pacemaker lead infection

The patient has infection of a cardiac implantable electronic device (CIED). A distinction is made between pocket infections and systemic infections (meaning involvement of the lead system in this context), although the two can coexist. In this patient, dimpling and erythema indicate pocket infection, but the persistent bacteremia (more than one positive culture with a potential skin organism) along with evidence of vegetation on the lead (visualized on transesophageal echocardiography) indicate systemic infection. The diagnosis of systemic CIED infection on the basis of echocardiography alone can be challenging, particularly if a device has been present for some time, as it can be difficult to distinguish fibrous stranding on a chronically implanted lead from lead infection. The diagnosis is made using integration of clinical presentation and microbiology. Bilateral nodular opacities on chest radiography in this case suggest the possibility of septic embolism, further strengthening the case for systemic/lead infection.

Infections are also characterized as early (within the first 6 months of implantation or generator) or late, the latter being more common and more likely to be associated with morbidity and mortality. In-hospital mortality with CIED approaches 10%. Risk factors are patient related, procedure related, and device related. The most common organisms are Staphylococcus aureus and coagulase-negative staphylococci, particularly S epidermidis.

Appropriate treatment of systemic CIED infection entails removal of the entire system, including the generator and the leads. The morbidity and mortality associated with device infection far exceed those associated with device removal (choice A is correct). The entire system must be removed to allow for adequate treatment of systemic CIED infection; neither removal of the generator alone nor antibiotics alone is adequate (choices B and D are incorrect). Local debridement of the generator site is insufficient as well (choice C is incorrect).

When to reimplant an infected device is a separate issue, with its own complexity. The risk of infection of a new device must be balanced against the risk of not having a device in place. In general, for systemic CIED infection, a new device may be implanted once surveillance blood cultures following device removal are negative for at least 14 days. By that time, the seeding of a newly placed lead is unlikely.123

Footnotes

  1. SEEK Questionnaires ↩

  2. Blomström-Lundqvist C, Traykov V, Erba PA, et al; ESC Scientific Document Group. European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections—endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020;41(21):2012-2032. PubMed ↩

  3. Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al. 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14(12):e503-e551. PubMed ↩