Antibiotic prophylaxis justified for ICD implants
Staph schleiferi most likely infection
The need for prophylactic antibiotics with pacemaker or defibrillator implantation remains controversial, but considering their cost and safety, prophylactic use seems justified, says John P. DiMarco, MD, PhD, professor of medicine in the division of cardiology at the University of Virginia in Charlottesville.
A meta-analysis of seven clinical trials examined the effect of systemic antibiotics - penicillins or cephalosporins - on pacemaker- related infections in over 2,000 patients.1 Implantable cardioverter defibrillators (ICDs) are usually implanted using similar techniques, but they are larger and need more complex intraoperative testing. It is likely, says DiMarco, that infection complications relative to ICD implantation will be more common. "Infection of either a pacemaker or ICD is often a life-threatening illness due to the effects of sepsis, loss of arrhythmia control, or complications from device explant."
The incidence of pacemaker infection in the study ranged from 0% to 12%. Overall, the incidence was 0.5% among the antibiotic-treated patients and 3.7% in the control patients. The investigators conclude that those data support the use of prophylactic antibiotics at the time of insertion to prevent short-term pocket infection, skin erosion, or septicemia.
The investigators went on to review the incidence of infections at their institution.2 They prospectively collected implantation site and pocket cultures from 103 patients undergoing pacemaker implant.
Positive cultures were obtained from 88% of skin samples, 48% of preinsertion pocket samples, and 37% of post-surgery pocket samples. Staphylococcus species were most commonly identified. During follow-up, four patients developed infections at the pacemaker site at one, four, 10, and 16 months after implant. S. schleiferi caused two of the four infections; S. aureus and S. epidermidis were responsible for one infection each. The S. schleiferi infections were caused by the same strains of the organism that were isolated at implants; the latter two infections were caused by strains not present at implant. The investigators conclude that S. schleiferi is a possible cause of infection, with a high incidence if the organism is present at time of implant. If that organism is a frequent cause of device-related infection, says DiMarco, "changes in the antibiotics . . . may be necessary. This could cause concern regarding cost, side effects, and development of antibiotic-resistant strains."
References
1. Da Costa A, Kirkorian G, Cucherat M, et al. Antibiotic prophylaxis for permanent pacemaker implantation: A meta-analysis. Circulation 1998;97:1796-1800.
2. Da Costa A, Lelièvre H, Kirkorian G, et al. Role of the preaxillary flora in pacemaker infections: A prospective study. Circulation 1998;97:1791-1795.
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