A 62-year-old woman comes in for evaluation of her pacemaker generator, which has been visible for the past 3 days. She reports no fevers, presyncope, or syncope. Medical history is significant for complete heart block; a permanent pacemaker was placed 8 years ago, and the generator was replaced 2 months ago because the battery was nearing the end of its life. She takes no medications.

On physical examination, her temperature is 37.2°C (99.0°F), blood pressure is 128/82 mm Hg, and pulse rate is 60/min. A corner of the pacemaker is seen eroding through the skin. Minimal erythema is seen surrounding the exit site. No drainage or pus is present.

Electrocardiogram shows atrial sensing and ventricular pacing. Transthoracic echocardiogram shows the two leads with no vegetations on the leads or valves. Blood cultures are negative.

Which of the following is the principal therapy in the treatment of this patient?

This patient should undergo extraction of her pacemaker and leads. Infection is an increasingly common complication of pacemakers and other implanted cardiac devices, likely owing to an increase in comorbidities of patients receiving devices. Even though this patient has no symptoms of systemic infection, a visible generator indicates that the entire pacemaker system is infected, as microorganisms track down the leads, including the intravascular portions. Proper management of a pacemaker infection includes extracting the generator and leads. A temporary pacemaker may then be needed until the patient has received antibiotics for at least 72 hours and a new pacemaker can be implanted. Patients with pacemaker erosion and negative blood cultures should then receive a 7- to 14-day course of antibiotics based on sensitivities of the organism cultured intraoperatively from the pacemaker pocket. Coagulase-negative staphylococci and Staphylococcus aureus are the most common causative agents. For patients with bacteremia or endocarditis, it may be prudent to wait a longer period of time before reimplantation and extend the duration of antibiotic therapy.

In the setting of a device erosion or pocket infection, either oral or intravenous antibiotics may be used prior to explantation to prevent the development of a systemic infection, but are not enough to cure the infection and extraction is still needed. In patients with localized pocket inflammation but no erosion, pocket aspiration should not be performed because it can introduce infection and risks damaging a lead. Blood cultures should be obtained before starting antibiotics to determine if bacteremia is present. In patients with positive blood cultures or previous antibiotic treatment, transesophageal echocardiography should be performed to assess for lead or valvular vegetations.

Surgically closing the wound repairs the erosion, but does not treat the underlying infection, and it is highly likely the device will re-erode, develop signs of pocket inflammation, or lead to an endovascular infection in the future.

Key Point

• Management of implanted cardiac device infection includes extraction of the device and leads.