APCU25CR22 CRTD surgical site infection with MSSA: a gateway to infective endocarditis

Introduction Cardiac implantable electronic device (CIED)-related infective endocarditis (IE) is associated with high morbidity and mortality, which is frequently caused by Staphylococcus aureus.Case Presentation We report the case of a 43-year-old man with diabetes mellitus, hypertension, hypothyroidism, ischaemic stroke, and non-ischaemic dilated cardiomyopathy post cardiac resynchronisation therapy with defibrillator (CRTD) insertion, who presented with fever, redness, and itchiness over the skin surrounding the CRTD site three months post device implantation. He had high-grade temperature, and the CRTD surrounding skin was erythematous, warm, and tender. Cardiovascular examination revealed no murmur on auscultation. Blood investigations showed WBC 18.3 × 10^9, C-reactive protein 205 mg/L with methicillin-susceptible S. aureus bacteraemia. Transthoracic echocardiography (TTE) showed no obvious vegetation; hence, we proceeded with transoesophageal echo (TEE), which visualised vegetations at the right atrial lead and pulmonary valve. He received intravenous cloxacillin, gentamicin, and oral rifampicin for four weeks. Repeated blood culture after the completion of antibiotics showed no growth. However, he succumbed to death due to superimposed nosocomial sepsis with the background of overt hypothyroidism and uncontrolled diabetes with target organ complications.Discussion A high index of clinical suspicion must always be considered in the presence of unexplained fever in a patient with a CIED, particularly in S. aureus bacteraemia. A negative TTE does not rule out CIED IE; hence, in this case, a confirmatory TEE was done, which is more sensitive and specific for the diagnosis of lead-related endocarditis. A localised infection may be either a superficial incisional or an isolated pocket infection. Meanwhile, systemic CIED infection may occur with or without pocket infection or visible vegetations on the valves or pacing leads. The FDG-PET/CT has good sensitivity and specificity, particularly in CIED IE without signs of pocket infection. CIED IE requires at least 4 to 6 weeks of initial empirical antibiotic therapy directed at MRSA and Gram-negative bacteria. In patients with confirmed CIED lead infection, CIED removal is recommended due to the increased mortality associated with conservative treatment.Conclusion Multidisciplinary approaches, including optimisation of the modifiable risk factors, appropriate antimicrobial prophylaxis and diligent postoperative care, are essential for the prevention of CIED infection.