Regional Antibiotics for Implanted Cardiovascular Electronic Device Infections

Quick Takes

  • Delivery of high concentrations of antibiotics into the implantation site can cure pocket infections in patients at high risk of complications with lead extraction.
  • Complete device/lead removal is associated with higher rates of cure than regional antibiotic therapy but is associated with a greater risk of complications.

Study Questions:

What is the efficacy of delivering continuous, in situ–targeted, ultrahigh concentration of antibiotics (CITA) into the infected subcutaneous device pocket without concomitant device or system extraction?


A total of 80 patients with pocket infection were treated with CITA. Nine patients had prohibitively high operative risk, six patients had questionable indications for extraction, and 65 patients were eligible for extraction, but opted for CITA treatment (CITA group). The CITA group was compared with 81 patients with pocket infection and similar characteristics who underwent device and lead extraction as primary therapy.


A total of 80 patients with pocket infection were treated with CITA. CITA was curative in 85% of patients at a median follow-up of 3 years. In the case-control study of CITA versus device/lead extraction, cure rates were higher after device/lead extraction than after CITA (96 vs. 85%, p = 0.027). Rates of serious complications were higher after extraction (n = 12 vs. n = 1; p = 0.005). All-cause 1-month and 1-year mortality were similar for CITA and device/lead extraction (0.0% vs. 3.7%; p = 0.25 and 12.3% vs. 13.6%; p = 1.00, respectively). Extraction was avoided in 91 extraction-eligible patients treated with CITA.


The authors concluded that CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction.


Pocket infections account for about 30-60% of cardiac implantable electronic device infections. The standard of care of pocket infections requires a complete removal of those devices along with extraction of all intracardiac electrodes. In this avant-garde and provocative study, the authors undertook opening the pocket, debridement, pocket cleansing with 1.5% hydrogen peroxide and 5% povidone-iodine, percutaneous insertion of a 6 French catheter, and administration of antibiotics directly into the pocket continuously for 10-14 days. The authors report relatively high rates of long-term clearing of infections without removal of the hardware. It is imperative to note that patients with signs of systemic infection, fever, positive blood cultures, or lead vegetations were excluded from this approach, as were patients with Staphylococcus aureus. This study presents a possible option for high-risk extraction patients, which may be associated with more favorable outcomes than chronic suppressive antibiotic therapy. A lot of further research will have to be done before this can be more broadly accepted.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Anti-Bacterial Agents, Arrhythmias, Cardiac, Cardiac Surgical Procedures, Defibrillators, Implantable, Geriatrics, Heart Failure, Infections, Myocardial Ischemia, Pacemaker, Artificial

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