Pacemaker pocket infection due to environmental mycobacteria: Successful management of an outbreak and steps for prevention in future.

BACKGROUND: An outbreak of surgical site infection (SSI) due to environmental mycobacteria (EMB) occurred in a hospital in Eastern India. METHOD: A quality improvement project (QIP) was undertaken to analyze the causes and prevent further outbreak. Step (1) Proof of the need: Four patients who had undergone pacemaker implantation consecutively during a 10-day period developed SSI. Step (2) Diagnostic journey: Since all patients developed SSI within 2 months of implantation, a common source of infection was likely. Atypical mycobacteria (AMB) were grown from surgical sites as well as from the surface of operation table, image intensifier, and lead aprons. It was a rapid growing variety that lacked pigment, a characteristic of EMB with pathogenic potential. The EMB was finally traced to its source, the overhead water tank. Step (3) Remedial journey: By thorough cleaning of the water tank and enriching its chlorine content, the EMB was eliminated from its source. Step (4) Holding the gains: Protocol for cleaning the water tank once in 3 months was made. A checklist was prepared to ensure compliance to asepsis protocol in the operation theater. In the ensuing 5 years, the infection did not recur. RESULT: The bacteria that caused SSI were identified as EMB that grew in the water tank and contaminated the operation room. It could be eliminated by appropriate measures. INTERPRETATION: Water is a potential reservoir for EMB. Use of the term 'environmental mycobacteria' instead of 'atypical mycobacteria' will generate awareness about contamination as the cause of SSI.

Redo surgery after permanent pacemaker implantation: performance indicator of surgical techniques and pacing technology.

BACKGROUND: The incidence of permanent pacemaker-related complications is reducing due to advancement of technology and increasing operator experience. There are only few series from India reporting the annual complication rates from a single center over the years. This is a series of 782 pacemakers implanted over 20 years in a secondary healthcare set-up. METHODS AND RESULTS: Eighty-two patients underwent redo surgery, either for a procedure-related complication (n=34) or for replacement of a malfunctioning/end-of-life pacemaker (n=48). Through critical analysis and corrective measures, all the procedural complications were reduced to less than 4% of the annual implantations. The introduction of a pacemaker follow-up clinic contributed to reducing the rate of elective replacement for battery depletion from 19.17% of the implanted VVI pacemakers to 0.63%. CONCLUSIONS: Despite being a low-volume center, with less than 100 pacemakers implanted annually, the performance of our pacing practice has shown continuous improvement.