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1、Pacemaker infection Case presentation,Dr. Cheuk Ming Yan, Candy Alice Ho Miu Ling Nethersole Hospital,Mr. Chui, 81-years-old Presented with recurrent syncope Holter showed sick sinus syndrome VVI implanted in July 2005, procedure uneventful,In Accident and Emergency department (AED),Attended AED in
2、Oct, 2005 and complained of pacer wound pain and swelling Treated as cellulitis with ampicillin and cloxacillin 3 days later, attended AED again for increasing pacer wound pain and swelling Incision and drainage was done in AED ! Referred to general clinic for wound dressing ! Noticed pacemaker expo
3、sed by general clinic nurse,Admitted to medical ward and cardiologist was then informed at this juncture Open wound with pacer exposed Afebrile Treated as infected pacing wound with exposure of the pacer box,Emergency operation arranged and pacer was removed Wound swabs were taken Pocket was cleaned
4、 by hydrogen peroxide Put on a course of cefazolin As the patient remained asymptomatic after removal of pacer, he refused to have pacemaker implantation,Followed up,Noticed have painful erythematous lesion with scaling and pus-like discharge at lateral edge of pacing site Wound was explored and cle
5、aned again Cloxacillin was given Wound swabs yield MSSA in both occasions,However, granuloma developed over the pacer wound again Cauterization by silver nitrate tried but failed Surgeron was consulted for surgical removal of granuloma together with the underlying and surrounding tissue (? due to th
6、e irritation of the tissue by the pacing leads or underlying chronic infection) Granuloma regrew after surgery Eventually, patient was referred to Queen Elizabeth Hospital for removal of pacing lead by laser sheath due to suspected lead infection,However, patient refused lead removal because of the
7、risk of the procedure The pacer lead was cut short with radical sterilization done by hydrogen peroxide No granuloma was seen afterwards Patient remained asymptomatic,Pacemaker infection review,Prevalence of Cardiac Device implantation,Infection of permanent pacemaker systems is uncommon, occurring
8、in approximately 1-7% of implanted pacing system Among study period, there was a 49% rise in number of new devices implantation (from 159,585 in 1996 to 237,720 in 2003) 160% for ICDs and 31% PMs The number of hospitalization with devices infection increased by 3.1-fold (2.8-fold for PMs, 6-fold for
9、 ICDs),Rising Rates of Cardiac Rhythm Management Device Infections in the Unites States:1996 through 2003 Andrew Viogt, Alaa Shalaby, and Samir Saba J.Am. Coll. Cardiol. 2006;48;590-591,Clinical presentations,Early infection (within one month) 25% Procedure related Late infection (within one year) 3
10、3% Delayed infection (at least one year) 42% Manipulation of the device e.g. battery change or bloodstream infection Pocket infection Local symptoms: Pocket erythema, pain, swelling, warmth and erosion Draining sinus from pocket Systemic symptoms: fever, malaise, nausea, anorexia Endocarditis,Common
11、 Organisms,Coagulase-negative staphylococci Staphylococcus aureus Gram negative bacilli,Risk factors of cardiac device infection,Total number of device-related procedures Number of operators Procedure time Operator experience Temporary pacing leads prior to implantation Implanted central catheter,Ca
12、rdiac device infections: getting to the heart of the matter. Uslan, Daniel Z; Baddour, Larry M. Current opinion in infectious Disease 194;346-348 August 2006,Treatment,Early removal of infected device Antibiotics Without systemic symptoms/ bacteraemia 7- 10 days 2nd generation cephalosporin Bacterae
13、mia At least 2 weeks IV cloxacillin if organism is methicillin sensitive Endocarditis At least 6 weeks IV cloxacillin,Timing of reimplantation,Replacement of pacing system on the opposite side of chest immediately (1 stage) or Period of temporary pacing, then replace the pacemaker after antibiotics
14、(2 stages),Removal of leads,Endovascular leads extraction: Traction Byrd myocardial countertraction technique Laser sheath Surgical removal,Outcome after complete percutaneous removal of infected pacemaker systems and implantable cardiac defibrillators J.J Post, C. Alexopoulos, C. Fewtrell Internal Medicine Journal 36 (2006) 790-792,Endovascular lead extraction,Procedure related complications Severe haemorrhage Tamponade Haematoma Transient hypotension Pulmonary embolism Tricuspid regurgitation Leads break,End,