We present a 68-y-old female who had undergone aortocoronary bypass and developed Staphylococcus aureus sternal osteomyelitis. Despite prolonged therapy with different antibiotics and several local debridements and drainage, the wound remained open and suppurative. Only after sternectomy and wide excision of infected costal cartilage was the diagnosis of sternal tuberculosis made, 24 months later. This case illustrates the necessity of a high degree of suspicion to diagnose this very rare entity which coexists with more common causes of sternal osteomyelitis.

Fifty-five episodes of bacteraemia arising in patients with a permanent endocardial pacemaker (PEP), from May 1987 to March 2006, were reviewed to determine whether clinical and microbiological data might assist in individual clinical management. Episodes of PEP-related bacteraemia were divided into early-onset bacteraemia, occurring within 6 months after device implantation or manipulation, and late-onset bacteraemia, occurring thereafter. Episodes with a source different from the PEP were classified as out-of-system bacteraemia. The PEP was the source of infection in 27 (49%) patients. Among patients with early-onset PEP-related bacteraemia (n = 16), Staphylococcus aureus was isolated in 87.5% (14/16) of cases; 81% of them (13/16) had local signs of infection at the PEP pocket and 25% (4/16) died. Conversely, patients with late-onset PEP-related bacteraemia (n = 11) had a protracted clinical course; local signs of infection were infrequently observed (18%); a coagulase-negative staphylococcus was isolated in 91% of cases, and no death-related infection was registered. In patients with out-of-system bacteraemia (n = 28), the device became colonized and required explantation in 56% (5/9) of patients with S. aureus infection; the remaining 19 patients with out-of system bacteraemia caused by a microorganism other than S. aureus were successfully managed with medical treatment. Early-onset and late-onset PEP-related bacteraemia differ regarding the microorganism involved, the clinical presentation, and the prognosis. When the pacing system is involved, a complete explantation of the device is necessary to cure the infection. However, most episodes of bacteraemia arising outside the PEP, mainly those not caused by S. aureus, can be conservatively managed.

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