Impact of antibiotic treatment prior to device extraction in isolated pocket infections of cardiac implantable electronic devices
J Meseguer Donlo, A M Gutierrez Baena, J Iglesias-Varea, N Fernandez-Hidalgo, M Hernandez Meneses, F Escrihuela-Vidal, E De Blas Escudero, M Lucas Torres, M Villamarin Melio, L Escola-Verge, J M Guerra Ramos, S Grillo, A Bonet BasieroAbstract
Introduction
Management of cardiac implantable electronic device (CIED) infections relies on complete device extraction and appropriate antibiotic therapy. In cases of isolated pocket infections, current recommendations advocate initiating intravenous antibiotics after obtaining blood cultures, suggesting that withholding antibiotics until device removal may be reasonable in patients with mild local inflammation. However, in clinical practice there is considerable variability in whether antibiotics are started before extraction, often because of local inflammation or delays in scheduling the procedure, and this can lower culture yield and complicate truly targeted antibiotic therapy.
Purpose
To assess whether initiating antibiotic treatment prior to device extraction in isolated CIED pocket infections influences clinical management or outcomes.
Methods
We conducted a multicenter retrospective observational cohort study including all CIED infections reported from 2013 to 2023 across four referral hospitals. Isolated pocket infection was defined as infection confined to the generator pocket without systemic symptoms. Patients with systemic symptoms (fever or constitutional syndrome) or without device extraction were excluded. The cohort was divided into two groups: those receiving antibiotics before extraction (ATB+) and those who didn't (ATB–). Baseline characteristics, management and outcomes (infection recurrence, in-hospital mortality and extraction complications) were compared.
Results
Among 591 identified CIED infections, 329 isolated pocket infections were analyzed after exclusions. Of these, 213 (65%) received antibiotics before extraction (ATB+) and 116 (35%) did not (ATB-). Baseline characteristics, including age, sex, device type, and comorbidities were comparable between groups, except for a higher prevalence of prosthetic valves in ATB+ [29/213 (14%) vs 7/116 (6%), p= 0.035] and less frequent erythema presentation [8/213 (4%) vs 12/116 (10%), p=0.017]. Pocket swab cultures were more often positive in ATB+ [103/146 (71%) vs 27/49 (55%), p=0.047], while surgical material cultures were less frequently positive [161/207 (78%) vs 104/112 (92%), p=0.001]. Median pre-extraction antibiotic duration was 8 days [1-10]. Rates of bacteraemia were similar [12/199 (6%) vs 6/97 (6%), p=0.958]. Complete extraction and complication rates did not differ, with one post-extraction sepsis in each group. Postextraction antibiotic duration was longer in ATB+ (24.5 vs 15 days, p=0.075) as did reimplantation of a new device rates [187/213 (88%) vs 93/116 (81%), p=0.090], with no differences in site or timing. No significant differences were observed in relapse or in-hospital mortality, with a median follow up of 3.8 years [1.4-6.1].
Conclusions
Routine pre-extraction antibiotics may be unnecessary for all patients with isolated pocket infection. Prospective studies are warranted to confirm these results and identify subgroups that could benefit.Table 1Table 2