What Are the Signs and Treatment for a Pacemaker Infection?

A pacemaker infection can show up in two places: on the chest where the device sits, or deep inside on the wires that run to the heart. The inside kind can produce nothing you can see, only fever and a general sense of being ill.¹ Unlike most infections, a real device infection usually can’t be cleared with antibiotics alone, because the hardware generally has to come out.²

Signs of an Infection Around the Device

The pacemaker box sits in a small pocket under the skin, usually below the collarbone. Thin wires, called leads, run from it through a vein into the heart. Infection can start in the pocket or on the leads.³ Staphylococcus bacteria, often from the skin, cause most device infections, whether they appear early or late.⁴ Once on the device, bacteria can form a sticky film over its surface that shields them.⁵

When the pocket is involved, the signs are usually visible:

Color change: redness or darkening of the skin over the device
Warmth, swelling, or tenderness: it grows rather than fades
Drainage: pus or fluid leaking from the incision
Skin changes: thin, shiny, or stretched skin, or any part of the device or wire poking through
Healing problems: an incision that reopens or won’t heal

After surgery, some bruising, mild soreness, and slight swelling are normal for the first week or two. Normal healing improves day by day, so pain that grows after the first few days is a warning sign. Pus is never normal healing.

Thinning skin over the box can be the first sign of a slow infection. Once metal or a wire shows through, the device is considered infected even if there is no pus. Don’t cover it and wait; it needs a same-day call.

Signs of an Infection on the Wires Inside the Heart

When bacteria settle on the wires inside the heart, doctors call it lead endocarditis, an infection of the wires and nearby heart lining. It can happen with a perfectly normal-looking pocket, showing up only as high fever and abnormal blood tests.⁶ Fever and shivering occur in a little over half of people with wire infection.⁷ About 1 in 4 have pneumonia-like lung infections, because infected clumps can break off and travel to the lungs.⁸

Day to day, wire infection can look like fevers that come and go, night sweats, or shaking chills. Over weeks you might feel tired, lose your appetite, or lose weight. Some people have shortness of breath or a cough that keeps returning, or simply feel vaguely unwell with no obvious cause.

Antibiotics can be misleading here. A course may ease the fever for a while, but a fever that returns after the course ends is a clue that the device may be the source. If possible, ask for blood cultures before any antibiotics are started.

These internal infections are subtle and often diagnosed late, which worsens outcomes.⁹ When you have an unexplained fever, tell every doctor you see that you have a device.

When to Call Your Doctor

Infections that spread into the bloodstream are more dangerous than those confined to the pocket.¹⁰ Timing is also less predictable than people expect: infection can appear years after surgery, and nearly 4 in 10 infections needing wire removal began more than three years after the last procedure.¹¹

Call the cardiology or device clinic that implanted it, not just a general clinic. Say that you have a pacemaker, when it was placed or last changed, and what you see. Dated photos of the skin help show how things are changing. For high fever, shaking chills, or confusion, go to emergency care.

Don’t squeeze, drain, or lance a swelling over the device. Don’t start leftover antibiotics yourself, since they can hide the bacteria from blood tests. And don’t assume a late infection can’t be the device just because surgery was long ago.

How Doctors Confirm a Pacemaker Infection

Diagnosis rests on examining the site, growing bacteria from blood samples or wound swabs, and a detailed heart ultrasound.¹² This often means a transesophageal echocardiogram, or TEE, which passes a small ultrasound probe down the throat to see the wires and valves closely.¹³ That’s needed because an ordinary ultrasound through the chest wall often can’t see clumps on the wires.¹⁴

For the TEE, your throat is numbed and you are usually given sedation. You’ll need to fast beforehand and arrange a ride home. The probe stays in for a short time, often under half an hour, and a sore throat for a day afterward is common.

Several separate blood samples are drawn, often from different spots, because a single positive sample can be skin bacteria that contaminated the bottle. When the same bacteria grow in several samples, that pattern points toward a real bloodstream infection. Cultures can take a day or more to turn positive, so treatment may begin on suspicion before the result arrives.

When there are no visible signs or the ultrasound is unclear, a PET/CT scan, which lights up areas of active inflammation, can help.¹⁵ It picks up about 8 in 10 device infections and wrongly flags about 1 in 10 people without one.¹⁶ It can also show whether infection has spread elsewhere in the body.¹⁷

Treatment Usually Means Removing the Whole Device

For an established device infection, removing the entire system, box and wires, is standard treatment.¹⁸ The reason is the protective bacterial film on the hardware, which lets infection survive antibiotics. When an infected device is left in place, death rates from heart-lining infection range from about 31% to 66%.¹⁹ With complete removal and antibiotics, about 96% of people are cured.²⁰ A shallow infection of the incision that doesn’t reach the device may not need removal.²¹

Most wires are removed through the vein using special sheaths, a procedure called lead extraction. It is usually done under sedation or general anesthesia, with the team prepared for the rare emergency of a tear in the heart or a vein. The surgeon opens the pocket, frees the box, and then works the wires loose from scar tissue inside the vein using thin sheaths that slide over them. Scar tissue builds up around wires over the years, which is why older wires are harder to remove.

In a large national record, serious complications happened in about 2 in 100 extractions, and deaths during the procedure in fewer than 2 in 1,000.²² Risk is higher with more wires, wires in place many years, and with infection itself.²³ So extraction is best done at an experienced center with heart surgery available on site. Before the procedure, it’s reasonable to ask how many extractions the team does each year, whether a heart surgeon is on standby in the room, how your heart rhythm will be supported while the device is out, and how long you’ll be in hospital.

Antibiotics and How Long Treatment Lasts

IV antibiotics begin after blood cultures are taken, and the first choice is made to cover staphylococcus.²⁴ Up to half of staph in device infections can be resistant to common antibiotics, so vancomycin is often used until results return.²⁵ Once the lab identifies the bacteria, treatment is narrowed to a more precise drug.²⁶

Length depends on spread. For a pocket-only infection, switching to pills after device removal is reasonable.²⁷ If blood cultures are positive, treatment stays intravenous.²⁸ If wires or valves have infected clumps, treatment follows heart-infection rules, usually four to six weeks.²⁹

Weeks of IV treatment are often finished at home through a long-term line in the arm. A nurse may visit, or you may learn to give doses yourself. Watch the line site for redness and report any fever.

Getting a New Pacemaker After Removal

The typical wait between removal and the new device is about 10 days, often 6 to 19.³⁰ The pause gives the antibiotics time to clear bacteria from the blood and surrounding tissue, so new hardware isn’t placed into an active infection. Exact timing depends on how quickly the blood cultures turn negative.

The results are encouraging. Among people who got a new device, only about 2 in 100 had another infection within 6 months.³¹ People who kept their original hardware had a repeat infection rate of about 11 in 100.³²

People whose heart can’t beat adequately on its own may get temporary pacing until the new device goes in. Some centers place pacing wires on the outside of the heart in the same operation that removes the infected system.³³

The new device is usually placed in a fresh site away from the infection. Blood cultures are often repeated first to confirm the infection is gone, and you can expect wound checks and clinic visits in the first weeks.

Not everyone needs a new device. Doctors reassess whether pacing is still needed, and some people no longer need it or need a different type. Ask what would happen to your rhythm if no device is replaced.

Who Gets Infections and How They Are Prevented

About 1.2% of people develop a device infection within a year of implantation, and nearly half of those appear in the first month.³⁴ Risk is higher after repeat operations on the device, early redo procedures, fever in the day before surgery, and temporary pacing beforehand.³⁵ Men and younger people also have a somewhat higher risk.³⁶

Antibiotics given just before implantation cut infection risk by more than half.³⁷ An antibiotic-releasing mesh envelope around the device reduced serious infections by about 40%.³⁸ If you are high risk or having a box change, ask whether an envelope is suitable.

Leadless pacemakers are small capsules placed directly inside the heart, with no pocket or wires, and they have very rarely been reported infected.³⁹ They have stayed infection-free even in people who previously had device infections.⁴⁰ They suit only some rhythm problems and pace one chamber, so not everyone qualifies. After an infection, ask your cardiologist whether one fits your case.

You can help too. Report any fever or skin infection before your procedure date. Follow wound-care instructions and keep the incision dry as told. Keep diabetes and other illnesses well controlled, and tell dentists and other doctors you have a device.

Outlook After a Pacemaker Infection

In one center, about 2.5% of people with pocket-only infection died, versus about 11% with bloodstream infection.⁴¹ About 18% of people with device infections died within 6 months, with higher rates when there were spread clots, valve leakage, or kidney problems.⁴² Three years later, about 54% of people with a pacemaker infection had died, versus 33% of similar pacemaker patients without one.⁴³ These figures partly reflect that many device patients are older and have other illnesses.