Dr. Carmine Sorbera
Preventing Cardiac implantable electronic Device Infection: Is it time to Update the Guidelines?
Purpose: The purpose of this article is to examine whether a more aggressive antibiotic prophylaxis regimen will help prevent infections peri-operatively in patients who are undergoing implantation of a cardiac implantable electronic device (CIED). Recent clinical trials using different antibiotic regimens and special wraps impregnated with antibiotics seem promising and may lead to updates in the current guidelines.
Method: A PubMed Search was performed using the terms, antibiotic prophylaxis, implantable cardiac devices, infections and complications of CIED’s, and healthcare costs of CIED infection. Nineteen pertinent articles were retrieved and serve as the basis for this Special Topic article.
Results: Currently, there is still a lack of evidence to support deviation from the AHA/ACC antibiotic prophylaxis guidelines. However, the use of an antibacterial envelope as a standard of care corresponds to a decreased rate of CIED infection and may make fiscal sense when considering the morbidity, mortality and economic burden of CIED infection.
Conclusion: The indications for cardiac implantable electronic devices are expanding and they are being utilized with greater frequency. At the same time, the rate of CIED infection is rising disproportionately. One of the reasons for this is that many of these implants are being performed in older patients with multiple medical co-morbidities, which predispose them to infection. CIED infections are life-threatening and expensive to treat, and even though the AHA/ACC guidelines do not recommend post-procedure antibiotics, most implanters deviate from this counsel. There have been multiple studies evaluating various preventive measures and this continues to be an area of clinical research interest in the world of electrophysiology. The most recent study (PADIT Trial) did not suggest that additional antibiotic prophylaxis affected infection rates and although the WRAP-IT trial, which compared the TYRX antibiotic eluting envelope with standard local pocket prevention illustrated reduced infection rates, the NNT=100, which makes its use in every CIED implant questionable. The cost of these envelopes influences whether they are utilized extensively in everyday clinical practice. This strategy may be expensive, but in certain higher risk patient populations, the use of antibacterial envelopes may make fiscal and therapeutic sense. Future studies are needed to evaluate which high risk population would benefit from the drug eluting envelope.
Forman J. Preventing Cardiac Implantable Electronic Device Infection: Is it time to Update the Guidelines?. University of Lynchburg DMSc Doctoral Project Assignment Repository. 2020; 2(1).
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