Prophylactic antibiotics and the insertion of permanent transvenous cardiac pacemakers

Fully implantable and bioresorbable cardiac pacemakers without leads or batteries

Temporary cardiac pacemakers used in periods of need during surgical recovery involve percutaneous leads and externalized hardware that carry risks of infection, constrain patient mobility and may damage the heart during lead removal. Here we report a leadless, battery-free, fully implantable cardiac pacemaker for postoperative control of cardiac rate and rhythm that undergoes complete dissolution and clearance by natural biological processes after a defined operating timeframe. We show that these devices provide effective pacing of hearts of various sizes in mouse, rat, rabbit, canine and human cardiac models, with tailored geometries and operation timescales, powered by wireless energy transfer. This approach overcomes key disadvantages of traditional temporary pacing devices and may serve as the basis for the next generation of postoperative temporary pacing technology.

A Review of Cardiac Implantable Electronic Device Infections for the Practicing Electrophysiologist

Cardiovascular implantable electronic device (CIED) infections are morbid, costly, and difficult to manage. This review explores the pathophysiology, diagnosis, and management of CIED infections. Diagnostic accuracy has been improved through increased awareness and improved imaging strategies. Pocket or bloodstream infection with virulent organisms often requires complete system extraction. Emerging prophylactic interventions and novel devices have expanded preventative strategies and options for re-implantation. A clear and nuanced understanding of CIED infection is important to the practicing electrophysiologist.

A 19-year study on pacemaker-related infections: a claim for using postoperative antibiotics

BACKGROUND

Although the incidence of pacemaker-related infection (PMINF) is low, it necessitates removal of the pacing system. There is currently no consensus on antibiotics during implantation.

METHODS

A prospective database on patients undergoing pacemaker surgery from 1991 to 2009 was reviewed to determine factors associated with PMINF. Specifically, three eras of antibiotic use were compared to elucidate the effect of antibiotics on PMINF: no antibiotics, perioperative antibiotics, and peri- plus postoperative antibiotics.

RESULTS

There were 3,253 procedures with PMINF identified in 46 (1.4%) patients. Over 19 years, PMINF incidence fell from 3.6% (no antibiotics) to 2.9% (perioperative antibiotics), to 0.4% (peri- plus postoperative antibiotics). On univariate analysis, the following were associated with PMINF: nonuse of postoperative antibiotics (3.0% vs 0.4%, P < 0.001), year of implant (P < 0.001), repeat procedures (2.3% vs 1%, P = 0.006), nonuse of perioperative antibiotics (3.6% vs 1.3%, P = 0.027). With postoperative antibiotics, rates were significantly reduced in new implants (1/1,289 = 0.1% vs 22/967 = 2.3%, P < 0.001) and repeat procedures (7/692 = 1.0% vs 16/305 = 5.2%, P < 0.001). On multivariate analysis, the following were significant (standardized coefficients denote relative importance): postoperative antibiotics (0.776), repeat procedures (0.508), year of implant (0.142), perioperative antibiotics (0.088).

CONCLUSIONS

The PMINF rate is reduced significantly by perioperative antibiotics with a further significant reduction with postoperative antibiotics. However, the reduction in PMINF rate could be a result of changes in practice in the different time eras. This study suggests consideration of perioperative followed by postoperative antibiotics to minimize pacemaker infections.

The Impact of Povidone-Iodine Pocket Irrigation Use on Pacemaker and Defibrillator Infections

BACKGROUND

Infection is a devastating complication of permanent pacemakers (PMs) implantable cardioverter defibrillators (ICDs). Many implanting physicians commonly use povidone-iodine solution to irrigate the device pocket before implanting the device. We sought to assess if such a measure would alter the rate of infection.

METHODS

A total of 2,564 consecutive patients who received implantable PM or ICD devices between 1994 and 2002 were studied. Povidone-iodine was used for pocket irrigation in 53% and saline in 47%. A total of 18 (0.7%) patients developed pocket infections with 0.7% (10/1,359) in povidone-iodine (group I) and 0.6% (8/1,205) in saline (group II) pocket irrigation (p = ns). Groups I and II were studied for various clinical and demographic variables described in the results section.

RESULTS

There was no statistical difference in the baseline demographic and clinical characteristics between groups I and II, respectively. ICDs were most frequently infected than PMs (56% vs 44%). Most (83%) of the devices were dual chamber. Reopening of the pocket for either lead or generator replacement had a higher incidence of infection than new implants (61% vs 39%). There was no difference in the use of preimplantation antibiotic prophylaxis. Late (61%) and deep pocket infections (78%) were more common than early (39%) and superficial infections (22%). Blood cultures were positive in 67% and Staphylococcus aureus was the common most pathogen (50%). The mean duration of antibiotics use after the diagnosis of device infection was 35 +/- 23 days with 72% requiring device explantation. The device was reimplanted on the contralateral side in 56% cases. One patient in each group died due to device infection and related complications. No significant allergy to iodine was seen in either group.

CONCLUSION

Povidone-iodine irrigation of the subcutaneous pocket did not alter the rates of pocket infection after pacemaker/defibrillator implantation.

Septicémie récidivante après extraction incomplète de sondes de stimulateur cardiaque

INTRODUCTION

Septicaemia on endocardial pacemaker leads is very rare but the presentation is insidious and the prognosis very bad if all the implanted materiel is not completely removed.

OBSERVATION

A 55 year-old woman presented three episodes of Staphylococcus epidermidis septicaemia in three years, after incomplete removal of the pacing system. Permanent cure was finally obtained after complete removal of the pacemaker material.

COMMENT

Emphasis must be placed on the difficulty in diagnosing and treating such affections, their severity and also the interest of a certain number of prophylactic measures.

Prophylactic use of vancomycin in adult cardiology and cardiac surgery

The recent appearance of Staphylococcus aureus and Staphylococcus epidermidis strains that have reduced susceptibility to vancomycin, and the spread of vancomycin-resistant enterococci, raise the specter of endovascular infections that will be difficult or impossible to cure with available drugs. We review issues concerning the prophylactic use of vancomycin in adult cardiology and cardiac surgery with special attention to dosing and indications. There is no indication for the routine use of prophylactic vancomycin in pacemaker implantations, cardiac catheterization, and transesophageal echocardiography. In institutions with a high incidence of methicillin-resistant S. aureus and S. epidermidis, vancomycin may be used for antibiotic prophylaxis in place of cephalosporins for pacemaker or defibrillator implantation. The strongest evidence in support of the prophylactic use of vancomycin is during cardiac surgeries, particularly valvular surgeries in institutions with a high prevalence of methicillin-resistant S. aureus and S. epidermidis. When vancomycin is used prior to open heart surgery, the dose should be 15 mg/kg rather than the standard 1 g dose that is often recommended in the literature and used by 85% of institutional pharmacists who responded to our survey. Cardiologists and cardiac surgeons should assume leadership roles in promoting its responsible use.

Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis

BACKGROUND

Infection remains a serious complication after permanent pacemaker implantation. Antibiotic prophylaxis is frequently prescribed at the time of insertion to reduce its incidence, although results of well-designed, controlled studies are lacking.

METHODS AND RESULTS

We performed a meta-analysis of all available randomized trials to evaluate the effectiveness of antibiotic prophylaxis to reduce infection rates after permanent pacemaker implantation. Reports of trials were identified through a Medline, Embase, Current Contents, and an extensive bibliography search. Trials that met the following criteria were included: (1) prospective, randomized, controlled, open or blind trials; (2) patients assigned to a systemic antibiotic group or a control group; (3) end point events related to any infection after pacemaker implantation: wound infection, septicemia, pocket abscess, purulent secretion, right infective endocarditis, inflammatory signs, a positive culture, septic pulmonary embolism, or repeat operation for an infective complication. Seven trials met the inclusion criteria. They included 2023 patients with established permanent pacemaker implantation (new implants or replacements). The incidence of end point events in control groups ranged from 0% to 12%. The meta-analysis suggested a consistent protective effect of antibiotic pretreatment (P=.0046; common odds ratio: 0.256, 95% confidence interval: 0.10 to 0.656).

CONCLUSIONS

Results of the present meta-analysis suggest that systemic antibiotic prophylaxis significantly reduces the incidence of potentially serious infective complications after permanent pacemaker implantation. They support the use of prophylactic antibiotics at the time of pacemaker insertion to prevent short-term pocket infection, skin erosion or septicemia.

Infections in transvenous cardiac pacemakers: two more cases

Two patients with metastatic pacemaker infections, one caused by Pseudomonas aeruginosa, 5 months after implantation, and the second by Streptococcus pneumoniae, 8 years after implantation, were treated successfully by removal of the pacemaker systems. Infection reoccurred in the patient with Pseudomonas aeruginosa, who initially underwent partial pacing system removal allowing the atrial lead to remain. Repeat partial atrial lead removal and contralateral pacemaker implantation was followed by clinical infection, which was resolved when both the implanted atrial lead fragment and the recently implanted pacemaker were both removed. Removal of all hardware is required for cure of pacemaker infection.

A new approach to the management of infected pacemakers

Management of infected pacemakers always presents a problem. This report describes a method of managing infected pacemakers, using the infected unit as a temporary pacer. This method has worked well in four patients.

Permanent transvenous pacemaker implantation in forty dogs

Permanent transvenous cardiac pacemakers were implanted in 40 dogs. Electrocardiographic diagnoses included persistent atrial standstill (3 dogs), sick sinus syndrome (8 dogs), and high-grade second-degree or third-degree atrioventricular (AV) block (29 dogs). Thirteen dogs were alive and well 4 to 42 months after pacemaker implantation (mean, 16.9 months). The mean and median survival times of the 26 dogs that died or were euthanatized during the study were 17.9 months and 13 months, respectively. Most of these dogs succumbed to problems unrelated to the arrhythmia and pacemaker implant. One dog was lost to follow-up. Complications associated with permanent transvenous pacemaker implantation included lead dislodgement, infection, hematoma formation, skeletal muscle stimulation, ventricular arrhythmia, migration of the pulse generator, and skin erosion. Lead dislodgement was the most common complication, occurring in 7 of 9 dogs paced using untined electrode leads and in 6 of 30 dogs paced using tined leads. Lead dislodgement did not occur in the only dog paced using an actively fixed endocardial lead. It was concluded that permanent transvenous cardiac pacing is a feasible, less traumatic alternative to epimyocardial pacing in dogs, but that successful use of this technique requires careful implantation technique and anticipation of the potential complications.

Right-sided infective endocarditis with acquired tricuspid valve stenosis associated with transvenous pacemaker: a case report

Five years prior to presentation, a 29-year-old woman received a transvenous pacemaker (DDD) for sick sinus syndrome and nodo-hisian pathology. After pacemaker insertion, she complained of recurrent febrile episodes. Her pacemaker related endocarditis was quite unusual for the infecting organism (a micrococcus) and for an acquired tricuspid valve stenosis. The suspected cause was confirmed at surgery.

Prophylactic mezlocillin-netilmicin combination in permanent transvenous cardiac pacemaker implantation: a single-center, prospective, randomized study

A prospective, randomized study was carried out in order to assess the efficacy and safety of the mezlocillin-netilmicin combination in the prophylaxis of first permanent transvenous cardiac pacemaker implantation. Five hundred and fifty-two consecutive patients were randomly administered either 2 g mezlocillin and 200 mg netilmicin both as an i.v. bolus before implantation or 2g mezlocillin before and then 6 and 12 hours after surgery and 200 mg netilmicin before and then 12 hours after implantation. No adverse events were seen. Neither pocket nor electrode infections were observed in the 457 subjects still alive (mean follow-up: 29.2 months) or in patients who died after 1 year of follow-up (mean follow-up: 20.1 months) or before this time (mean follow-up: 4.7 months). The serum and pocket concentrations of mezlocillin and netilmicin at the end of surgery were found to be adequate to cover microorganisms that most often cause infections, including methicillin-resistant staphylococci.

Antibiotic prophylaxis in pacemaker surgery: a prospective double blind trial with systemic administration of antibiotic versus placebo at implantation of cardiac pacemakers

In a double blind clinical trial, 106 consecutive patients scheduled for pacemaker implantation were randomly assigned either to a systemic prophylaxis group (SPG) (to be given flucloxacillin) or to a control group who would be given a placebo (CPG). The SPG group received 2 g IV flucloxacillin 1 hour before the operation, then 1 g perorally every 8 hours for the next five days. In the CPG group, placebo infusions and tablets were given at the same schedule. There were a total of 106 patients (SPG 52, CPG 54) who met the criteria of the study. Of these, 102 patients (SPG 50, CPG 52) completed a follow-up of 7-35 months. Infection of the pacemaker system was not diagnosed in any patient in either group. Tissue fluid was drawn 24 hours postoperatively from the pacemaker pocket for culture and for determination of pocket antibiotic concentration. The mean flucloxacillin concentration of pocket fluid from 23 patients in the SPG was 7.5 micrograms/ml. The bacteriological cultures were positive in 9/32 patients in the SPG group and in 10/34 patients in the CPG group. This study suggests that antibiotic prophylaxis need not routinely be given at implantation of permanent pacemaker systems.

Management of the infected pacemaker: explantation, sterilization, and reimplantation

From January, 1970, through December, 1984, nineteen infected or eroded pacemaker units were reimplanted in 17 patients. Characteristics of the patients, types of infecting organisms, surgical management, and complications are described. Optimal treatment of the infected generator pocket requires explantation of the generator unit with utilization of the in situ leads for pacing by an external-demand pacemaker unit. The generator unit is sterilized, and new leads are placed with relocation of the pocket. The old leads are then removed. This technique has been used safely and with excellent results for the past fourteen years.

Pacemaker infections. A 2-year follow-up of antibiotic prophylaxis

To evaluate the long-term effect of systemic antibiotic prophylaxis at pacemaker surgery, an analysis was made of infections in 272 patients submitted to 303 consecutive pacemaker operations. The follow-up time was 24-33 months. Antibiotic prophylaxis had been given in all cases. The overall infection rate was 4.0%: The incidence after new implant was 3.8%, generator replacement 2.4%, electrode replacement 15% and early reoperation 4.2%, with the only statistically significant difference between electrode replacement and generator replacement. The interval between operation and appearance of infection was 3 days to 18 months. The causal microorganisms were methicillin-resistant Staphylococcus epidermidis in four patients, methicillin-sensitive S. epidermis in one patient and methicillin-sensitive S. aureus in three. An anaerobic gram-positive coccus was cultured in one patient and a nonenteric gram-negative rod in another. Five infections were cured by antibiotic treatment alone, but in seven cases surgery was also needed. The incidence of infection was significantly increased when potential predisposing factors--diabetes mellitus, postoperative hematoma and use of a temporary electrode--were present.

Antibiotic prophylaxis for pacemaker implantation: a prospective randomized trial

Prophylactic antibiotics are frequently prescribed for patients undergoing permanent pacemaker implantation even though data confirming their effectiveness are limited. Five hundred patients requiring elective permanent pacemaker implantation or generator replacement were prospectively randomized either to receive or not receive prophylactic antibiotic treatment at the time of implantation. The implantation site was treated with 10% povidone-iodine solution and 0.5% alcoholic chlorhexidine preoperatively. The wound were inspected for evidence of infection at 3 days and 1, 3, 6 and 12 months postimplantation. Three patients (two receiving prophylactic antibiotics and one no antibiotics) developed pacemaker pocket infection; Staphylococcus aureus was the pathogenic organism in each case (P = 0.56). Eighteen patients developed clinical evidence of superficial wound inflammation requiring antibiotic treatment but not pacemaker removal. Six had received prophylactic antibiotics and 12 had not (P = 0.27). We conclude that pacemaker pocket infection is unusual with careful preoperative skin preparation and close postoperative follow-up. Under these circumstances prophylactic antibiotic treatment is of no practical value.

Investigations on staphylococcal infection of transvenous endocardial pacemaker electrodes

Infections of pacemaker electrodes and/or aggregate pockets are usually caused by staphylococci, primarily Staphylococcus epidermidis. From in vitro experiments it can be demonstrated that staphylococci are able to adhere to the plastic electrode sheath, to multiply there, and to form microcolonies. Furthermore, the staphylococci produce a slimy amorphous substance with which they are completely covered after a 24-hour incubation. No difference was noticed between the in vitro experiment situation and that occurring in pacemaker infection in humans. This slimy material may be responsible for the maintenance of the infection and the protection of the enclosed bacterial cells against natural host defense mechanisms and antibiotic treatment.

Antibiotic prophylaxis in pacemaker surgery--a prospective study

To evaluate the effect of antibiotic prophylaxis in pacemaker surgery, 100 patients were randomly assigned to a prophylaxis group receiving cloxacillin or to a control group with no antibiotics. Cloxacillin was given intravenously (2 g) 2 hours before operation, followed by 1 g every 6 hours for 2 days and the same dose perorally for 8 more days postoperatively. Adequate plasma concentrations were obtained in all patients. The follow-up time was 1-43 months. The infection rate was 2% (1/50) in the prophylaxis group and 14% (7/50) in the control group (p less than 0.05). The interval from operation to manifest infection was 9-35 days. In the control group the causal microorganism was Staphylococcus aureus in two patients, Staphylococcus epidermidis in two and unknown in three patients. In the only patient with infection in the prophylaxis group, a methicillin-resistant S. epidermidis was isolated. Infection was initially localized to the pacemaker pocket in seven patients, but septicemia developed in one of them and endocarditis in another. In one patient septicemia appeared initially, without local signs of infection. This study suggests that cloxacillin prophylaxis is of value in routine pacemaker surgery.

Prophylactic antibiotics for cardiac pacemaker implantation. A prospective trail

A prospective trial was conducted to assess the value of prophylactic antibiotic treatment in preventing postoperative infection of permanent transvenous pacemaker systems. Four hundred and thirty-one patients were randomly allocated to treatment (234) or no-treatment (197) groups. Treated patients received systemic benzylpenicillin and flucloxacillin just before operation and one and six hours afterwards. Nine primary generator pocket infections occurred without evidence of wound dehiscence or skin erosion. Seven infections were in untreated patients and two in treated patients. Antibiotic prophylaxis diminishes the risk of infection after pacemaker implantations.

Permanent pacemaker infections: characterization and management

From January 1974 to June 1980, a total of 46 patients were treated for infections involving permanent pacing systems. Demographic characteristics, types of infecting organisms, specific clinical features, significance of an infected foreign body and various medical and surgical treatment methods are described. Likely infecting organisms depend on the mode of presentation and the time course of the infection. Optimal treatment for the large majority of patients requires removal of the entire infected pacing system. In a subgroup of patients, a short course of antibiotic therapy followed by one stage surgery involving implantation of a new pacing system and concurrent explanation of the infected pacemaker was used safely with excellent results.