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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 46-48

Permanent Pacemaker Infection By Pasteurella Aerogenes A Rare Case Report From Bihar


1 Senior Resident, Department of Microbiology, IGIMS, Patna, India
2 Associate Professor, Department of Cardiology, IGIMS, Patna, India
3 Professor, Department of Microbiology, IGIMS, Patna, India
4 PG Student, Department of Microbiology, IGIMS, Patna, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Namrata Kumari
Professor, Dept. of Microbiology, IGIMS, Patna
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Infection is one of the serious complications in an implanted permanent pacemaker. Pasteurella species are a component of the normal oropharyngeal flora in many different animals. In humans, the skin and soft tissue are the most common sites for Pasteurella infection. We report a case of permanent pacemaker infection by Pasteurella aerogenes in a patient after four month of implantation. There was no history of contact with any animal during this period.

Keywords: Pasteurella aerogenes, Pacemaker, Implantation


How to cite this article:
Prakash V, Kumar N, Kumari N, Singh N, Priya P, Shahi S K. Permanent Pacemaker Infection By Pasteurella Aerogenes A Rare Case Report From Bihar. J Indira Gandhi Inst Med Sci 2018;4:46-8

How to cite this URL:
Prakash V, Kumar N, Kumari N, Singh N, Priya P, Shahi S K. Permanent Pacemaker Infection By Pasteurella Aerogenes A Rare Case Report From Bihar. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2021 Dec 4];4:46-8. Available from: http://www.jigims.co.in/text.asp?2018/4/2/46/302955




  Introduction: Top


Permanent pacemaker (PM) implantation has been worldwide used modality and treatment of choice for bradyarrhythmias.1 Infection is one of the serious complications in an implanted permanent pacemaker. This infection may occur either within one year of implantation as surgical site infection (SSI) or after one year mostly in the form of endocarditis.[2] Pacemaker implantation rate has increased and population with this implantation has grown for it being better treatment modality in cardiac diseases. As a result, there is increase in cases of infection in cardiac implants. It has been suggested that the relative rate of infection is also increasing.[3] However, no large studies support this suggestion, and the overall statistics for PM infection remain largely unknown.

Eighty percent of the pacemaker related infections are caused by Staphylococci, including S aureus and coagulase- negative Staphylococci. Gram-negative bacilli, such as Escherichia coli, Serratia, Pseudomonas, Klebsiella, Enterobacter species; fungi, such as Candida species, Torulopsis glabrata, Aspergillus species; and Mycobacterium avium-intracellulare etc account for rest 20% of the infections.[4],[5]

Pasteurella species are facultative anaerobic Gram- negative coccobacilli, which colonize the oral cavity and nasopharynx, and also the upper respiratory tract of many domestic and wild animals, particularly cats and dogs. Majority of human infections are caused by Pasteurella multocida (subspecies multocida, septica and gallicida), Pasteurella canis, Pasteurella stomatis and Pasteurella dagmatis.[6]

Pasteurella species is most commonly isolated species from skin and soft tissue infections following an animal bite, lick or scratch. Pain, tenderness, swelling, and erythema often develop and progress rapidly.

The respiratory tract is the second most common site of Pasteurella infection. It includes sinusitis, otitis, mastoiditis, tracheobronchitis, and pneumonia with accompanying empyema.

Other less common Pasteurella infections include, septicaemia; endocarditis; central nervous system infections like meningitis, brain abscess, and subdural empyema; intra-abdominal infections like appendicitis and spontaneous bacterial peritonitis.


  Case Report: Top


A 60-year-old nondiabetic, afebrile male patient reported to the Cardiology OPD of Indira Gandhi Institute of Medical Sciences, Patna, with complaints of pus discharge from insertion site of permanent pacemaker implant, done four months back in the same department. He was resident of north Bihar and by occupation farmer having no history of contact with animals like cat, dog or pig.

On general examination, vitals were within normal limits and routine investigations like Complete blood count, Liver function test and Renal Function test showed all parameters within normal range.

He was advised culture and sensitivity of the discharge and was planned for removal of implant. A pair of pus swab samples were collected from the wound. First sample was taken at the time of first visit, when removal of implant was planned and second sample was taken at the time of removal of the implant with proper aseptic precautions. [Figure 1].
Figure 1: Showing pacemaker at the time of

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The samples were processed according to the standard laboratory protocol. These were inoculated on nutrient, blood, chocolate and MacConkey agar media, and simultaneously also in Brain Heart Infusion (BHI) broth.

Blood and chocolate agar were incubated overnight at 37°C with 5% CO2. Mac-Conkey and nutrient agar were incubated overnight at 37°C aerobically. Gram stain was also done directly from the samples, which showed gram- negative bacilli with bipolar staining: safety pin like appearance [Figure 2]. On next day growth was observed on nutrient, chocolate and blood agar plates. Colonies were viscous, grayish white, flat with irregular margin, non- haemolytic and not easily emulsifiable in normal saline [Figure 3]. On BHI broth, surface pellicles were observed. Bacterial colonies were catalase positive, oxidase positive and nonmotile.
Figure 2: Showing gram negative bacilli with bipolar staining and safetypin

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Figure 3: Showing growth on nutrient agar culture media

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Further identification was done by using NMIC/ID-55 Panel in BD Phoenix M50 instrument. The organism was identified as Pasteurella aerogenes with 96% confidence value [Figure 4].
Figure 4: Showing test result in BD Phoenix M50 instrument by using NMIC/ID-55 Panel

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As MIC value of antimicrobials for this bacteria was not available in this instrument, we performed antimicrobial susceptibility testing (AST) by Kirby- Bauer disc diffusion method. The isolate was sensitive to amoxycillin, doxycycline, ciprofloxacin, piperacillin-tazobactam, ceftazidime , meropenem and co-trimoxazole [Figure 5]. In both samples Pasteurella aerogenes was isolated with similar antimicrobial sensitivity pattern.
Figure 5: Showing antibiotics sensitivity by Kirby- Bauer disc diffusion method

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Patient was empirically treated with doxycycline (200mg) twice a day and azithromycin (500mg). After antimicrobial sensitivity test report he was put on meropenem and ceftazidime for 2 weeks.

The patient responded well to the treatment. No discharge from wound site and better look of the wound could be noticed by 7thday of treatment. The permanent pacemaker was reimplanted on right side of the chest in right subclavian vein. The patient was discharged from the hospital in fully asymptomatic condition.


  Discussion: Top


Surgical site infection is considered as major cause of Pacemaker infection. If infection occurs within 3 months of implantation, it is referred as early infection. Late infections occur between 3 to 12 months. After 12 months of implantation, source of infection mostly is some other cause, not related to endogenous flora, surgical team or environmental factors.

Cardiac implantation infection is also defined and classified as pocket infection and deeper infection. Pocket infection involves subcutaneous pocket which contain device and subcutaneous part of the leads. Deeper infection involves transvenous portion of the lead, which is usually associated with bacteraemia and/ or endovascular infection.

According to the source of infections classified as primary and secondary infection. In primary infection device/ pocket itself is the source of infection, usually due to contamination at the time of implantation. On the other hand, secondary infection is mainly associated with bacteraemia from other sources.

Epidemiologically Pasteurella infections are divided into three groups,: 1) those associated with animal bites and scratches; 2) those associated with animal exposures but without a clear history of an invasive incident; and, 3) those that occur in the absence of any known animal contact.

There are many predisposing factors like Immuno- suppression, advanced age, cancer therapy, chronic kidney disease, diabetes mellitus, cirrhosis, active infection, and intervention associated with these infections. Bacterial inoculation often occurs as a result of bacterial colonisation of the operative site at time of implantation. Staphylococcus species from the skin, may specially, contaminate the wound, likely during pocket formation, and later cause pocket infection.

Pathogenic mechanisms that contribute to the development of infections in patients with permanently implanted cardiac pacemakers involve pre-existing heart disease; dental procedures; infections in cardiac valves; and surgical procedures on the already implanted device, such as battery replacement.

Here, source of bacterial inoculation could not be established as the patient didn't give any history of contact with pet animals. We also did culture of irrigation fluids (normal saline, savlon, betadine etc) and instruments used during operation but could not find any growth from them. So this case was a primary, late pocket infection without any known predisposing factor and no any history of contact with animals.

Pasteurella aerogenes infection is very rare. Infection by this bacterium is mainly associated with low immune status, patients living with cattles or accidental bite of wild animals. A case report from Denmark has described Pasteurella aerogenes Isolated from ulcers in a man with occupational Exposure to Pigs.[7]


  Conclusion: Top


Rare organisms can also be associated with cardiac implant infections. Infection of implanted cardiac device is a growing problem. In any form, cardiac infection is a severe complication requiring extraction of cardiac device and targeted antibiotic therapy. As there is no fixed guideline regarding treatment and prevention of these cases, further extensive study is necessary to determine the best prevention strategy, optimal duration and timing of antibiotic therapy, and effective guideline for reimplantation.



 
  References Top

1.
Mond HG, Irwin M, Ector H, Proclemer A. The world survey of cardiac pacing and cardioverter-defibrillators: calendar year 2005 an International Cardiac Pacing and Electrophysiology Society (ICPES) project. Pacing ClinElectrophysiol. 2008;31:1202-1212.  Back to cited text no. 1
    
2.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control HospEpidemiol. 1999;20:250-278.  Back to cited text no. 2
    
3.
Khaldoun GT, Christopher RE, Pascal D, Charles K. Cardiac Implantable Electronic Device Infection in Patients at Risk. Arrhythm Electrophysiol Rev. 2016;5(1):65-71. doi: 10.15420/aer.2015.27.2  Back to cited text no. 3
    
4.
Cabell CH, Heidenreich PA, Chu VH, Moore CM, Stryjewski ME, Corey GR, Fowler VG., Jr Increasing rates of cardiac device infections among Medicare beneficiaries: 1990-1999. Am Heart J. 2004;147:582-586.  Back to cited text no. 4
    
5.
Voigt A, Shalaby A, Saba S. Rising rates of cardiac rhythm management device infections in the United States: 1996 through 2003. J Am CollCardiol. 2006;48:590-591.  Back to cited text no. 5
    
6.
Zurlo JJ. Pasteurella species. In: Mandell GL, Bennett JE, Dolin R, editors. (eds) Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 7th ed. Philadelphia, PA: Elsevier, 2010, pp. 2939-2942.  Back to cited text no. 6
    
7.
Ejlertsen T, Gahrn-Hansen B, Søgaard P, Heltberg O, Frederiksen W. Scand J Infect Dis. 1996;28(6):567-70).  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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