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Year : 2017  |  Volume : 60  |  Issue : 2  |  Page : 185-188
Risk of cardiac pacemaker pocket infection in a tertiary care hospital

1 Department of Microbiology, AFMC, Pune, Maharashtra, India
2 Department of Cardiology, Command Hospital, Chandimandir, Haryana, India
3 Department of Pathology, Command Hospital, Chandimandir, Haryana, India

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Date of Web Publication19-Jun-2017


Background: The risk of pacemaker pocket infections (PPIs) is rare with good antisepsis techniques and use of advanced antibiotics. However, injudicious antibiotic usage leads to the rise of multidrug-resistant bacteria, which may cause PPI. Few reports exist about the microbial spectrum of the PPI from our country, prompting us to study the same. Methods: We conducted this retrospective observational study for 3 years (January 2013–February 2016) from all the patients with PPI. We collected the relevant clinical samples (blood and pus) for the microbial culture using a standard protocol. We included 100 samples collected from the medical staff and the hospital environment as a control sample. The data were analyzed using appropriate statistical methods and a P< 0.05 was considered statistically significant. Results: Our data showed that 17 out of 160 (10.6%) patients had PPI. Coagulase negative Staphylococcus sp. was isolated in 7 (41.2%) patients, followed by Staphylococcus aureus in 4 patients (23.5%). Other isolated bacteria include multidrug-resistant Burkholderia cepacia (n = 3), Mycobacterium abscessus (n = 2) and polymicrobial infection in a single patient. One out of hundred surveillance samples grew B. cepacia. Conclusion: Our data revealed a high incidence of Gram-positive cocci causing PPI. Every hospital should formulate their antibiotic policy based on the pattern of the hospital flora and their drug sensitivity.

Keywords: Burkholderia cepacia, drug resistance, Mycobacterium abscessus, pacemaker pocket infection, staphylococci

How to cite this article:
Gill JS, Singh N, Khanna S P. Risk of cardiac pacemaker pocket infection in a tertiary care hospital. Indian J Pathol Microbiol 2017;60:185-8

How to cite this URL:
Gill JS, Singh N, Khanna S P. Risk of cardiac pacemaker pocket infection in a tertiary care hospital. Indian J Pathol Microbiol [serial online] 2017 [cited 2021 Aug 4];60:185-8. Available from: https://www.ijpmonline.org/text.asp?2017/60/2/185/208382

   Introduction Top

A permanent pacemaker is the most commonly used cardiac rhythm management devices. The use of permanent pacemakers has increased because of several factors, including an aging population and an increasing number of indications for the use of these devices.[1] The cardiologists are scared of the pacemaker pocket infection (PPI) for the associated morbidity.[2] Very often the indolent PPI necessitates removal of the pacemaker thereby defeating the very purpose of its placement. Cardiac pacemakers can get infected by patient's own flora, distant infection through the bloodstream or nosocomial infection. Nosocomial PPIs are associated with a prolonged hospital stay, rise in the morbidity and mortality.[3],[4],[5] Hence, it is mandatory to determine the risk and the spectrum of the hospital-acquired cardiac PPI. This data will enable to plan the effective preventive strategies and management. Till date, very limited studies exist about the microbial profile of the nosocomial PPI from our country.[12] Hence, we conducted this study to find the risk of nosocomial PPI in a tertiary care hospital along with the identification of the microbial spectrum.

   Methods Top


The study was conducted retrospectively in the Department of Microbiology over the period from 1 January 2013 to 29 February 2016. During this study, a total of 160 pacemakers were implanted in our center under strict aseptic precautions. All patients were given prophylactic antibiotics with third generation cephalosporins and aminoglycosides for 5 days and were discharged thereafter. Postprocedure, all the patients were managed at the Intensive Care Unit for 48 h followed by the cardiac ward till the time of discharge. We included the patients whose pacemakers were implanted in our center only and excluded patients with pacemaker implantation from other centers. All patients who reported to the cardiology department with clinical features of the PPI and isolation of pathogenic bacteria from pus samples taken from the pacemaker pocket were included in the study. Echocardiography was performed on all the patients to diagnosis any device-related infective endocarditis and other cardiac complications.

Sample collection and processing

Routine hematology and biochemistry tests were conducted as per the protocol. Microbiological specimens were collected from all the patients with PPI and are termed as Group 1. A total of 100 environmental samples was collected as part of active surveillance of the hospital environment and staff, which are grouped as Group 2. These samples were collected from the medical staff (hand, throat, and nasal swabs) and the hospital environment (air, surgical instruments, dressing material, floors, door, walls, beds, sinks, and antiseptic solutions). Two blood culture samples (5–8 ml) were taken from all the patients with PPI in 50 ml BacT/Alert ® culture bottles and loaded into the instrument. The BacT/Alert system is a continuously monitored blood culture system for detecting bacteremia and fungemia.[6] Bottles flagged as positive by the BacT/Alert system were subcultured for bacteria and fungus and interpreted according to the standard protocols.[7] Pus samples from the PPI were processed as per the standard protocol, including the conduct of special stain, cultures (bacteria and Mycobacterium) and real-time polymerase chain reaction (PCR; Mycobacterium tuberculosis complex and atypical Mycobacterium).[7] We used real-time PCR equipment thermocycler 480 II and Bioneer's qualitative kit, and all the samples were cultured on MacConkey's agar, Blood agar, Sabouraud agar plate, and Lowenstein-Jensen (LJ) medium.

Microbial identification and antibiotic susceptibility testing

Any bacteria growth in these culture media was further processed for identification and antibiotic susceptibility testing using automated bacterial system VITEK 2 system (BioMérieux, France), compliant with CLSI guidelines 2014.[8],[9] Bacterial growth on LJ medium was studied for rate of growth, colony characteristics and biochemical reaction for species identification.

Statistical analysis

We present the data using descriptive statistics pertaining to the demographic and clinical parameters. Categorical variables were presented by frequency and quantitative data using the mean and standard deviation.

   Results Top

During the study, 17 patients (11:6 male:female) developed a PPI out of the total of 160 pacemakers implanted, giving an incidence rate of 10.6%. Briefly, the mean age of the patients was 62-year and mean duration of development of the PPI was 75 days after the pacemaker implantation. The demographic baseline details of the patients and associated comorbidities are given in [Table 1]. The most common pathogenic bacteria grown from the PPI was a coagulase negative Staphylococcus sp. in 7 patients, followed by Staphylococcus aureus in 4 patients. Other bacteria isolated were Burkholderia cepacia (n = 3), Mycobacterium abscessus (n = 2) and polymicrobial infection in the remaining one patient [Figure 1]. Polymicrobial infection was due to a combination of S. aureus and B. cepacia. One of the surveillance samples from trolley grew B. cepacia. All the blood cultures taken from the patients were negative for bacteremia and fungemia, and none of the patients had features of infective endocarditis.
Table 1: Baseline characteristics of the study population

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Figure 1: Pie diagram of bacteria isolated from permanent pacemaker pocket infection

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The Gram-positive isolates were sensitive to most of the common antibiotics tested.[8],[9]B. cepacia bacteria were isolated as pure culture colonies from pus sample of three patients and mixed culture colony from one pus sample. All these strains were of the same biotype with multidrug resistance to all antibiotic categories except colistin, piperacillin/tazobactam combination, and meropenem.[8],[9]M. abscessus grew within 3–5 days and lacked pigmentation, which is the characteristic of this group of atypical Mycobacterium with pathogenic potential.[10],[11]

   Discussion Top

Our study showed a 10% risk of PPI, which is similar to that of the previous reports.[12],[13],[14] Previous reports have shown the prevalence of PPI ranging from 1% to 20%, depending on the inclusion criteria and case definition. We used a positive microbial culture also as an inclusion criterion. This could have led to partial underreporting of the prevalence, as culture positivity rate is not seen in all the pus samples. Our bacterial isolates spectrum were similar to previous studies on the subject.[13],[14] In our study, six patients had multidrug-resistant emerging bacteria isolates. This is a cause of concern as these patients have high morbidity and require a prolonged duration of antibiotic therapy. PPI due to atypical Mycobacterium is a very rare presentation.[15] Atypical Mycobacterium is an opportunistic pathogen that grows in water and dust and may lead to PPI. Surgical site infection with atypical or environmental Mycobacterium due to contamination of endoscopes has been reported earlier.[16],[17],[18],[19]

Infection after a clean elective surgical procedure like permanent pacemaker implantation is expected to be low. The pacemaker is an expensive cardiac device and removal of the same due to infectious causes much anguish to the patient and the treating physician. Our study showed Gram-positive cocci as the most common organism responsible for the PPI. This could be acquired due to break in the aseptic protocol or through the hematogenous route. PPI due to common skin organisms is often easy to treat and prevent by reinforcing aseptic surgical norms. PPI due to atypical Mycobacterium and multidrug-resistant bacteria does not respond to the common antituberculous drugs and antibiotics. A prolonged course of treatment and even wound debridement are required to eliminate these infections. As a preventive measure, strict aseptic or sterilization protocol should be implemented.

Patients requiring cardiac pacemakers with associated comorbidities such as diabetes mellitus and hypertension also require prolonged treatment. In this study, 2 of patients had diabetes mellitus (11.7%), and 4 had hypertension (23.5%), which is comparable to other studies.[20]

Four of the patients in this study had PPI due to multidrug-resistant B. cepacia. B. cepacia complex (BCC) is an important group of pathogens affecting patients with cystic fibrosis and chronic granulomatous disease as well as immunocompromised and hospitalized patients. Therapeutic options are limited owing to high levels of resistance of the organism, either intrinsic or acquired to many antimicrobial agents. In our study, all the PPI with B. cepacia infection were managed with implant removal and piperacillin/tazobactam combination leading to resolution of the infection. PPI with multidrug-resistant BCC is rare and is commonly hospital acquired.[21],[22]

Several species of atypical Mycobacterium that are ubiquitous in nature and the colonies of potentially pathogenic species lack pigment. Identification of the type of mycobacteria is possible in any health-care service with basic laboratory facilities. However, accurate species differentiation would require PCR-restriction enzyme analysis (PCR-REA).

The species differentiation and evaluation of antibiotic sensitivity are essential in managing infection with atypical mycobacteria.[23] A variety of drugs in various combinations have been used that includes ofloxacin, clarithromycin, amikacin, sulfonamides, ciprofloxacin, doxycycline, and linezolid. The duration of the treatment ranges from 3 weeks to 3 months or even longer.[21],[23] The patients with atypical Mycobacterium (M. abscessus) in our series responded to implant removal, frequent wound dressing and combination therapy with linezolid and ciprofloxacin for 6 weeks.

The strengths of our study include the data being derived from a single tertiary level care center of the uniformed services with close follow-up of the patient. The limitations of our study include the small number of patients with PPI, exclusion of patients who did not have positive microbial culture and the retrospective nature of the study. Finally, the data pertain to the clientele of the uniformed services, which may not be a true representative sample of the community.

   Conclusion Top

Our study showed that the risk of PPI is about 10% in patients undergoing the permanent pacemaker implantation. This can be minimized by the use of strict antisepsis measures and postimplant care. The emergence of multidrug-resistant strains is a cause of concern which often entails the removal of the implant. Further large-scale prospective studies are required from India to determine the microbial spectrum of the PPIs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Eggimann P, Waldovogel FA. Pacemaker and defibrillator infections. In: Waldvogel FA, Bisno AL, editors. Infections Associated with Indwelling Medical Devices. Washington, DC: American Society for Microbiology Press; 2000. p. 247.  Back to cited text no. 1
Baddour LM, Cha YM, Wilson WR. Clinical practice. Infections of cardiovascular implantable electronic devices. N Engl J Med 2012;367:842-9.  Back to cited text no. 2
Klug D, Balde M, Pavin D, Hidden-Lucet F, Clementy J, Sadoul N, et al. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: Results of a large prospective study. Circulation 2007;116:1349-55.  Back to cited text no. 3
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Correspondence Address:
Jaswinder Singh Gill
Department of Microbiology, AFMC, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPM.IJPM_190_16

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