A local doctor refers an active well 78 year old man to your ED. He had just attended for his regular blood pressure checkup that morning and mentioned in passing that his pacemaker had been a bit red for a few days. Intrigued, the doctor suggested he take a look at it…
[DDET Describe and interpret his image]
The pacemaker has eroded through the subcutaneous tissue pocket and skin, which is now red with a purulent exudate. There is an old midline sternotomy scar. The breakdown of the skin over this cardiac implanted electronic device (CIED) provides a potential direct route of entry for bacteria to the blood and endocardium and mandates its urgent removal and assessment for replacement. Antibiotics must be administered parenterally to treat/prevent bacteraemia and endocarditis, with Staphylococcal species the most likely pathogen in this setting.
He’s currently well, with normal vital signs and general examination. He’s a little surprised at all the fuss this has caused… What are the next steps to take now?
Bedside ECG BSL
Blood FBE, U+E, CRP, ESR, Blood cultures x 3
Other Skin swabs for M+C+S
After consultation with his cardiologist and an infectious disease specialist, he was commenced on IV Meropenem and Vancomycin, and admitted for device removal. As an inpatient he had a transoesophageal echo later that day to assess for presence of endocarditis vegetations, this was fortunately normal.
This is an example of an infection related to a cardiac implanted electronic device (CIED) On this occasion there was no evidence of associated serious infection on his initial workup or subsequent blood cultures, and another CIED was re-sited on the opposite side several days later.
So to recap the major goals of his management:
- Assess for clinical and investigation evidence of infection
- Early consultation with cardiology and ID
- Initiate broad spectrum parenteral antibiotics
- Remove IECD
- Assess whether replacement is required
- Replace when blood cultures negative > 72 hours
More information in this excellent 2011 CCJM review by Dababneh and Sohail