Doctoral Project

Implementing evidence based practices for preventing cardiac implantable electronic device (CIED) infection and the role of post-operative oral antibiotics

Cardiac pacemakers and implantable cardioverter defibrillators (ICD) are standard therapy for patients with a bradyarrhythmia, tachyarrhythmia or heart failure (HF) with a left bundle branch block (LBBB) (Wilkoff, et al., 2008). Millions of cardiac implantable electronic devices (CIED) have been implanted worldwide and this clinical practice has improved the quality of life for millions (Epstein, DiMarco, & Ellenbogen, 2008). With the increase of implants there has been an increase in the infection rates (Klug et al., 2007). Research studies have evaluated pre-procedure, during procedure and after procedure risk and protocols. Studies have also evaluated operative factors, procedural related factors, intravenous preoperative and postoperative prophylaxis and topical antibiotics (Padfield et al., 2015). There is no consensus on the use of oral antibiotics post CIED implant at discharge to reduce the rate of infection. With no clear consensus, protocols vary greatly among institutions and clinical practice to reduce the rate of infections. The purpose of this study was to address gaps in the literature and determine whether prophylactic oral post-operative antibiotic administration reduced the incidence of infection related to device implantation. In addition, an evaluation of institutional infection prevention program. The study describes the clinical practice at a single center tertiary care hospital for implanting CIED’s including initial and replacement pacemaker, ICD’s and loop recorders (ILR). The study compared infection rates before and after the institution of prophylactic oral post-operative antibiotics. Statistically- Sample size N= 1200 ± 25 between 2013 and 2016, ICD’s 50.6%, Pacemakers 42.2%, ILR 5.5, lead revision 1.8%. Both pacemaker and ICD initial implants were 64.3%, replacement 35.2% and upgrades 11%. Patient characteristics were male 57.9%, female 42.1%, mean age was 65.8 years old. Use of oral antibiotics consisted of Keflex 8.2%, Doxycycline 17.6%, other 3.8% and no antibiotic usage was 70.5%. Findings note the use of prophylactic post-operative oral antibiotics in whole was not statistically significant with CI of 95%. Statistical significance (P .030) was noted in provider and incisional assessment and interaction between provider and antibiotic (P.019). No statistical difference was noted in implants between years for incisional site assessment.Recommendations include adherence to pre-operative, peri-operative and postoperative protocols. In addition we recommend adherence to infection prevention by consistently cleaning device programmer heads with antiseptic wipes between patients interactions.