An 86-year-old Chinese Han man was diagnosed as having third-degree atrioventricular block and received a permanent double-chamber pacemaker in his left prepectoral area 15 years ago. Nine years later, the entire system was removed because of confirmed infection...
Posted June 6,2019 in General Medicine.
An expansion in the clinical indications for implantation of cardiovascular implantable electronic devices (CIEDs), such as bradycardia, tachyarrhythmia, and heart failure, has led to a significant increase in the use of CIEDs over the past several decades [1,2]. Concurrently, CIED infection (CIEDI) has become increasingly prevalent . Sandoeet al.defined complicated pacemaker pocket infection as pacemaker pocket infection with evidence of lead involvement, systemic symptoms of infection, or positive blood cultures . For patients with complicated pacemaker pocket infection, expert consensuses universally advocate complete device and leads removal followed by delayed replacement on the contralateral side [4,5,6,7]. Unfortunately, some patients may not be candidates for device removal due to multiple comorbidities, limited life expectancy, or personal preference, which leads to reassessment of the optimal management strategies for these infections. We report a case of a patient with complicated pacemaker pocket infection who was cured by partial generator removal, reimplantation of the sterilized pulse generator on the ipsilateral side, debridement, and antimicrobial therapy. Few studies in the literature have reported such conservative treatment.
An 86-year-old Chinese Han man, with a known history of hypertension, heart failure, and chronic kidney disease, was diagnosed as having third-degree atrioventricular block and received a permanent double-chamber pacemaker in the left prepectoral area 15years ago. Nine years later, the entire system (generator and leads) was removed because of confirmed infection, and a new device was reimplanted in the contralateral area. Unfortunately, he developed skin necrosis around the pacemaker pocket after 1 year and the generator was renewed without leads extraction at another medical center. After this procedure, a focal area at the mid portion of the wound failed to fully heal. He was subsequently admitted several times due to extended skin necrosis with massive purulent secretion and cellulitis around the incision site. His primary physician used multiple courses of antibiotics, local wound care, and debridement. This conservative management was continued for 5 years at another institution. There was ongoing pressure necrosis of the overlying skin which led to the gradual extrusion of his leads.
No social, environmental, family, or employment histories were related to his illness. He was born in China and has been living in Guangzhou for nearly 60years. There is no hereditary disease in his family. He has a son who is in good health. He was an engineer before he retired 26years ago. The following orally administered medications were given regularly to control his hypertension, heart failure, and chronic kidney disease in other hospitalizations: benazepril (10mg once daily), niaoduqing (Chinese herbal medicine) particles (5g three times daily), furosemide (20mg once daily), and spironolactone (20mg once daily). Throughout his periods of infection in other hospitals, his doctors once treated him with intravenously administered levofloxacin (500mg once daily)/ciprofloxacin (200mg every 12hours)/Tazocin (piperacillin-tazobactam; 4.5g every 8hours)/latamoxef (2g twice daily)/ceftriaxone (2g once daily).
Laboratory test results on admission
30mL/minute per 1.73m2
The intravenously administered antibiotic was changed to penicillin (3,200,000IU every 8 hours) according to the antimicrobial drug susceptibility profile of our patient. Considering that he had severe infection, heart failure, and hypoalbuminemia, we treated him with intravenously administered immunoglobulin (2.5g once daily), human albumin (10g once daily), and furosemide (20mg once daily). At the same time, fosinopril sodium (10mg once a day), furosemide (20mg twice daily), and spironolactone (20mg twice daily) were taken orally to control hypertension and reduce severity of heart failure. Orally administered niaoduqing (Chinese herbal medicine) particles (5g three times daily) were also taken to improve renal function. After 1 month of conservative treatment, he was afebrile and his heavy breathing had improved.
We presented a patient with complicated generator pocket infection. Leads removal might not have been an option for him because he was at very high risk because of age and concomitant diseases. We treated him with partial generator removal and reimplantation of the sterilized pulse generator on the ipsilateral side. Few studies in the literature have reported such therapeutic strategy.
CIEDI is a serious cardiovascular disease and it is associated with a high mortality. In a large cohort of patients with CIEDI, the 30-day mortality rate was 5.5%, and 1-year mortality was 14.6% . Erosion of any part of the CIED indicates contamination of the entire system, and complete device removal should be performed. Conservative antibiotic therapy combined with limited debridement and irrigation of infected sites without removal of the infected device system may lead to poor outcomes. Leet al.reported that antimicrobial therapy without device removal was associated with a sevenfold increase in 30-day mortality .
Although complete removal of an infected CIED is first-line therapy, there may be complications about device removal. According to previous statistics, the risk of major complications (for example, vascular laceration, death) approaches 2% for all extraction attempts . Risk factors associated with procedural complications and death are not completely known. In the LExICon study , patients with a body mass index (BMI) 25kg/m2were more likely to experience major adverse events related to the lead extraction procedure. Some risk factors such as low BMI, renal disease, diabetes mellitus, and extraction for infection, increased the risk for death during their hospitalization. Another study confirmed the relevance of these risk factors. Brunneret al.produced a nomogram for the risk of 30-day all-cause death after leads extraction . The factors with the highest predictive value for death were heart failure, older age, abnormal BMI, and extraction for infection .
The patient we described was elderly, and suffered from heart failure (New York Heart Association Functional Class III), chronic renal failure, and low BMI (18kg/m2). The removal of the entire pacing system could predispose our patient to unexpected events. In addition, he preferred conservative therapy as he had experienced complete extraction of the pulse generator and leads on the contralateral side 6years previously. As a result, we decided to partially remove the generator combined with conservative treatment (antibiotic therapy, debridement, and irrigation).
Some case reports and small case series suggested that salvage of an infected CIED may sometimes be successful. Lopez saved the pulse generators and leads of five patients by using mechanical means (scrubbing and pulsed lavage) and a closed antimicrobial irrigation system . Tanet al.retrospectively analyzed 33 patients who initiated chronic antibiotic suppression without device removal, only 18% (6/33) developing into relapse within 1year . Peacocket al. reported on 127 patients for whom conservative management with device retention was attempted, 20% met the study definition for successful salvage . Even with more serious forms of device infection, such as leads endocarditis, medical management without device removal may be successful. In the study of Tascini and colleagues , two out of nine patients with CIED endocarditis were too sick for the removal of their CIED, and were cured with 6mg/kg of daptomycin without adverse event.
Review of literature regarding salvage of cardiovascular implantable electronic devices
Present study, 2018
Partial removal + conservative therapy + sterilized generator reimplantation (1)
Lopez , 2013
Scrubbing + pulsed lavage + closed antimicrobial irrigation system (5)
Tanet al. , 2017
Chronic antibiotic suppression (33)
Infection relapse (6)
Peacocket al. , 2018
Device retention + antibiotics (127)
Early failure of salvage (74); infection relapse (6); chronic suppression (7); death (14)
Tasciniet al., 2012
CIED endocarditis (2)
Margeyet al. , 2010
Partial removal or conservative therapy (13)
Infection relapse (8); death (1)
It is sometimes difficult to determine the causative organism. This is because the results of each culture from different sites may suggest different organisms. Bongiorniet al.reported on one of the largest (1204 patients) microbiology studies in CIEDI . They investigated 116 cases of materials from pockets and 359 cases where blood samples were obtained for culture. The results were consistent with those from electrodes in 59% and 35% of cases respectively. Golzioet al. gave a definition of causative organism as consistent species detected from at least two different sites . Each blood culture was counted as a different material, and pocket material was considered a single site. Nine sets of blood and pocket excretion samples of our patient were cultured for aerobic, anaerobic bacteria and fungi. Three blood cultures revealedS. epidermidis, four revealed other coagulase-negativeStaphylococcus, and the other two were negative. Four pocket excretion cultures revealedC. striatumand the other five were negative. Therefore, we can regard coagulase-negativeStaphylococcusas the causative organism. According to the study findings of Fukunagaet al., the causative organism of the CIEDI was mainlyStaphylococcus aureusand coagulase-negativeStaphylococci(for example,S. epidermidis), butS. aureusshowed a higher concordance in leads and pocket cultures than coagulase-negativeStaphylococci. Gram-positive bacteria (excludingStaphylococcus), such asCorynebacteriumspecies, showed relatively low concordance, which meant a benign coexisting organism . In the case of our patient, blood cultures were coagulase-negativeStaphylococcusbutC. striatumgrew in the pocket excretion cultures. This could be explained by the use of antibiotic therapy previously and preexisting surgical tissue debridement before his new admission. Eventually, we identified coagulase-negativeStaphylococcusas the causative organism whileC. striatumtended to coexist as a benign organism. As with most infections, an antimicrobial drug initially should cover common organisms broadly and antibiotic administration should begin after collection of blood and excretion cultures. Narrowing of the antimicrobial spectrum should be based on antimicrobial drug susceptibility. The duration of antibiotic treatment after removal of an infected device varied in different studies. In general, the more residual devices left in place, the longer the duration of treatment. We used antimicrobial therapy for 47days in total and for 7days after reimplantation in our patient, which was in accordance with the guidelines .
The pulse generator of our patient was removed for sterilization. For patients who are pacemaker-dependent, temporary pacing is required as a bridge to the reimplantation of a new permanent device . However, it has been associated with higher mortality , and increased risk of infection . We daringly did not use a temporary pacemaker in our patient, although his heart rate was sometimes only 33 times per minute. Customary treatment for lead infection would involve contralateral implantation of a new device. Given complete contralateral venous occlusion and our patients rejection of a new generator, the sterilized prior generator was reimplanted in a different position on the same side connecting old electrodes. No report has introduced the surgical technique to date.
We would posit that partial removal of infected generators combined with conservative treatment may be a proper treatment of complicated generator pocket infection, especially for those who are susceptible to cardiac complications or lack the necessary financial resources. Although not a widely accepted practice, reimplantation of the sterilized pulse generator on the ipsilateral side may be an option if a patient rejects a new device and contralateral vascular condition is not really suitable. Opting for such treatment should be at the consideration of the primary care physician based on the condition of the patient, and the pulse generator and remaining leads must be completely sterilized to eradicate infection. On the basis of a limited number of patients, further studies are needed to better define the optimal subpopulation that would benefit from the approach.