Continuous in situ-targeted antibiotics for CIED pocket infections yielded lower cure rates than device extraction (84.6% vs 96.2%; P=0.027) but fewer serious complications (1.5% vs 14.8%; P=0.005).
Case-Control (n=161)
Does continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) improve cure rates and reduce complications compared to device/lead extraction in patients with CIED pocket infections?
CITA provides a safe and effective alternative to complete device extraction for localized CIED pocket infections, significantly reducing serious complications while maintaining an 85% cure rate.
Absolute Event Rate: 84.6% vs 96.2%
p-value: p=0.027
BACKGROUND Present guidelines endorse complete removal of cardiovascular implantable electronic devices (pacemakers/defibrillators), including extraction of all intracardiac electrodes, not only for systemic infections, but also for localized pocket infections. OBJECTIVES The authors evaluated the efficacy of delivering continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) into the infected subcutaneous device pocket, obviating the need for device/lead extraction. METHODS The CITA group consisted of 80 patients with pocket infection who were treated with CITA during 2007-2021. Of them, 9 patients declined lead extraction because of prohibitive operative risk, and 6 patients had questionable indications for extraction. The remaining 65 patients with pocket infection, who were eligible for extraction, but opted for CITA treatment, were compared with 81 patients with pocket infection and similar characteristics who underwent device/lead extraction as primary therapy. RESULTS A total of 80 patients with pocket infection were treated with CITA during 2007-2021. CITA was curative in 85% (n = 68 of 80) of patients, who remained free of infection (median follow-up 3 years IQR: 1.0-6.8 years). In the case-control study of CITA vs device/lead extraction, cure rates were higher after device/lead extraction than after CITA (96.2% n = 78 of 81 vs 84.6% n = 55 of 65; P = 0.027). However, rates of serious complications were also higher after extraction (n = 12 14.8% vs n = 1 1.5%; 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 90.8% (n = 59 of 65) of extraction-eligible patients treated with CITA. CONCLUSIONS CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction. (Salvage of Infected Cardiovascular Implantable Electronic Devices CIED by Localized High-Dose Antibiotics; NCT01770067).
“The continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) study by Dr. Topaz and colleagues is a breath of fresh air in the field of cardiac implantable electrical device infection management. In this setting, where complete and often complex system extraction remains the gold standard, the CITA study offers a glimmer of hope that perhaps in some select cases where the complication risk of a complex system extraction is prohibitive a more conservative approach to manage CIED pocket infection might be feasible.”
Topaz et al. (Sun,) conducted a case-control in Cardiovascular implantable electronic device (CIED) pocket infection (n=161). Continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) vs. Device/lead extraction was evaluated on Cure rate (remaining free of infection) (p=0.027). Continuous in situ-targeted antibiotics for CIED pocket infections yielded lower cure rates than device extraction (84.6% vs 96.2%; P=0.027) but fewer serious complications (1.5% vs 14.8%; P=0.005).