treatment with a cardiac implantable electronic device ( cied ) , including a permanent pacemaker ( ppm ) or implantable cardioverter 
an icd is needed not only to rescue survivors of life - threating ventricular arrhythmias , but is also first - line primary prevention to save patients with marked cardiac dysfunction . moreover ,
medical technology for resynchronization therapy has advanced , with a resulting increased rate of device implantation , . along with the increase in device implantation ,
the incidence of cied infection , which can have serious or fatal complications , has also increased , , , , .
reported that a total of 3390 ( 1.7% ) out of 200,909 implanted icds developed a device infection within six months .
other studies have reported a similar rate of cied infection ( 0.72.2% ) , , , .
the management of infected cied patients is difficult , and requires special knowledge and effort by physicians .
intensive treatment of cied infections is recommended , including administration of appropriate antibiotics and complete removal of the infected device , , , , , , , , , , , , .
consensus reports and statements from the literature also recommend prompt and complete device removal in combination with antimicrobial therapy , , . in this article , we present the role of conservative therapy for the management of cied infection .
when cied infection is diagnosed , early complete removal of the infected device is strongly recommended because of the high association with increased mortality .
no prospective randomized studies have assessed the value of conservative antibiotic therapy alone , compared with combined complete device removal and administration of appropriate antibiotics .
however , some reports cited the poor outcome using conservative antibiotic therapy in patients with cied infection , .
about 30 years ago , lewis et al . reported on treatment of patients with permanent pacemaker infections .
thirty - two patients received conservative antibiotic therapy without removal of the infected pacing system , which included limited debridement and irrigation or aspiration of the infected sites .
this conservative therapy failed in all , but one of the 32 patients , and complete removal of the device system was needed in 31 .
molina et al . subsequently reported the outcome of management in 38 patients with an infected cied , including 17 icds .
twelve patients received intravenous antibiotics without removal of the cied , but with relocation to a different area , with or without aspiration of the infected area .
the remaining 26 cied patients who underwent primary removal of the entire device system were completely cured .
although complete removal of an infected cied is first - line therapy , there can be a risk of device removal complications .
it was reported that complications of device extraction were associated with increased mortality in patients with cied infections at both 30 days ( hazard ratio [ hr ] : 4.33 , 95% confidence interval [ ci ] : 1.4712.70 ) and one year ( hr : 3.77 , 95% ci : 1.887.55 ) .
however , delayed device removal was associated with a 3-fold increase in one - year mortality , and antibiotic therapy without device removal was associated with a 7-fold increase in 30-day mortality , compared to immediate device removal in the previous paper .
margey et al . also described outcomes and mortality in infected cied patients . of 39 ( 82% ) patients ,
32 underwent device extraction , and complete device removal was accomplished in 27 ( 84% ) .
of these , none relapsed , and mortality was 7.4% during a median follow - up period of 36 months .
of those managed with only generator removal or conservative therapy , relapse occurred in 8 of 12 ( 67% ) , with mortality occurring in 8.4% . using data on patients with infective endocarditis and a cardiac device , athan et al reported that 28 of 141 ( 19.9% ) who underwent device removal during the index hospitalization died at one year , compared with 13 of 34 ( 38.2% ) who did not undergo device removal ( hr : 0.42 , 95% ci : 0.220.82 ) , which suggested that device removal was associated with improved survival at one year .
some patients have severe complicated medical problems and are considered too ill to tolerate aggressive surgical intervention .
in addition , some patients refuse surgery , or have a limited life span . in such cases ,
successfully treated exposed pacemakers relocated to deeper subfascial planes without relapse of infectious signs in 10 patients .
they concluded that subfascial relocation of a properly functioning pacemaker generator should be considered as an alternative to complete replacement of the unit .
hurst et al . also reported that 19 infected or extruded pacemaker patients were treated with local debridement and insertion of a closed irrigation system using solutions of tyloxapol and tobramycin . in order to achieve successful treatment , they insisted on careful debridement of the infected pocket and large pocket space to ensure adequate closure without tension . using this method ,
they have been successful in salvaging infected pacemaker pockets , and all 19 patients healed without complications after treatment ( the maximum follow - up period was 70 months ) .
clinical data on 51 patients with intravascular device - related infections who were administered long - term suppressive antibiotic therapy were also reported .
the categories included vascular graft infections in 30 ( 59% ) patients , prosthetic valve endocarditis in 12 , pacemaker - related infections in 5 , aortic graft infections in 3 , central venous catheter infections in 3 , and venous filter infection in one .
of 41 followed - up patients , 3 ( 7% ) had an infection relapse while on long - term antibiotic therapy .
three patients died , including one who had an infection relapse and died of the infection .
the report stated that long - term antibiotic therapy was well - tolerated and efficacious in nonsurgical candidates .
reviewed 18 patients with infected orthopedic prostheses who had been treated with long - term antibiotic therapy .
although side effects related to antibiotics occurred in 22% , 15 ( 83% ) patients with a mean follow - up of 5 years had a good response to suppression of infection and could retain a functional prosthesis .
ortler et al . experienced the case of one epileptic patient implanted with an infected vagus nerve stimulator system who underwent successful open wound treatment without removal of the system .
they reported that the deep wound was initially opened and debrided . with continuous antibiotic therapy and daily rinsing with 3% hydrogen peroxide solution and 5% saline , granulation tissue gradually appeared . in this case ,
the value of local treatment with 3% hydrogen peroxide for prevention of foreign body infection has been previously reported .
of 990 cieds treated with 3% hydrogen peroxide during the implant procedure , 2 ( 0.2% ) developed an infection , which was a significantly reduced infection rate compared to that of cieds treated without hydrogen peroxide during implantation ( 1.83% , p<0.05 ) .
although conservative therapies might be useful in limited cases , retained infectious devices have a risk of mortality .
additionally , these papers were published more than 10 years ago , and medical technology has advanced since then .
the excimer laser has also been used for cied lead removal in many countries . if possible , initial complete hardware removal is strongly recommended , and the indications for conservative antibiotic therapy for cied infections should be determined with great caution .
in 2010 , satsu et al . reported the use of a vacuum - assisted wound closure ( vac ) system as an option for treating an infected device . the vac system is comprised of polyurethane foam with an evacuation tube , a vacuum pump , and adhesive drape .
treatment with vac has been reported to be an efficacious modality for chronic and difficult wounds , .
after opening the wound , the polyurethane is cut and positioned on the defect area , with connection of the evacuation tube .
the wound is then covered with an adhesive drape , and suction is continued with a negative pressure of 100  mmhg .
the wound is treated by changing the foam every 2 or 3 days until healing occurs , or the incision is sutured when granulation appears . according to this paper ,
infections never relapsed after treatment with vac in all 4 patients for 515 months , and cied infection healed without complete removal of the pacemaker system in 2 patients . in our hospital ,
the vac system is sometimes applied to a large wound after removal of the cardiac device system and debridement of the pocket ( fig .
according to the heart rhythm society expert consensus report , cied removal is not recommended for a superficial or incisional infection without involvement of the device or lead ( class iii indication ) ( fig .
2 ) . however , it is difficult to distinguish whether a superficial pocket infection might have extended through the device .
it was reported that the intravascular parts of leads yielded positive cultures in 79% of 105 study patients who had local pocket complications , which were associated with a risk of progression to systemic infection .
chamis et al . reported no local signs or symptoms related to pocket infection in 60% of patients ( 9 of 15 ) with confirmed cied infections .
when superficial or incisional infection of a cied occurs , conservative antibiotic therapy may be administered as needed , and the patient should be closely followed for progression to a deeper infection , which would require extraction .
computed tomography ( fdg - pet / ct ) could diagnose cied infections , . in some suspected cied cases
, this new imaging modality may be useful in differentiating a superficial from a systemic infection , and may lead to appropriate therapy .
although several successful conservative therapies for cied infection have been reported , retained infectious devices remain a source of relapse , which is closely related to a higher mortality rate .
presently , complete hardware removal is initially recommended for infected cied patients , and the indication of conservative therapy for cied infections should be determined with great caution
 along with the increased frequency of implantation , the incidence of cardiac implantable electronic device ( cied ) infection , which can have serious or fatal complications , has also increased . 
 although several successful conservative therapies for cied infection have been reported , retained infected devices remain a source of relapse , which is closely related to a higher mortality rate . 
 presently , complete hardware removal is initially recommended for infected cied patients , and indications for conservative therapy , including continuous administration of antibiotics , require careful consideration.on the other hand , complete removal is not required for superficial or incisional infection at the device pocket if an infection does not involve the device , but the patient should be closely followed for progression to deeper infection , which would require extraction . 
Introduction
Role of continuous antibiotic therapy
Mortality
Possibility of successful conservative therapy
Recent studies
Superficial or incisional infection
Conclusion
Conflict of interests