Conservative management of infected pacemaker and implantable defibrillator sites with a closed antimicrobial irrigation system

Current guidelines recommend that patients with infected cardiac rhythm management device (CRMD) sites undergo removal of all system components (pulse-generator and leads). However, lead removal may not be an option for patients who lack access to state-of-the-art technology, lack the necessary financial resources, or are at very high risk because of age or concomitant disease. In this case series, we report our successful experience with conservative treatment of five such patients, who had CRMD infections localized to the device pocket. The device pocket and remaining hardware were completely sterilized to successfully eradicate the infection. First, all non-viable tissue, chronically inflamed tissue, granulation tissue, and scar tissue were completely removed, with special attention to complete haemostasis. Secondly, all non-essential foreign materials, including old sutures and plastic suture anchoring sleeves, were removed, and the remaining hardware was completely sterilized. To achieve this goal, we used mechanical means (scrubbing and pulsed lavage), as well as a closed antimicrobial irrigation system. In all five cases, the pulse-generator site was saved, lead removal was avoided, and the patients were free of local or systemic infection for a minimum of 1 year after treatment. Our conservative approach to the management of infected CRMD sites is feasible and beneficial in selected patients who are at very high risk for lead removal or who lack access to the technology necessary for safe performance of this procedure, provided that the infection is limited to the implant site.