CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 10, November 2012
e2
AFRICA
within 24 hours of implantation, use of a temporary pacemaker,
early re-operation, pre-operative length of stay), clinical and
laboratory signs, treatment and evolution.
The data were entered and analysed using Epi Info version
3.5.1.
We used Microsoft Excel 2007 for the quantitative data
and to calculate averages.
Results
Infection was noted in six patients, including three women
and three men, with a mean age of 66.2 years and a range of
23
to 83 years. This represented 5.6% of patients implanted
with pacemakers during the study period. The indication for
implantation was complete atrio-ventricular block in all cases.
Table 1 summarises the observations of the six patients.
Factors associated with the occurrence of infection were
diabetes and dermatosis, the average duration of pre-operative
hospital stay which was eight days (range from 24 hours to
36
days), use of a temporary pacemaker (three patients), the
number of people in the ward (between four and five, average
4.5),
postoperative haematoma (one case), and repeating the
procedure (change of pacemaker box: one case, repositioning
of leads: one case, and re-placement of pacemaker box:
one case).
The delay time of onset of clinical signs of infection was 6.6
months, with a range of eight days to 12 months. The clinical
signs were represented by the externalisation of the pacemaker
pouch (Fig. 1) with skin necrosis, suppuration in five cases and
signs of inflammation in one case.
Haematologically, there was leukocytosis (one case), positive
C-reactive protein (three cases), raised erythrocyte sedimentation
rate (five cases) and anaemia due to inflammation (one case).
There was no blood culture for any of the patients. Local culture
samples were positive in five patients and negative in one
patient. The bacteria found were
Staphylococcus epidermidis
(
two cases),
Staphylococcus aureus
(
two cases) and
Klebsiella
pneumoniae
(
one case).
Transthoracic echocardiography showed no objective signs
of endocarditis. Transoesophageal echocardiography was not
performed.
As for the treatment, all patients had received intravenous
antibiotics prior to oral intake. The average duration of antibiotic
therapy was 50.4 days. Surgical treatment was conservative:
debridement and cleaning of the infection focus, repositioning
of the same pouch (five cases) and evacuation of the pus with
cleaning of the infection focus (one case).
After six months there was a recurrence in four patients.
They had local infection associated with externalisation of the
pacemaker box. The treatment was again with antibiotics and
conservative surgery. At 12 months, these four patients had
another recurrence. Two patients had their pacemakers implanted
onto the contralateral site, one patient had conservative surgery
and one died of septicaemia.
Discussion
Infectious complications after implantation of a pacemaker or
defibrillator are numerous and often have serious consequences.
3
Because of the steady increase in the number of long-lasting
devices implanted each year, the incidence of these complications
is expected to rise over the coming years.
3
The overall rate of infection after pacemaker implantation
was estimated in 2007 to be 1.6%.
4
The incidence of localised
infection in the pacemaker pouch was estimated at 1.33 per
1 000
in the USA.
5
In an update published in 2008, the frequency
of pacemaker infections ranged from less than 1% to more
TABLE 1. SUMMARY OF DATA OF SIX PATIENTS
No
Age
(
years) Gender
Number
of leads
in place
Date and type of
last intervention
Onset of
complication
after last
implantation Type of complication Pathogen
Treatment
Outcome
1 23
M 2 March 2005
first implantation
8
months
Infection of pacemaker
pouch + externalisation
of box
Staphylococcus
epidermis
Antibiotics +
repositioning
of box
Treatment failure with
recurrence of infections
Good evolution after
removal of pacemaker
and transferred to the
contralateral site
2 83
M 1 January 2006
replacement of
box
5
months
Infection of pacemaker
pouch + externalisation
of box
Staphylococcus
epidermis
Antibiotics +
repositioning
of box
Treatment failure with
re-infection
Good evolution after
removal of pacemaker
and transferred to the
contralateral site
3 76
M 1 February 2007
first implantation
8
months
Infection of pacemaker
pouch + externalisation
of box
Negative
culture
Antibiotics +
repositioning
of box
Good evolution at
6
months
4 73
F
1
October 2007
first implantation
8
days
Infection of pouch
Staphylococcus
aureus
Antibiotics +
repositioning
of box
Good evolution at
6
months
5 74
F
1
December 2005
re-implantation
of box
6
months
Infection of pacemaker
pouch + externalisation
of box
Staphylococcus
aureus
Antibiotics +
repositioning
of box
Treatment failure four
times
6 68
F
2
March 2005
repositioning of
lead
12
months Infection of pacemaker
pouch + externalisation
of box
Klebsiella
pneumoniae
Antibiotics +
repositioning
of box
Treatment failure with
recurrence of infection
with
Staphylococcus
aureus
Died of septic shock
