What is the management of an infected abdominal pacemaker pocket?

Management of Infected Abdominal Pacemaker Pocket

Complete removal of the entire pacemaker system, including all leads and the generator, is mandatory for all patients with an infected abdominal pacemaker pocket. 1, 2

Diagnosis of Pocket Infection

• Local device infection is defined as an infection limited to the pocket of the cardiac device and is clinically suspected when there are local signs of inflammation including erythema, warmth, fluctuance, wound dehiscence, erosion, tenderness, or purulent drainage 3
• Blood cultures should be obtained before initiating antimicrobial therapy to identify the causative pathogen 2
• Transesophageal echocardiography (TEE) is recommended to evaluate for lead vegetations and valvular involvement to rule out cardiac device-related infective endocarditis (CDRIE) 2

Microbiology

• Staphylococci account for 60-80% of pacemaker infections, with coagulase-negative staphylococci being the most common pathogens 3, 1
• Staphylococcus aureus is the second most common pathogen, accounting for 40-46% of infections 4
• Methicillin resistance should be considered when selecting empiric antibiotics, as it can be present in up to 27-29% of cases 4

Management Algorithm

Step 1: Complete Device Removal

• Complete removal of the entire pacemaker system (generator and all leads) is mandatory 1, 2
• Conservative management with antibiotics alone has been associated with 100% relapse rates and should be avoided 1
• For pacemaker-dependent patients, consider:
  • Active-fixation temporary leads connected to external devices as a bridge until permanent reimplantation 2
  • Transcatheter pacing systems (TPS) may be an option for patients with severe device infection, especially those with blocked venous access 5

Step 2: Antimicrobial Therapy

• Empiric therapy should be initiated after blood cultures are obtained 2
• First-line options for uncomplicated pocket infections include oxacilina, nafcilina, cefazolina (1-2g IV every 8 hours), or cefalexina 4
• For patients with beta-lactam allergies or suspected MRSA, vancomycin (15-20 mg/kg IV every 12 hours) is recommended 4
• Duration of antimicrobial therapy:
  • 10-14 days after device removal for uncomplicated pocket-site infection 1, 4
  • At least 14 days for bloodstream infection 1
  • 4-6 weeks for complicated infections (endocarditis, septic thrombophlebitis, osteomyelitis) 1

Step 3: Reimplantation

• New device implantation should be delayed until blood cultures are negative, typically 7-14 days for non-complicated infections 2
• New device placement should be on the contralateral side when possible 2
• For patients with limited venous access, options include:
  • Epicardial lead placement
  • Leadless pacemakers when appropriate 5
  • Venoplasty for venous stenosis 6

Special Considerations for Abdominal Pocket Infections

• Abdominal placement of pacemakers is associated with higher infection rates compared to pectoral transvenous device placement 3
• In patients with limited subcutaneous tissue or poor nutrition who are at increased risk for erosion, a retropectoral pocket should be considered for reimplantation 1
• For complex non-healing wounds following superficial pocket infections, modified negative pressure wound therapy may be beneficial in select cases 7

Prevention of Recurrent Infection

• Prophylaxis with an antibiotic that has activity against staphylococci should be administered intravenously before incision for reimplantation 1
• Meticulous attention to sterile technique during reimplantation is mandatory 1
• Prevention of hematoma during the procedure is important as hematoma is a risk factor for subsequent infection 1

Common Pitfalls and Caveats

• Failure to remove the entire system (including all leads) significantly increases the risk of recurrent infection 1, 8
• Underestimating the extent of infection - what appears to be a localized pocket infection may involve the leads or endocardium 3
• Inadequate duration of antimicrobial therapy can lead to treatment failure 1
• Reimplanting too early before complete eradication of infection 2