A 29-year-old male patient with a history of hiatal hernia repair two months earlier and recent pacemaker implantation due to bradycardia with multiple pauses detected on preoperative Holter monitoring. One month after cardiac device implantation, he presented with chest pain, fever, and agitation. Admission laboratory tests showed leukopenia, thrombocytopenia, elevated C-reactive protein, acute kidney injury, and metabolic acidosis, with electrocardiographic findings suggestive of pericarditis. He was admitted to an intensive care unit due to sepsis and started on meropenem and daptomycin. Blood cultures were repeatedly positive for methicillin-susceptible Staphylococcus aureus (MSSA), with de-escalation to oxacillin after identification. Transesophageal echocardiography revealed vegetation on the tricuspid valve. Persistence of bacteremia and a new echocardiogram demonstrating vegetations attached to the pacemaker lead indicated device-related infection, leading to complete surgical removal of the pacemaker, without the need for valvular intervention. Follow-up echocardiography showed absence of vegetations, and given clinical improvement, therapy was switched to intravenous cefazolin with a plan to complete four weeks of antibiotic therapy via homecare. Infections associated with cardiovascular implantable electronic devices present diagnostic and management challenges and are associated with high mortality. Preventive measures in the pre-, peri-, and postoperative periods—such as antibiotic prophylaxis and prevention of hematoma formation—are essential to reduce incidence. Staphylococci are the main etiologic agents, accounting for more than 70% of cases, followed by enterococci, streptococci, and Cutibacterium spp. Findings such as fluctuation and purulent drainage at the pacemaker pocket are diagnostic criteria. In patients with fever and no local signs, at least two sets of blood cultures should be collected, ideally before initiating antimicrobial therapy. Transesophageal echocardiography is essential, although limited in distinguishing infectious from noninfectious findings. Positron emission tomography may be useful in inconclusive cases. Persistent bacteremia caused by Staphylococcus aureus or coagulase-negative staphylococci requires device removal. Even in infections caused by other agents, device removal is recommended if no other source is identified. Early removal is associated with better outcomes, although evidence regarding optimal antimicrobial choice and duration remains limited.
Silva et al. (2026) studied this question.