Periprocedural Antibiotic Prophylaxis for Cardiac Implantable Electrical Device Procedures

Cardiac implantable electrical device (CIED) infections are morbid and costly, with incidence estimates ranging up to 2.0% to 3.0% or more (1,2). Use of perioperative antibiotics is the standard of care for CIED implantation (3), but there are no high-quality data supporting antibiotic prophylaxis after the closure of the incision for CIED implantation or any other surgical procedure (4). Thus, guidelines recommend only a single dose of pre-incision prophylactic antibiotics for CIED placement (3,5). However, actual practice patterns are not clear. Given the urgent need for careful stewardship of antimicrobial agents, we aimed to characterize antibiotic practice surrounding CIED procedures.

Physician members of the Heart Rhythm Society were eligible for survey participation and were recruited by e-mail (no honorarium). The study was approved by the Beth Israel Deaconess Medical Center Institutional Review Board.

The survey presented hypothetical cases of new pacemaker or implantable cardioverter-defibrillator (ICD) implantation, subcutaneous ICD implantation, pacemaker or ICD replacement, and implantable loop recorder implantation. For each scenario, physicians were asked to indicate whether their practice included any of the following: pre-incision intravenous antibiotics; antibiotic-impregnated pouch; pocket irrigation with antibiotic solution; and post-procedure intravenous, oral, or topical antibiotics. Next, we asked physicians to indicate clinical factors that influence decisions to extend antibiotics use, as well as circumstances in which agents targeting methicillin-resistant Staphylococcus aureus (MRSA) would be selected. Lastly, physicians were asked whether or not they believed post-procedure antibiotics to be the standard of care for either new or replacement CIED procedures, and if fear of medicolegal consequences influenced their practice.

The survey was sent to 2,174 physicians, of whom 871 opened the e-mail and 164 completed the survey. Characteristics of study participants and selected responses to survey questions are noted in Table 1. Use of antibiotics after wound closure was considered to be the standard of care for both new pacemaker and ICD implants by 28% of respondents, and by 32% for replacement procedures, with 14% “not sure” for both scenarios. Only 10% of respondents identified medicolegal concerns as influencing decision making. Of note, 66% of providers indicated that they would not provide MRSA-active prophylaxis in patients with nares screens positive for MRSA.

TABLE 1.

Characteristics of Survey Participants and Responses to Selected Queries Regarding Antibiotics Practice

	Percentage Response
Participant Characteristics
Geographic area
United States	56.0
Europe	15.1
Number of years in practice
0–5	29.8
6–10	26.7
>10	42.5
Personal volume of annual pacemaker and/or ICD procedures
0–25	7.5
26–50	5.0
51–100	28.0
>100	59.6
Board certifications
Internal medicine	42.9
Cardiovascular diseases	75.8
Clinical cardiac electrophysiology	78.9
Surgical specialty	2.5
Factors Influencing Extended Use of Antibiotics
No factor changes practice	40.6
Prior endovascular infection	36.9
Immunosuppression	33.8
Elderly patient	3.8
Diabetes	15.6
Artificial heart valve	14.4
Long-standing existing intravascular PM/ICD leads	8.8
Anticoagulation	2.5
Perceived high risk for infection	31.3
Situations in Which Operator Would Use Anti-MRSA Antibiotics
Allergy to cefazolin	62.5
Allergy to penicillins	57.5
Known history of MRSA infection	66.3
Hospital inpatient with stay >48 h	36.3
Positive nasal screen for MRSA	44.4
Long-standing intravascular PM/ICD leads	11.3

ICD = implantable cardioverter-defibrillator; MRSA = methicillin-resistant Staphylococcus aureus; PM = pacemaker.

Actual practice for antibiotics use according to different procedures is noted in Figure 1. Pre-incision prophylaxis for new and replacement pacemakers and ICD was nearly universal, but less common for subcutaneous ICD (92%) or implantable loop recorders (70%). Pocket irrigation with antibiotic solution (most commonly gentamicin, vancomycin, or both) was common (53% to 62%), whereas use of an antibiotic-impregnated pouch was more frequent for replacement procedures (16% vs. 6% for new implants).

FIGURE 1. Infection Prophylaxis Strategies.

Proportion of physicians indicating use of each of the listed approaches to infection prophylaxis for the indicated procedures. ICD = implantable cardioverter-defibrillator; PM = pacemaker; SQ-ICD = subcutaneous implantable cardioverter-defibrillator.

A substantial proportion of physicians indicated that they would use additional post-procedure intravenous (25% to 50%) or oral (22% to 36%) antibiotics after closure of the wound. For implantable loop recorder implants, 70% used pre-incision antibiotics, but 29% used no antibiotics at all.

Despite the morbidity of CIED infections and the need for meticulous adherence to evidence-based prevention, there is no high-quality evidence to support the practices of post-procedure antibiotic administration and antibiotic irrigation identified in our survey (3,4,6). Approaches to managing suspected MRSA-colonization—a risk factor for MRSA infection—similarly conflict with guidelines (3).

Though limited by our response rate and sample restriction to Heart Rhythm Society members, these findings resonate with a recent Centers for Disease Control report arguing for immediate implementation of more rational use of antibiotics across all specialties, aimed at reducing the more than 50% of all antibiotics use currently estimated to be inappropriate (7). As seen in other studies (6,8), current cardiology practice appears to vary widely and commonly includes usage contrary to the recommended single dose at the time of the procedure. This apparent overuse of antibiotics may contribute to bacterial resistance while needlessly exposing patients to adverse drug effects (9).

Ongoing studies will hopefully provide further clarity on the utility of infection prophylaxis strategies (6,10), our study suggests that current practice is diffuse and greatly in need of standardization.