What is the best course of action for an elderly female with a pacemaker (permanent artificial cardiac pacemaker) experiencing fever, flank pain, chest pain, dizziness, nausea, vomiting, and a gout flare?

Immediate Hospitalization and Urgent Evaluation for Pacemaker Infection

This patient requires immediate hospitalization with urgent evaluation for pacemaker infection and possible lead endocarditis, given the constellation of fever (102.8°F), chest pain, flank pain, and systemic symptoms in a pacemaker patient. 1

Critical Initial Actions

Obtain Blood Cultures Before Antibiotics

• Draw a minimum of three sets of blood cultures before initiating any antimicrobial therapy 1
• This is essential for identifying the causative organism and guiding definitive treatment 1

Assess for Pacemaker-Related Infection

• Examine the pacemaker pocket for local signs of infection: erythema, warmth, fluctuance, wound dehiscence, erosion, tenderness, or purulent drainage 1
• The combination of fever and systemic symptoms in a pacemaker patient should raise immediate concern for cardiac device-related infective endocarditis (CDRIE) 1

Urgent Echocardiography

• Obtain transesophageal echocardiography (TEE) to evaluate for lead vegetations and valvular involvement 1
• TEE is superior to transthoracic echo for detecting lead vegetations and is the recommended imaging modality 1, 2

Evaluate for Alternative or Concurrent Diagnoses

Rule Out Pyelonephritis/Urosepsis

• The right flank pain radiating anteriorly with fever, nausea, and vomiting strongly suggests acute pyelonephritis 1
• Obtain urinalysis, urine culture, and renal imaging (CT or ultrasound) to evaluate for kidney infection or obstruction
• This could be the primary source of bacteremia that secondarily seeded the pacemaker leads 3, 4

Assess Pacemaker Function

• Obtain 12-lead ECG to evaluate for pacemaker malfunction 5, 6
• Check for appropriate pacing spikes, capture, and sensing 5, 6
• The chest pain and dizziness could represent pacemaker malfunction, though infection is more likely given the fever 5
• Document vital signs including orthostatic blood pressure changes to assess hemodynamic stability 5

Empiric Antimicrobial Therapy

Initiate Broad-Spectrum Antibiotics After Blood Cultures

• Start empiric therapy immediately after obtaining blood cultures, given the presence of sepsis (fever >102°F with systemic symptoms) 1
• Cover for Staphylococcus species (most common cause of pacemaker infections, accounting for 82% of cases) and gram-negative organisms 1, 2
• Vancomycin plus an anti-pseudomonal beta-lactam (such as ceftazidime or piperacillin-tazobactam) provides appropriate empiric coverage 1, 3, 4
• Tailor therapy based on culture results and susceptibility testing once available 1

Definitive Management of Pacemaker Infection

Complete Device Removal is Mandatory

• The American Heart Association recommends complete removal of the entire pacemaker system, including all leads and the generator, for documented infection 1
• This applies to both local pocket infections and cardiac device-related infective endocarditis 1, 2
• Percutaneous lead extraction is successful in 77% of cases and can be performed even with vegetations >10mm 2
• Surgical extraction is reserved for cases where percutaneous removal fails or is contraindicated 2

Timing of Device Removal

• Device removal should occur promptly once infection is confirmed 1, 2
• For pacemaker-dependent patients (such as those with complete heart block), consider active-fixation temporary leads connected to external devices as a bridge until permanent reimplantation 1
• This patient's underlying rhythm and pacemaker dependency must be assessed before device removal 7

Duration of Antimicrobial Therapy

• Minimum 2 weeks of IV antibiotics after device removal for uncomplicated pocket infections 1
• For lead endocarditis, the median duration is 28 days (range 19-42 days) after infected device explantation 2
• Continue antibiotics until blood cultures are negative 1

Reimplantation Strategy

• Delay new device implantation until blood cultures are negative, typically 7-14 days for non-complicated infections 1
• Place new device on the contralateral side when possible 1
• Ensure complete resolution of infection before reimplantation 1

Address the Gout Flare

Manage Gout Cautiously

• The acute gout flare in the knee requires treatment, but medication choices must consider the acute infection and renal function
• NSAIDs should be avoided given potential pyelonephritis and risk of acute kidney injury
• Colchicine dosing must be adjusted for renal function if pyelonephritis is confirmed
• Corticosteroids increase infection risk and are a known risk factor for pacemaker infections 1
• Consider low-dose colchicine or intra-articular corticosteroid injection if the gout is severely limiting mobility needed for hospitalization

Common Pitfalls to Avoid

Do Not Attribute Symptoms to Other Causes Without Ruling Out Device Issues

• Syncope, dizziness, or confusional states in pacemaker patients must be presumed pacemaker-related until proven otherwise 5
• However, in this case, the fever makes infection the primary concern 1

Do Not Delay Device Removal Once Infection is Confirmed

• Mortality is 14% with device removal and appropriate antibiotics 2
• Attempting to treat pacemaker infection with antibiotics alone without device removal has poor outcomes 1, 2

Do Not Assume Single Pathology

• This patient may have both pyelonephritis (explaining flank pain) and secondary pacemaker seeding from bacteremia 3, 4
• Enterobacter and other gram-negative organisms can cause both urinary tract infections and pacemaker endocarditis 4

Prognosis

• With prompt complete hardware removal and prolonged parenteral antibiotics, 96% of patients remain infection-free at follow-up 2
• In-hospital mortality is approximately 14% even with appropriate treatment 2
• The presence of large vegetations (>10mm) is not a contraindication to percutaneous extraction 2