Elsevier

Heart, Lung and Circulation

Volume 16, Issue 6, December 2007, Pages 434-439
Heart, Lung and Circulation

Original Article
Pacemaker Infections: A 10-Year Experience

https://doi.org/10.1016/j.hlc.2007.02.097Get rights and content

Background

Infection is a major complication of pacemaker and defibrillator (PPM/ICD) implantation. The experience in an Australian regional centre is reported.

Methods

Ten years’ (1994–2004) cases of PPM/ICD infection retrospectively analysed and compared to overall insertion data; management and outcomes examined.

Results

A total 39 cases (79.5% male, median age 71.3 years) identified, 24 in the primary centre where 1481 procedures performed (infection rate 1.6%). Patients with infection had average 2.2 procedures performed (odds ratio for infection if >1 procedure = 4.7); 14 (36%) first implantations, 35 (90%) pacemakers, 11 (28%) recurrent. No difference in operation duration or difficulty between infected and non-infected cases. Infection in 18 cases (46%) involved lead/s, 16 (41%) generator and 5 (13%) both. Median time to presentation was 7.9 months. Echocardiography demonstrated lead vegetations in 8 cases. Organisms identified in 25 (64%)—92% Staphylococci (65% S. aureus); blood cultures positive in 18. PPM/ICD removed in 26 (67%), including lead/s in 89%; average hospital stay 37 days. One death attributable to PPM/ICD infection (mortality 2.6%), median follow-up 29.3 months.

Conclusions

A PPM/ICD infection rate of 1.6% (endocarditis 0.3%) demonstrated. Second and subsequent procedures carried almost 5 times greater infection risk.

Introduction

Infection is an uncommon but increasingly important complication of permanent pacemaker (PPM) and implantable cardioverter-defibrillator (ICD)—insertion, carrying significant morbidity. Between 1990 and 1999 there was a 42% increase in the number of PPMs inserted in Medicare beneficiaries in the USA; the number of infections rose by 124% in the same period.1 Between 1997 and 2001 there was a 48% increase in new implants performed in Australia (9498 new implants and 1536 replacements in 2001).2 Given the ever-widening indications for PPM/ICD insertion for heart failure therapy and prevention of arrhythmic death, these numbers are likely to rise dramatically.

There is no published Australian experience of this problem and documentation and description in the medical literature has been limited. Past studies have reported overall infection rates ranging from <1%3 and 1.8%,4 to 5.6%5 and higher in earlier reports. Lead endocarditis rates of 0.6%6 and 0.06%7 have been reported. Overall complications have been demonstrated more frequently in repeat procedures and generator replacements than in first implants, and when performed by inexperienced operators.8, 9

This study aimed to evaluate the rate, predisposing factors, management and outcome of PPM/ICD-related infection in a large, tertiary referral, regional centre of Australia.

Section snippets

Methods

Geelong is a regional centre in South-eastern Australia with a local population of approximately 270,000. The health services include a large tertiary referral centre (primary centre) and two smaller private hospitals. Referrals are received from a larger area comprising over 100,000 people.

Cases of PPM/ICD-related infection (presentations between June 1994 and December 2004) were identified using the infectious diseases service's prospective database encompassing all cases treated among the

Infection rate (primary centre)

During the study period 1481 operations (56% male, median age 75.3 years) were performed at the primary centre. There were 24 cases (71% male, median age 71.2 years) of infection, yielding an infection rate of 1.6%; 14 (0.9%) of these involved PPM/ICD leads and 5 were ‘confirmed’ giving a lead endocarditis rate of 0.3%. The infection rate varied from year to year during the study period from 0 to 3.3%.

The infection rate in patients who had undergone a single operation was 0.88%, and in those

Epidemiology and Risk Factors

To the authors’ knowledge, this is the first description of PPM/ICD infection in Australia. The results (infection rate 1.6%, endocarditis rate 0.3%) are consistent with reports from other centres. Males appear to be at higher risk of infection than females. The median age did not differ significantly between infected and non-infected cases (71.2 years versus 75.3 years, respectively).

Eighteen percent of cases were diabetic. The overall prevalence of DM in all PPM/ICD recipients at the study

Conclusions

The experience with pacemaker and ICD infection over the last 10 years is reported; this is an emerging problem with significant morbidity. The diagnosis and management of PPM/ICD infection is complex.

The rate of infection was 1.6% and lead endocarditis 0.3%. The strongest risk factor for infection was the number of prior procedures: the infection risk was nearly five times higher with second and subsequent procedures. Advanced age, DM, procedure duration and operator inexperience were not

Acknowledgements

The authors acknowledge A/Prof. S. Black, Director of Cardiology and Dr. Allen Cheng, Infectious Diseases Physician, Barwon Health (Geelong Hospital), and Dr. Margaret Henry, Statistician in Epidemiology & Biostatistics, University of Melbourne, for their valuable input and assistance.

No financial assistance was received by any author or contributor in the preparation of this work.

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