What are the management guidelines for an infected pacemaker pocket?

Management of Infected Pacemaker Pocket

Complete device and lead removal is recommended for all patients with pacemaker pocket infection as evidenced by abscess formation, device erosion, skin adherence, or chronic draining sinus. 1

Diagnosis of Pacemaker Pocket Infection

• Local device infection is defined as an infection limited to the pocket of the cardiac device and is clinically suspected in the presence of local signs of inflammation at the generator pocket, including erythema, warmth, fluctuance, wound dehiscence, erosion, tenderness or purulent drainage 1
• Differentiation between local pocket infection and cardiac device-related infective endocarditis (CDRIE) can be challenging, but is important for determining treatment duration 1
• Staphylococci, particularly coagulase-negative staphylococci, account for 60-80% of pacemaker infections, with Staphylococcus aureus being the second most common pathogen 1

Management Algorithm for Infected Pacemaker Pocket

Step 1: Complete Device Removal

• Complete device and lead removal is mandatory for all patients with definite pacemaker pocket infection 1
• Device removal is indicated even without clinically evident involvement of the transvenous portion of the lead system 1
• Percutaneous extraction is recommended in most patients with cardiac device infections 1
• Conservative management (antibiotics without device removal) has been associated with 100% relapse rates and should be avoided 1

Step 2: Antimicrobial Therapy

• Choice of antimicrobial therapy should be based on the identification and in vitro susceptibility results of the infecting pathogen 1
• Duration of antimicrobial therapy should be 10 to 14 days after device removal for pocket-site infection 1
• For bloodstream infection, antimicrobial therapy should be administered for at least 14 days after device removal 1
• For complicated infections (endocarditis, septic thrombophlebitis, osteomyelitis), antibiotics should be continued for at least 4-6 weeks 1

Step 3: Assessment for New Device Implantation

• Each patient should be carefully evaluated to determine whether there is a continued need for a new device 1
• One-third to one-half of patients may not require new device placement 1
• When implantation of a new device is necessary, it should be performed on the contralateral side if possible 1
• If contralateral implantation is not possible, a transvenous lead can be tunneled to a device placed subcutaneously in the abdomen 1

Step 4: Timing of New Device Implantation

• New device implantation should be delayed until blood cultures are negative for at least 72 hours 1
• For patients with valvular infection, new transvenous lead placement should be delayed for at least 14 days after device system removal 1
• For pacemaker-dependent patients who cannot be discharged with a temporary pacemaker, alternative approaches such as active-fixation temporary leads or leadless cardiac pacemakers may be considered 2

Special Considerations

• CIED removal is not indicated for superficial or incisional infection without involvement of the device and/or leads 1
• Needle aspiration of a pocket hematoma should be avoided because of the risk of introducing skin flora into the pocket and subsequent development of infection 1
• For patients who are at extremely high risk for lead extraction or lack access to necessary technology, conservative management with complete debridement, sterilization, and closed antimicrobial irrigation systems has been reported, but is not recommended as standard practice 3
• Complete device removal reduces the risk of reinfection by 75% compared to partial removal or conservative management 4
• One-stage exchange (removal and reimplantation during the same procedure) increases the risk of reinfection six-fold and should be avoided 4

Prevention of Pacemaker Pocket Infection

• Prophylaxis with an antibiotic that has in vitro activity against staphylococci should be administered intravenously before incision 1
• Meticulous attention to sterile technique during implantation is mandatory 1
• Prevention of hematoma during the procedure is important as hematoma is a risk factor for subsequent infection 1
• In patients with limited subcutaneous tissue or poor nutrition who are at increased risk for erosion, a retropectoral pocket should be considered 1

By following this comprehensive management approach, cure rates of 95-96% can be achieved in patients with pacemaker pocket infections 1, 5.