Recovery of Enterococcus gallinarum in patients with infected cardiac pacemaker pockets.

Objective: Patients with permanent pacemakers can suffer from local- ized generator pocket infections. The accurate identification of cardiac device infection is essential to ensure that patients are treated appropri- ately. Most frequent agents involved are Staphylo-cocci. An accurate microbiological evaluation is essential to correctly administrate specific antibiotics. Methods: We studied 4 patients (3 women and 1 men, range 77-88 years, mean range 82,5). Comorbid conditions included arterial hyper- tension (4 pz), diabetes mellitus (3 pz) and dyslipidemia (3 pz). The time from pacemaker implantation to onset of infection ranged from 10 days to 2 years. No one received presurgical antibiotic therapy. Pacemaker systems were removed in 2 patients: one did not require reimplantation and one had reimplantation of the same pacemaker in another pocket. All 4 patients had pocket surgical debridment. 2 patients received intra- venous antibiotics (teicopla-nin + levofloxacin + ceftriaxon + fluconazol; ceftriaxon + claritro-micin) while 2 patients received oral antibiotics ciprofloxacin + amoxicillin + clavulanic/amoxicillin; clavulanic/amoxicillin + levofloxacin). Results: Mycrobiological tests were performed on all patients: the cul- tures of pulse generator pocket were positive in 1 case for Staphylococcus aureus, in 1 case for Corynebacterium Spp/E.coli and in 1 case for Enterococcus gallinarum. Conclusions: The incidence of pacemaker pocket infections, right now, is about 3%. The most frequent agent involved in early infections is Staphylo-coccus aureus while late infections due to Staphylococcus epi- dermidis. To our knowledge, this is the first case of Entero-coccus galli- narum published in the English-language medical literature as a cause of pace-maker permanent device infection. E. gallinarum makes part of the normal stool flora of general individuals: it’s rarely encountered in human clinical specimens and is primarily found in the gastrointestinal tracts of various animals (1). It is also rarely associated with disease, but can be implicated in invasive infections, especially in immuno-compromised or chronically ill patients. E. gallinarum has the capacity to express resist- ance to low-level vancomycin (2-3). Our patient was a 79-year-old immunocompetent female with a history of arterial hypertension and dys- lipidemia. E. Gallinarum, detected by API kit system, was vancomycin- resistent but teicoplanin-suscectible. We obtained the complete clinical resolution after 7 weeks of treatment with teicoplanin 400 mg/die i.v. + ceftriaxon 2g /die i.v. + fluconazol 100mg x 2 /die o.s