Prosthesis-Related Infections: Artificial Pacemakers

Prosthesis-Related Infections: Artificial Pacemakers

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By: Patricia Lawrence, RN, BSN, MS
Edited by: Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems
Description/Etiology
Artificial pacemakers are electrophysiologic devices (i.e., devices that provide electrical activity in the body) that provide life-saving assistance for many individuals with cardiac rhythmdisorders. The generator, the main portion of the device, along with a portion of the leads (i.e., wires that originate from the generator and are embedded into the vessels of the heart) rests within a surgically created “pocket” of subcutaneous tissue in the upper chest, usually one to two fingerbreadths below the clavicle. Most postsurgical pacemaker implant infections occur in the pocket area andare usually caused from direct contamination of the device or tissue during implantation. The portion of the leads that transverse into vessels may show vegetation (i.e., active microbial growth), which may result in endocarditis (i.e., infection of the endocardium [i.e., inner lining of the heart muscle and valves]). Postsurgical pacemaker infection may also occur indirectly from another infectionlocated in a different part of the body (e.g., urinary tract infection that spreads through the bloodstream, infecting the surgical area of implantation or the implanted device and associated leads), although these cases are not as common as infections caused by direct contamination during surgical procedures. The two most common causes of postsurgical pacemaker implant infections areStaphylococcus aureus (23%) and Staphylococcus epidermidis (68%); both are common skin flora. Gram-negative organisms are less commonly the cause of postsurgical pacemaker infections and are more frequently reported in patients who are immunocompromised (e.g., those with AIDS) or taking immunosuppressive drugs (e.g., steroids).

Pacemakers rely on a battery-powered generator that requires subsequentreplacement every 5 to 7 years. Individuals who have subsequent replacements are at higher risk of developing infection at the site of surgery because subsequent surgeries require larger incisions into tissue, more extensive dissection, and longer procedure times, all of which increase the risk of infection. In addition, the presence of fibrotic tissue (i.e., inflamed tissue that has become scarred)impedes the delivery of blood to the area, increasing the risk of infection. The majority of pacemaker implantations are performed in an electrophysiology or interventional cardiology laboratory. Neither of these locales are considered as sterile as a surgical suite/operating room (OR), so strict adherence to sterile technique prior to, during, and after surgery is imperative to reduce the risk ofpostsurgical infection. Sterile technique involves wearing appropriate OR attire (e.g., mask, gown, gloves, head cap, full face mask, and/or ‘bunny suit’ if wearing street clothes), surgical scrubbing with chlorhexidine prior to donning surgical attire, and covering radiographic and lighting equipment with sterile plastic. Other prevention strategies include the administration of I.V. antibiotics(e.g., vancomycin) one hour before incision, limiting the length of surgery, and irrigating the wound with antibiotics, although there is little evidence to support that the latter technique reduces risk of postsurgical infection.

Signs and symptoms of postsurgical pacemaker implant infection vary, ranging from the mild (e.g., local inflammation) to severe (e.g., septic shock). Treatment alsovaries depending on the severity of infection and consists of antibiotic therapy and, if necessary, removal and replacement of the artificial pacemaker.

Facts and Figures
Over 3 million pacemakers are implanted worldwide each year. The number of implantations continues to increase as the population ages. A review of U.S. Medicare beneficiaries who had pacemaker implantations during the...