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Dao KT, Ghadiya K, Inga Jaco E, Sharma R, Rahimi R, Sukkar M, Adebayo M, Bhandohal J, Dhillon H, Joolhar F. A Case of Revelation Due to Pegfilgrastim. Cureus 2024; 16:e63777. [PMID: 39100048 PMCID: PMC11296959 DOI: 10.7759/cureus.63777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/06/2024] Open
Abstract
Pegfilgrastim is a granulocyte colony-stimulating factor used in non-myeloid cancer patients to prevent infections and neutropenic fevers. Although this medication is widely used to induce granulocytosis in pancytopenia patients, there are certain instances where such a situation can cause severe side effects. In this case, we present a patient with a history of metastatic colon cancer who is currently taking pegfilgrastim to counter the agranulocytosis caused by his chemotherapy treatment. However, the patient shortly developed localized left-sided jaw swelling, and upon further investigation, the granulocyte colony-stimulating factor revealed an underlying bacteremia. A discussion will also be held regarding the mechanism of action of how pegfilgrastim induced this patient's symptoms as well as the risks and benefits.
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Affiliation(s)
- Kevin T Dao
- Internal Medicine, Kern Medical, Bakersfield, USA
| | | | | | - Rupam Sharma
- Internal Medicine, Kern Medical, Bakersfield, USA
| | | | - Marah Sukkar
- Internal Medicine, Kern Medical, Bakersfield, USA
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Korantzopoulos P, Sideris S, Dilaveris P, Gatzoulis K, Goudevenos JA. Infection control in implantation of cardiac implantable electronic devices: current evidence, controversial points, and unresolved issues. Europace 2016; 18:473-478. [DOI: 10.1093/europace/euv260] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Polyzos KA, Konstantelias AA, Falagas ME. Risk factors for cardiac implantable electronic device infection: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2015; 17:767-77. [DOI: 10.1093/europace/euv053] [Citation(s) in RCA: 281] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Senaratne JM, Jayasuriya A, Irwin M, Gulamhusein S, Senaratne MPJ. A 19-year study on pacemaker-related infections: a claim for using postoperative antibiotics. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:947-54. [PMID: 24766534 DOI: 10.1111/pace.12403] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 02/01/2014] [Accepted: 03/02/2014] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Janek M Senaratne
- Division of Cardiac Sciences, Grey Nuns Hospital, Edmonton, Alberta, Canada
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Gurusamy KS, Koti R, Wilson P, Davidson BR. Antibiotic prophylaxis for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) related complications in surgical patients. Cochrane Database Syst Rev 2013; 2013:CD010268. [PMID: 23959704 PMCID: PMC11299148 DOI: 10.1002/14651858.cd010268.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Risk of methicillin-resistant Staphylococcus aureus (MRSA) infection after surgery is generally low, but affects up to 33% of patients after certain types of surgery. Postoperative MRSA infection can occur as surgical site infections (SSIs), chest infections, or bloodstream infections (bacteraemia). The incidence of MRSA SSIs varies from 1% to 33% depending upon the type of surgery performed and the carrier status of the individuals concerned. The optimal prophylactic antibiotic regimen for the prevention of MRSA after surgery is not known. OBJECTIVES To compare the benefits and harms of all methods of antibiotic prophylaxis in the prevention of postoperative MRSA infection and related complications in people undergoing surgery. SEARCH METHODS In March 2013 we searched the following databases: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); NHS Economic Evaluation Database (The Cochrane Library); Health Technology Assessment (HTA) Database (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. SELECTION CRITERIA We included only randomised controlled trials (RCTs) that compared one antibiotic regimen used as prophylaxis for SSIs (and other postoperative infections) with another antibiotic regimen or with no antibiotic, and that reported the methicillin resistance status of the cultured organisms. We did not limit our search for RCTs by language, publication status, publication year, or sample size. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion in the review, and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing binary outcomes between the groups and planned to calculated the mean difference (MD) with 95% CI for comparing continuous outcomes. We planned to perform meta-analysis using both a fixed-effect model and a random-effects model. We performed intention-to-treat analysis whenever possible. MAIN RESULTS We included 12 RCTs, with 4704 participants, in this review. Eleven trials performed a total of 16 head-to-head comparisons of different prophylactic antibiotic regimens. Antibiotic prophylaxis was compared with no antibiotic prophylaxis in one trial. All the trials were at high risk of bias. With the exception of one trial in which all the participants were positive for nasal carriage of MRSA or had had previous MRSA infections, it does not appear that MRSA was tested or eradicated prior to surgery; nor does it appear that there was high prevalence of MRSA carrier status in the people undergoing surgery.There was no sufficient clinical similarity between the trials to perform a meta-analysis. The overall all-cause mortality in four trials that reported mortality was 14/1401 (1.0%) and there were no significant differences in mortality between the intervention and control groups in each of the individual comparisons. There were no antibiotic-related serious adverse events in any of the 561 people randomised to the seven different antibiotic regimens in four trials (three trials that reported mortality and one other trial). None of the trials reported quality of life, total length of hospital stay or the use of healthcare resources. Overall, 221/4032 (5.5%) people developed SSIs due to all organisms, and 46/4704 (1.0%) people developed SSIs due to MRSA.In the 15 comparisons that compared one antibiotic regimen with another, there were no significant differences in the proportion of people who developed SSIs. In the single trial that compared an antibiotic regimen with placebo, the proportion of people who developed SSIs was significantly lower in the group that received antibiotic prophylaxis with co-amoxiclav (or cefotaxime if allergic to penicillin) compared with placebo (all SSI: RR 0.26; 95% CI 0.11 to 0.65; MRSA SSI RR 0.05; 95% CI 0.00 to 0.83). In two trials that reported MRSA infections other than SSI, 19/478 (4.5%) people developed MRSA infections including SSI, chest infection and bacteraemia. There were no significant differences in the proportion of people who developed MRSA infections at any body site in these two comparisons. AUTHORS' CONCLUSIONS Prophylaxis with co-amoxiclav decreases the proportion of people developing MRSA infections compared with placebo in people without malignant disease undergoing percutaneous endoscopic gastrostomy insertion, although this may be due to decreasing overall infection thereby preventing wounds from becoming secondarily infected with MRSA. There is currently no other evidence to suggest that using a combination of multiple prophylactic antibiotics or administering prophylactic antibiotics for an increased duration is of benefit to people undergoing surgery in terms of reducing MRSA infections. Well designed RCTs assessing the clinical effectiveness of different antibiotic regimens are necessary on this topic.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Rahul Koti
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Peter Wilson
- University College London HospitalsDepartment of Microbiology & Virology60 Whitfield StreetLondonUKW1T 4EU
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
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DAROUICHE RABIH, MOSIER MICHAEL, VOIGT JEFFREY. Antibiotics and Antiseptics to Prevent Infection in Cardiac Rhythm Management Device Implantation Surgery. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1348-60. [DOI: 10.1111/j.1540-8159.2012.03506.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Bertaglia E, Zerbo F, Zardo S, Barzan D, Zoppo F, Pascotto P. Antibiotic Prophylaxis with a Single Dose of Cefazolin During Pacemaker Implantation: Incidence of Long-Term Infective Complications. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:29-33. [PMID: 16441714 DOI: 10.1111/j.1540-8159.2006.00294.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Systemic and localized infections related to permanent pacemaker implantation are not common, but are serious and potentially life-threatening complications. The aims of this prospective observational study were: (1) to assess the safety and long-term efficacy of a simplified scheme of antibiotic prophylaxis, and (2) to identify the predictors of long-term infective complications, in patients undergoing pacemaker implantation or replacement. METHODS AND RESULTS From October 1998 to July 2001, 852 patients (mean age 77.0 +/- 9.2 years; 474 men) who underwent new permanent pacemaker implantation (69.6%) or pulse generator replacement (30.4%) received a mini-bag of 2 g of cefazolin diluted in 50 mL of saline solution, administered intravenously in 20 minutes before the beginning of the procedure. Early (within 2 months of implantation) and late major and minor infective complications were recorded. During the earlier phase, minor complications were observed in 9 patients (1%). During the long-term phase of the surveillance (mean 25.6 +/- 11.0 months, range 12-55 months) major infective complications were observed in 6 patients (0.7%). On multivariate analysis, no clinical or procedural variable predicted the occurrence of long-term infective complications. CONCLUSIONS Our data indicate the safety and efficacy of a single, intravenous 2 g dose of cefazolin in preventing infective complications related to pacemaker implantation or replacement. No clinical or procedural variable predicted the occurrence of long-term infective complications.
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Movahed MR, Kasravi B, Bryan CS. Prophylactic use of vancomycin in adult cardiology and cardiac surgery. J Cardiovasc Pharmacol Ther 2004; 9:13-20. [PMID: 15094964 DOI: 10.1177/107424840400900i103] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Mohammad-Reza Movahed
- Department of Medicine, Division of Cardiology, University of California-Irvine Medical Center, Building 53, Route 81, Room 100, 101 The City Drive South, Orange, CA 92868-4080, USA.
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Yamada M, Takeuchi S, Shiojiri Y, Maruta K, Oki A, Iyano K, Takaba T. Surgical lead-preserving procedures for pacemaker pocket infection. Ann Thorac Surg 2002; 74:1494-9; discussion 1499. [PMID: 12440598 DOI: 10.1016/s0003-4975(02)03949-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In the treatment of pacemaker pocket infection, removal of the entire pacing system has been considered necessary to avoid recurrent infection. We report a series of patients treated surgically by our lead-preserving procedures. METHODS Between 1990 and 2001, a total of 18 patients underwent one of two types of lead-preserving procedures. Procedure 1 preserves the full length of the lead, and procedure 2 preserves only the distal part of the lead. Signs of bacteremia, endocarditis, or purulent material within the lead insulation preclude application of these procedures in patients with potential or definite pacemaker pocket infection. RESULTS Seventeen patients who met the indications for our procedures were discharged 7 to 14 days (8.9 +/- 2.4 days, mean +/- SD) postoperatively without signs of infection and were followed up for a total of 987 patient-months until the close of the study or death without recurrent infection. The remaining 1 patient, who did not meet the indications, suffered reinfection soon after the operation. CONCLUSIONS The follow-up data suggest that our lead-preserving procedures should be considered as alternatives to conventional removal of the entire pacing system in cases of pocket infection that meet specific criteria.
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Affiliation(s)
- Makoto Yamada
- The First Department of Surgery, Showa University, Tokyo, Japan.
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Abstract
INTRODUCTION Infectious complications following pacemaker implantation are not common but may be particularly severe. Localized wound infections at the site of implantation have been reported in 0.5% of the cases in the most recent series, with an average of about 2%. The incidence of septicemia and infectious endocarditis is lower, about 0.5% of the cases. The operator's experience, the duration of the procedure and repeat procedures are considered to be predisposing factors. CURRENT KNOWLEDGE AND KEY POINTS The main cause of these infections has been recently demonstrated to be local contamination during implantation. The commonest causal organism is Staphylococcus (75 to 92% of the cases), Staphylococcus aureus being the cause of acute infections (less than 6 weeks), whereas Staphylococcus epidermidis is associated with cases of secondary infection (more than 2 months). The usual clinical presentation is infection at the site of the pacemaker but other forms such as abscess, endocarditis, rejection of the implanted material, septic emboli or phlebitis have been described. The diagnosis is confirmed by local and systemic biological investigations and by echocardiography (especially transesophageal echocardiography) in cases of right heart endocarditis. There are two axes of treatment: bactericidal double antibiotherapy and surgical ablation of the infected material either percutaneously or by cardiotomy. FUTURE PROSPECTS AND PROJECTS A recent meta-analysis supported the role of systematic, preoperative, prophylactic antibiotic therapy in the prevention of these complications. These data should be confirmed by suitably powered clinical trials.
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Affiliation(s)
- A Da Costa
- Service de cardiologie, hôpital Nord, CHRU, Saint-Etienne, France
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Alt E, Leipold F, Milatovic D, Lehmann G, Heinz S, Schömig A. Hydrogen peroxide for prevention of bacterial growth on polymer biomaterials. Ann Thorac Surg 1999; 68:2123-8. [PMID: 10616988 DOI: 10.1016/s0003-4975(99)00832-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Despite widespread use of potent antibiotics, infections of artificial implants and catheters are of increasing concern. We tested whether local treatment with 3% hydrogen peroxide (H2O2), long known as an inexpensive wound disinfectant, could prevent or reduce bacterial growth on polymer biomaterials. METHODS Two-centimeter-long pieces of polyurethane and silicone tubing were contaminated with a standardized solution of Staphylococcus epidermidis (10(5)/mL) and then rinsed and wiped with saline (0.9%) solution. Bacterial growth was assessed after incubation at 37 degrees C for 24 hours. Bacterial colonies were compared for the following treatments: wiping only with saline; wiping with 1.5%, 2%, or 3% H2O2; pretreating biomaterials with 3% H2O2 and subsequent contamination for 2 and 4 hours without treatment after contamination; and contamination of tubings 1 month after pretreatment with 3% H2O2. The effect of 3% H2O2 was also assessed on contamination with Escherichia coli. RESULTS Bacterial growth was reduced by more than 99% when the contaminated tubes were treated with 3% H2O2 compared with saline control (p < 0.001). Lower concentrations of H2O2 were less effective. The length of the contamination period had no influence on the effectiveness of H2O2 when used on polyurethane but did with silicone tubings. Pretreatment with H2O2 1 month before contamination still reduced bacterial growth rate by 90% on polyurethane and by 75% on silicone tubings. Comparable effects on bacterial growth rate were observed for staphylococci (-90%, p < 0.001) and escherichiae (-90%, p < 0.001). CONCLUSIONS Local treatment with 3% H2O2 significantly reduced bacterial growth on polymer biomaterials even for 1 month after treatment. This finding might influence clinical strategies of prevention of foreign body infection.
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Affiliation(s)
- E Alt
- Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany.
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Da Costa A, Lelièvre H, Kirkorian G, Célard M, Chevalier P, Vandenesch F, Etienne J, Touboul P. Role of the preaxillary flora in pacemaker infections: a prospective study. Circulation 1998; 97:1791-5. [PMID: 9603533 DOI: 10.1161/01.cir.97.18.1791] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Infection remains a severe complication after pacemaker implantation. The purpose of our prospective study was to evaluate the role of the local bacteriologic flora in its occurrence. METHODS AND RESULTS Specimens were collected at the site of implantation for culture from the skin and the pocket before and after insertion in a consecutive series of patients who underwent elective permanent pacemaker implantation. Microorganisms isolated both at the time of insertion and of any potentially infective complication were compared by using conventional speciation and ribotyping. There were 103 patients (67 men and 36 women) whose age ranged from 16 to 93 years (mean+/-SD, 67+/-15). At the time of pacemaker implantation, a total of 267 isolates were identified. The majority (85%) were staphylococci. During a mean follow-up of 16.5 months (range, 1 to 24), infection occurred in four patients (3.9%). In two of them, an isolate of Staphylococcus schleiferi was recognized by molecular method as identical to the one previously found in the pacemaker pocket. In one patient, Staphylococcus aureus, an organism that was absent at the time of pacemaker insertion, was isolated. In another patient, a Staphylococcus epidermidis was identified both at the time of pacemaker insertion and when erosion occurred; however, their antibiotic resistance profiles were different. CONCLUSIONS This study strongly supports the hypothesis that pacemaker-related infections are mainly due to local contamination during implantation. S schleiferi appears to play an underestimated role in infectious colonization of implanted biomaterials and should be regarded as an important opportunistic pathogen.
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Affiliation(s)
- A Da Costa
- Service de Cardiologie, Hôpital cardiovasculaire et pneumologique, Lyon, France
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Da Costa A, Kirkorian G, Cucherat M, Delahaye F, Chevalier P, Cerisier A, Isaaz K, Touboul P. Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis. Circulation 1998; 97:1796-801. [PMID: 9603534 DOI: 10.1161/01.cir.97.18.1796] [Citation(s) in RCA: 206] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- A Da Costa
- Service de Cardiologie, Hôpital cardiovasculaire et pneumologique, Lyon, France
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Abstract
Infections following cardiac surgery, although generally uncommon, are associated with difficult management decisions and significant morbidity and mortality. They often present while the patient is either in a critical care unit, or requires CCU management. This review analyzes infections related to median sternotomy wounds, prosthetic heart valves, transvenous permanent pacemakers, automatic implantable cardioverter-defibrillators, and left ventricular assist devices. The diagnosis, microbiology, treatment and outcome of each is also discussed.
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Affiliation(s)
- L I Lutwick
- Department of Medicine, Brooklyn Veterans Medical Center, Brooklyn, New York, USA
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Mounsey JP, Griffith MJ, Tynan M, Gould FK, MacDermott AF, Gold RG, Bexton RS. Antibiotic prophylaxis in permanent pacemaker implantation: a prospective randomised trial. Heart 1994; 72:339-43. [PMID: 7833191 PMCID: PMC1025543 DOI: 10.1136/hrt.72.4.339] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Pacemaker pocket infection is a potentially serious problem after permanent pacemaker implantation. Antibiotic prophylaxis is commonly prescribed to reduce the incidence of this complication, but current trial evidence of its efficacy is conflicting. A large prospective randomised trial was therefore performed of antibiotic prophylaxis in permanent pacemaker implantation. The intention was firstly to determine whether antibiotic prophylaxis is efficacious in these patients and secondly to identify which patients are at the highest risk of infection. METHODS A prospective randomised open trial of flucloxacillin (clindamycin if the patient was allergic to penicillin) v no antibiotic was performed in a cohort of patients undergoing first implantation of a permanent pacing system over a 17 month period. Intravenous antibiotics were started at the time of implantation and continued for 48 hours. The trial endpoint was a repeat operation for an infective complication. RESULTS 473 patients were entered into a randomised trial. 224 received antibiotic prophylaxis and 249 received no antibiotics. A further 183 patients were not randomised but were treated according to the operator's preference (64 antibiotics, 119 no antibiotics); these patients are included only in the analysis of predictors of infection. Patients were followed up for a mean (SD) of 19(5) months. Among the patients in the randomised group there were nine infections requiring a repeat operation, all in the group not receiving antibiotic (P = 0.003). In the total patient cohort there were 13 infections, all but one in the non-antibiotic group (P = 0.006). Nine of the infections presented as erosion of the pulse generator or electrode, three as septicaemia secondary to Staphylococcus aureus, and one as a pocket abscess secondary to Staphylococcus epidermidis. Infections were significantly more common when the operator was inexperienced (< or = 100 previous patients), the operation was prolonged, or after a repeat operation for non-infective complications (principally lead displacement). Infection was not significantly more common in patients identified preoperatively as being at high risk (for example patients with diabetes mellitus, patients receiving long term steroid treatment), although there was a trend in this direction. CONCLUSIONS Antibiotic prophylaxis significantly reduced the incidence of infective complications requiring a repeat operation after permanent pacemaker implantation. It is suggested that antibiotics should be used routinely.
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Affiliation(s)
- J P Mounsey
- Department of Cardiology, Northern Regional Cardiothoracic Centre Freeman Hospital, Newcastle upon Tyne
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Lehot JJ, Celard M, Etienne J, Brun Y, Bastien O, Fleurette J, Estanove S. [Antibiotic prophylaxis in heart surgery]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1994; 13:S78-87. [PMID: 7778817 DOI: 10.1016/s0750-7658(05)81780-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cardiac surgery enters mainly into the class I of Altemeier ("clean surgery"). However, many factors may explain an intraoperative contamination: surgery of long duration, extra-corporeal circulation, aspiration of blood and air, immunodepression...). In fact, the infectious risk decreases from about 25% with placebo to 5% with prophylactic antibiotics. The staphylococcal infections are the most frequent (mediastinitis, endocarditis, parietal infections...). Cephalosporins, particularly of second-generation type (cefamandole, cefuroxime), perform better than antistaphylococcal penicillins. The combination with an amino-side may be used when Gram negative bacilli infection prevalence is high. Vancomycin is efficient but hypotension and renal impairment have been reported. Therefore, vancomycin is used in patients allergic to cephalosporins, when a high prevalence of methicillin-resistant Staphylococcus or enterococci infections is reported, or when the patient has recently received broad-spectrum antimicrobial therapy. The antibiotic doses must take into account the haemodilution due to extracorporeal circulation and the necessity to obtain sufficient serum concentrations throughout surgery. A prophylaxis of more than 48 hours is not associated with an improved outcome. In cardiac transplantation a prophylaxis is essential, but is still questioned during the insertion of pace-markers. In any case, the antibiotic prophylaxis must take into account the bacterial prevalence of each institution.
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Affiliation(s)
- J J Lehot
- Département d'Anesthésie-Réanimation, Hôpital Cardiovasculaire Louis-Pradel, BP Lyon-Montchat
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Cox JN. Pathology of cardiac pacemakers and central catheters. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 1994; 86:199-271. [PMID: 8162711 DOI: 10.1007/978-3-642-76846-0_6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- J N Cox
- Department of Pathology, CMU, Geneva, Switzerland
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Affiliation(s)
- T T Yoshikawa
- Office of Geriatrics and Extended Care, Department of Veterans Affairs, Washington, D.C. 20420
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Segreti J, Levin S. The Role of Prophylactic Antibiotics in the Prevention of Prosthetic Device Infections. Infect Dis Clin North Am 1989. [DOI: 10.1016/s0891-5520(20)30268-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kaiser AB, Kernodle DS, Barg NL, Petracek MR. Influence of preoperative showers on staphylococcal skin colonization: a comparative trial of antiseptic skin cleansers. Ann Thorac Surg 1988; 45:35-8. [PMID: 3337574 DOI: 10.1016/s0003-4975(10)62391-0] [Citation(s) in RCA: 101] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We undertook a prospective randomized observer-blinded study comparing the ability of preoperative showers with chlorhexidine gluconate (Hibiclens), povidone-iodine (Betadine), and a lotion soap (Safe 'N Sure) to diminish the staphylococcal skin flora of patients. By block randomization, patients scheduled for an elective cardiac operation or coronary artery angioplasty were assigned to shower with one of the study skin cleansers either once (evening only) or twice (both evening and morning) before the procedure. Semiquantitative samples for culture were obtained from the subclavian and inguinal sites on the evening before the procedure (baseline culture) and again the next morning before the operation. The chlorhexidine skin cleanser consistently reduced staphylococcal colony counts at both the subclavian and inguinal sites before the procedure. This reduction was significant for patients showering both evening and morning (p less than 0.05). The use of the povidone-iodine skin cleanser inconsistently affected skin flora. Patients using lotion soap either experienced no change or had an increase in colony counts. Chlorhexidine is more effective than povidone-iodine in diminishing skin colonization with staphylococci in patients before operation. Repeated applications of chlorhexidine are superior to a single shower with this agent.
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Affiliation(s)
- A B Kaiser
- Department of Medicine, Saint Thomas Hospital, Nashville, TN 37202
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Bluhm G, Nordlander R, Ransjö U. Antibiotic prophylaxis in pacemaker surgery: a prospective double blind trial with systemic administration of antibiotic versus placebo at implantation of cardiac pacemakers. Pacing Clin Electrophysiol 1986; 9:720-6. [PMID: 2429279 DOI: 10.1111/j.1540-8159.1986.tb05421.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Bollaert PE, Canton P. [Prophylactic antibiotherapy in surgery]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1986; 5:502-17. [PMID: 3101555 DOI: 10.1016/s0750-7658(86)80037-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Bluhm GL. Pacemaker infections. A 2-year follow-up of antibiotic prophylaxis. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1985; 19:231-5. [PMID: 4081673 DOI: 10.3109/14017438509102724] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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