Prevention and management of intrathecal drug delivery and spinal cord stimulation system infections.

FULLY implantable devices or drug–device combinations, such as intrathecal drug delivery (DD) systems and spinal cord stimulation (SCS) systems, increasingly are used for the treatment of chronic intractable pain. Another approved indication for intrathecal DD systems is the administration of intrathecal baclofen (ITB) to treat medically intractable spasticity of spinal or cerebral origin. Although patients with cancer, spinal cord injuries, or cerebral palsy have a reduced life expectancy, the majority of intrathecal drug administration devices— and nearly all SCS devices—are implanted in patients with painful non–cancer-related disorders that are associated with a normal life span. Therefore, long-term implantable devices used for the treatment of pain and spasticity should have a relatively benign safety record. Device-related infection is the most common, potentially reducible, serious adverse event associated with intrathecal DD or SCS devices. Reducing the number of implantable DD and SCS device infections is important for various reasons. One is that treatment of an established infection often involves temporary or permanent removal of the device, which causes cessation of drug or stimulation therapy. Therapy cessation (with or without eventual device replacement) increases the risks, discomfort, inconvenience, and expenses of patients who experience infectious complications. Abrupt cessation of intrathecal drug therapy may precipitate drug withdrawal symptoms and, in the case of ITB, can have fatal consequences. In rare cases, device-associated infections can progress to fatal sepsis, meningitis, or both. Available data indicate that implantable DD and SCS device infections share important features with other surgical site infections (SSIs), including those that affect cerebrospinal fluid (CSF) shunts and electrophysiologic cardiac devices such as implantable pacemakers and cardioverter–defibrillators (ICDs). Management of infections associated with DD and SCS systems typically involves administration of antibiotics and explantation of the devices. Measures that reduce the incidence of other SSIs also should reduce the infection rate associated with the implantation of SCS and intrathecal DD devices.