心脏起搏器感染病

Pacemaker infection Case presentation Dr. Cheuk Ming Yan, Candy Alice Ho Miu Ling Nethersole Hospital lMr. Chui, 81-years-old lPresented with recurrent syncope lHolter showed sick sinus syndrome lVVI implanted in July 2005, procedure uneventful In Accident and Emergency department (AED), lAttended AED in Oct, 2005 and complained of pacer wound pain and swelling lTreated as cellulitis with ampicillin and cloxacillin l3 days later, attended AED again for increasing pacer wound pain and swelling lIncision and drainage was done in AED ! lReferred to general clinic for wound dressing ! lNoticed pacemaker exposed by general clinic nurse lAdmitted to medical ward and cardiologist was then informed at this juncture lOpen wound with pacer exposed lAfebrile lTreated as infected pacing wound with exposure of the pacer box lEmergency operation arranged and pacer was removed lWound swabs were taken lPocket was cleaned by hydrogen peroxide lPut on a course of cefazolin lAs the patient remained asymptomatic after removal of pacer, he refused to have pacemaker implantation Followed up, lNoticed have painful erythematous lesion with scaling and pus-like discharge at lateral edge of pacing site lWound was explored and cleaned again lCloxacillin was given lWound swabs yield MSSA in both occasions lHowever, granuloma developed over the pacer wound again lCauterization by silver nitrate tried but failed lSurgeron was consulted for surgical removal of granuloma together with the underlying and surrounding tissue (? due to the irritation of the tissue by the pacing leads or underlying chronic infection) lGranuloma regrew after surgery lEventually, patient was referred to Queen Elizabeth Hospital for removal of pacing lead by laser sheath due to suspected lead infection lHowever, patient refused lead removal because of the risk of the procedure lThe pacer lead was cut short with radical sterilization done by hydrogen peroxide lNo granuloma was seen afterwards lPatient remained asymptomatic Pacemaker infection review Prevalence of Cardiac Device implantation lInfection of permanent pacemaker systems is uncommon, occurring in approximately 1-7% of implanted pacing system lAmong study period, there was a 49% rise in number of new devices implantation (from 159,585 in 1996 to 237,720 in 2003) l160% for ICDs and 31% PMs lThe number of hospitalization with devices infection increased by 3.1-fold (2.8-fold for PMs, 6-fold for 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 lEarly infection (within one month) 25% lProcedure related lLate infection (within one year) 33% lDelayed infection (at least one year) 42% lManipulation of the device e.g. battery change or bloodstream infection lPocket infection lLocal symptoms: lPocket erythema, pain, swelling, warmth and erosion lDraining sinus from pocket lSystemic symptoms: lfever, malaise, nausea, anorexia lEndocarditis Common Organisms lCoagulase-negative staphylococci lStaphylococcus aureus lGram negative bacilli Risk factors of cardiac device infection lTotal number of device-related procedures lNumber of operators lProcedure time lOperator experience lTemporary pacing leads prior to implantation lImplanted central catheter Cardiac 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 lEarly removal of infected device lAntibiotics lWithout systemic symptoms/ bacteraemia l7- 10 days 2nd generation cephalosporin lBacteraemia lAt least 2 weeks IV cloxacillin if organism is methicillin sensitive lEndocarditis lAt least 6 weeks IV cloxacillin Timing of reimplantation l Replacement of pacing system on the opposite side of chest immediately (1 stage) or Period of temporary pacing, then replace the pacemaker after antibiotics (2 stages) Removal of leads lEndovascular leads extraction: lTraction lByrd myocardial countertraction technique lLaser sheath lSurgical removal Outcome after complete percutaneous removal of infected pacemaker systems and implantable cardiac defibrillators J.J Post, C. Alexopoulos, C. Fewtrell Internal