Antimicrobial Pocket Flush and Cardiac Implantable Electronic Device Infection: Meta-Analysis of Real-World Studies

Clinical guidelines do not recommend the routine rinsing of cardiac implantable electronic devices (CIED) with antimicrobials before pocket closure("antimicrobial pocket flush.") However, despite current recommendations and a lack of evidence regarding the utility of this practice for reducing CIED infections, the antimicrobial pocket flush is still commonly employed. Clarifying the true value of this technique is important for supporting evidence-based practice and avoiding unnecessary antimicrobial use. Therefore, we performed meta-analysis of observational studies to determine the effectiveness of this practice in preventing CIED infections.

We performed a systematic literature search for observational human studies investigating the effectiveness of employing the antimicrobial pocket flush to prevent CIED infection. A random effects meta-analysis was performed. Effectiveness was estimated with the study-level definitions of CIED infection. We performed subgroup analysis by type of antimicrobial-antiseptic or antibiotic.

A total of seven studies including 12,283 patients were analyzed. Over half of the CIED implantation procedures (61.5%) included the antimicrobial pocket flush, and between 8.4% and 85% of the implantations were revision procedures. Studies used various antimicrobials for pocket flush, and definitions of CIED infection varied. Overall infection rates ranged from 0.5%-1.5%. CIED infection rates did not differ significantly between procedures performed with versus without antimicrobial pocket flush (0.8% vs. 1.1%; relative risk 0.80; 95% confidence interval 0.39-1.63; p = 0.54). There was no difference in the subgroup analysis by antiseptic or antibiotic use.

Our results suggest that the antimicrobial pocket flush provides no benefit in preventing CIED infection, reinforcing the current guidelines that do not support its routine use.