Comparison of infective complications with two different antibiotic prophylaxis at two-years follow up in patients undergoing cardiac implantable electronic device procedure: a prospective study

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac implantable electronic device (CIED) infective complications are associated with high morbidity and mortality. Selection of proper antibiotic prophylaxis therapy is mandatory, as it can decrease the infective risk.

Purpose of the Study

Aim of the present study was to compare two different antibiotic strategy in term of procedural-related infective complications in a two-years follow-up.

Material and Methods

Patients undergoing CIED procedure (implant, replacement, or revision), with cefuroxime antibiotic prophylaxis during 2009 were consecutively enrolled as study group, with the purpose to have a long follow-up available (10 years). Patients undergoing CIED procedure (implant, replacement, or revision), with cefazolin antibiotic prophylaxis during 2020 were consecutively enrolled as control group. Primary endpoint was the evaluation of infective complications in the first 2 years follow-up (pocket infection, endocarditis and infective complication requiring CIED complete extraction). Multivariate analysis was performed to evaluate association between covariates resulted significantly different between the two study groups and study endpoint. Long-term follow-up incidence of infective complications was evaluated in the cefuroxime group.

Results

340 patients were enrolled in the cefuroxime prophylaxis group and 239 patients in the cefazolin prophylaxis group. There was no significative difference of median age between the two study groups. Patients in the cefazolin prophylaxis group compared to the cefuroxime group showed higher rate of diabetes (33.1% vs 22.1%, p=0.003), dyslipidemia (46.4% vs 36.5%, p=0.02) and higher rate of antiplatelet (45.2% vs 40.6%, p<0.001) and anticoagulation therapy (36.8% vs 31.8%, p<0.001) (Figure 1). ICD and CRT implant was more frequent in patients in the cefazolin group (33.3% vs 25.06%, p=0.05) (Figure 2). There was no significant difference of the primary endpoint in the two study groups: pocket infection (cefazolin group n=4, 1.7%, vs cefuroxime group n=5, 1.5%, p=0.85), endocarditis (cefazolin group n=1, 0.4%, vs cefuroxime group n=1, 0.3%, p=0.8) and infection requiring complete device extraction (cefazolin group n=2, 0.8%, vs cefuroxime group n=2, 0.6%, p=0.95). At multivariate analysis, there was an observed trend in reduction of infective complications in patients undergoing pacemaker (odds ratio 0.23) and CRT (odds ratio 0.82) implant.

At 10 years follow-up, 11 (3.2%) infective procedure-related complications were recorded in the cefuroxime group, 5 pocket infection, 5 pocket infection with erosion and 1 endocarditis.

Conclusion

Cefazolin antibiotic prophylaxis is effective as cefuroxime prophilaxis in reducing CIED procedure-related infections, even if patients in the cefazolin group showed higher prevalence of comorbidities and more complex device procedure (ICD and CRT implant).

S(+)-ketamine for control of perioperative pain and prevention of post thoracotomy pain syndrome: a randomized, double-blind study

BACKGROUND

Post-thoracotomy pain syndrome (PTPS) often complicates the long term outcome of patients; its appearance has been related to perioperative acute pain. The main goal of this study was to evaluate a possible role of S(+)-ketamine in the prevention of PTPS up to 6 months and secondarily its efficacy in the control of perioperative pain when added to thoracic epidural analgesia (TEA) and adjuvants.

METHODS

Sixty-six patients underwent thoracotomy under general anesthesia. A thoracic epidural catheter was placed for levobupivacaine and sufentanil administration. Thirty-three patients received an i.v. infusion of S(+)-ketamine (Group S(+)K) for 60 hours and 33 patients received i.v. placebo (Group PLAC). Pain was evaluated by Numeric Rating Scale (NRS) during the whole study. All patients had supplementary doses of analgesics, as needed, to have NRS targeted to a value of ≤3 in the 1st and <3 in the following days. Neuropathic Pain Symptom Inventory (NPSI) was evaluated at 1, 3 and 6 months.

RESULTS

All patients had NRS ≤3 in the early postoperative period and NPSI was less or equal to 1 in the follow-up control for each group with no significant difference at three (P=0.67, OR 0.8 [IC95% 0.3-2.2]) and at six months (P=0.23, OR 1.9 [0.7-5.4]). Incidence of moderate PTPS was 24.6% at 3 and 21.1% at six months while severe PTPS was 6.6% at 3 and 1.8% at six months. No difference was detected in NRS and NPSI at 3 and 6 months between groups.

CONCLUSION

S(+)-ketamine had no effects in respect to placebo in the prevention of PTPS at 3 and 6 months but had a significant role in maintaining a NRS≤3 in the early postoperative period. A tight control of perioperative pain seems to be associated with a low incidence of moderate and severe PTPS.