before pacemaker implantation 6
• Use vancomycin as an alternative for patients with cephalosporin allergy or in centers with high rates of MRSA 6
• Avoid prolonging antibiotic prophylaxis unnecessarily after the procedure 6
• Practice meticulous sterile technique and proper skin preparation 6, 1