A single case of pacemaker-related infective endocarditis with Staphylococcus aureus bacteremia was successfully managed with CIED extraction and 4 weeks of targeted antibiotic therapy.
Case Report (n=1)
No
This case report demonstrates the successful management of CIED-related infective endocarditis using device extraction and targeted antibiotic therapy, aligning with standard treatment principles.
Infective endocarditis (IE) related to cardiac implantable electronic devices (CIEDs) is rare and may involve infection of the generator pocket, leads, or both, with or without valvular involvement. Most cases occur one year after implantation and in multimorbid patients older than 40 years. IE is usually caused by Staphylococcus aureus or Staphylococcus epidermidis, and has variable presentation, most commonly with fever and pulmonary involvement. Classically, management involves CIED removal and parenteral antibiotic therapy. An elderly, multimorbid patient with a dual-chamber pacemaker implanted 4 years prior presented to the hospital with sepsis secondary to left ureteral obstruction. After stabilization, insertion of a double-J catheter and initiation of piperacillin-tazobactam, he was transferred to our ward. On examination, there was extrusion of the pacemaker generator with signs of inflammation and purulent discharge. Given the suspicion of IE, we initiated vancomycin and meropenem and ordered transthoracic echocardiography, which showed vegetations on the right ventricular lead and right atrial wall; three blood cultures, all positive for Staphylococcus aureus; and chest CT, which showed multiple cavitated nodules in the lung parenchyma. The patient was managed at another hospital, where CIED extraction and implantation of a new pacemaker were performed. He returned to our ward in the immediate postoperative period, where we continued targeted therapy for four weeks, and he was discharged cured. Classically, IE diagnosis is based on Duke criteria, but their usefulness is limited in the context of CIED infection. In such cases, findings of generator pocket infection or positive blood cultures for typical organisms should be considered definitive criteria. Treatment consists of CIED removal and parenteral antimicrobial therapy. Clinical trials suggest non-inferiority of partial oral step-down therapy. The optimal timing for CIED removal remains controversial, but early or immediate removal appears beneficial. Depending on the presence or absence of pus, treatment duration of 7 or 10 days, respectively, is recommended from the time of device removal. In the presence of valvular or bloodstream involvement, 4–6 weeks of therapy are recommended. Despite the low incidence of reinfection, implantation of a new CIED should be delayed until resolution of infection or at least 3–14 days after blood culture negativization (depending on valvular involvement).
Sant’Anna et al. (Sun,) conducted a case report in Infective endocarditis due to pacemaker infection (n=1). CIED extraction and antibiotic therapy was evaluated on Clinical cure. A single case of pacemaker-related infective endocarditis with Staphylococcus aureus bacteremia was successfully managed with CIED extraction and 4 weeks of targeted antibiotic therapy.