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Prolonged antimicrobial prophylaxis following cardiac device procedures increases preventable harm: insights from the VA CART program

  • Archana Asundi (a1), Maggie Stanislawski (a2) (a3), Payal Mehta (a4), Anna E. Barón (a2) (a5), Howard Gold (a6) (a7), Hillary Mull (a8) (a9), P. Michael Ho (a2) (a10) (a11), Kalpana Gupta (a4) (a8) (a12) and Westyn Branch-Elliman (a4) (a7) (a8)...



The rate of cardiovascular implantable electronic device (CIED) infection is increasing coincident with an increase in the number of device procedures. Preprocedural antimicrobial prophylaxis reduces CIED infections; however, there is no evidence that prolonged postprocedural antimicrobials additionally reduce risk. Thus, we sought to quantify the harms associated with this approach.


To measure the association between Clostridium difficile infection (CDI), acute kidney injury (AKI) and receipt of prolonged postprocedural antimicrobials.


CIED procedures entered into the VA Clinical Assessment Reporting and Tracking Electrophysiology (CART-EP) database during fiscal years 2008–2016 were included. The primary outcome was 90-day incidence of CDI and the secondary outcome was the 7-day incidence of AKI. The primary exposure measure was duration of postprocedural antimicrobial therapy. Associations were measured using Cox-proportional hazards and binomial regression.


Prolonged postprocedural antimicrobial therapy was identified following 3,331 of 6,497 CIED procedures (51.3%), and the median duration of prophylaxis was 5 days. Prolonged postprocedural antimicrobial use was associated with increased risk of CDI (hazard ratio [HR], 2.90; 95% confidence interval [CI], 1.54–5.46). Of the 27 patients who developed CDI, 11 subsequently died. Postprocedural antimicrobial use with ≥2 antimicrobials was associated with an increased risk of AKI (OR, 4.16; 95% CI, 2.50–6.90). The impact was particularly significant when one of the dual agents prescribed was vancomycin (adjusted OR, 8.41; 95% CI, 5.53–12.79).


Prolonged antimicrobial prophylaxis following CIED procedures increases preventable harm; this practice should be discouraged in procedural settings such as the cardiac electrophysiology laboratory.


Corresponding author

Author for correspondence: Westyn Branch-Elliman, MD, MMSc, VA Boston Healthcare System, Assistant Professor of Medicine, Harvard Medical School, 1400 VFW Parkway, West Roxbury, MA 02132. E-mail:


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1. Bradshaw, PJ, Stobie, P, Knuiman, MW, Briffa, TG, Hobbs, MS. Trends in the incidence and prevalence of cardiac pacemaker insertions in an ageing population. Open Heart 2014;1:e000177.
2. Greenspon, AJ, Patel, JD, Lau, E, et al. Trends in permanent pacemaker implantation in the United States from 1993 to 2009: increasing complexity of patients and procedures. J Am Coll Cardiol 2012;60:15401545.
3. Greenspon, AJ, Patel, JD, Lau, E, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol 2011;58:10011006.
4. Voigt, A, Shalaby, A, Saba, S. Rising rates of cardiac rhythm management device infections in the United States: 1996 through 2003. J Am Coll Cardiol 2006;48:590591.
5. Baman, TS, Gupta, SK, Valle, JA, Yamada, E. Risk factors for mortality in patients with cardiac device-related infection. Circ Arrhythm Electrophysiol 2009;2:129134.
6. Baddour, LM, Epstein, AE, Erickson, CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010;121:458477.
7. Darouiche, R, Mosier, M, Voigt, J. Antibiotics and antiseptics to prevent infection in cardiac rhythm management device implantation surgery. Pacing Clin Electrophysiol 2012;35:13481360.
8. de Oliveira, JC, Martinelli, M, Nishioka, SA, et al. Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter-defibrillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial. Circ Arrhythm Electrophysiol 2009;2:2934.
9. Bratzler, DW, Dellinger, EP, Olsen, KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195283.
10. Berrios-Torres, SI, Umscheid, CA, Bratzler, DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784791.
11. McDonald, M, Grabsch, E, Marshall, C, Forbes, A. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review. Aust N Z J Surg 1998;68:388396.
12. Rosenberger, LH, Politano, AD, Sawyer, RG. The surgical care improvement project and prevention of post-operative infection, including surgical site infection. Surg Infect (Larchmt) 2011;12:163168.
13. Branch-Elliman, W, Ripollone, J, Strymish, J, Itani, K, Gupta, K. Unintended consequences of double versus single antimicrobial prophylaxis in patients undergoing cardiac surgery. Paper presented at: Open Forum Infectious Diseases, 2016.
14. Branch-Elliman, W, Ripollone, JE, O’Brien, WJ, et al. Risk of surgical site infection, acute kidney injury, and Clostridium difficile infection following antibiotic prophylaxis with vancomycin plus a beta-lactam versus either drug alone: a national propensity-score-adjusted retrospective cohort study. PLoS Med 2017;14:e1002340.
15. Branch-Elliman, W, Stanislawski, M, Strymish, J, et al. Cardiac electrophysiology laboratories: a potential target for antimicrobial stewardship and quality improvement? Infect Control Hosp Epidemiol 2016;37:10051011.
16. Mehrotra, P, Gupta, K, Strymish, J, et al. Implementation of infection prevention and antimicrobial stewardship in cardiac electrophysiology laboratories: results from the SHEA research network. Infect Control Hosp Epidemiol 2017;38:496498.
17. Maddox, TM, Plomondon, ME, Petrich, M, et al. A national clinical quality program for Veterans Affairs catheterization laboratories (from the Veterans Affairs clinical assessment, reporting, and tracking program). Am J Cardiol 2014;114:17501757.
18. Hensgens, MP, Goorhuis, A, Dekkers, OM, Kuijper, EJ. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother 2012;67:742748.
19. Kuntz, JL, Smith, DH, Petrik, AF, et al. Predicting the risk of Clostridium difficile infection upon admission: a score to identify patients for antimicrobial stewardship efforts. Perm J 2016;20:2025.
20. Mehta, RL, Kellum, JA, Shah, SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31.
21. Bratzler, DW. Surgical care improvement project performance measures: good but not perfect. Clin Infect Dis 2013;56:428429.
22. Bratzler, DW, Houck, PM, Surgical Infection Prevention Guidelines Writers Working Group, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38:17061715.
23. Epitools: Epidemiology Tools. R package [computer program] version 0.5-9 2017.
24. R: A language and environment for statistical computing. [computer program]. Vienna, Austria: R Foundation for Statistical Computing; 2017.
25. Harbarth, S, Samore, MH, Lichtenberg, D, Carmeli, Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation 2000;101:29162921.
26. Poeran, J, Mazumdar, M, Rasul, R, et al. Antibiotic prophylaxis and risk of Clostridium difficile infection after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2016;151:589597.
27. Bamgbola, O. Review of vancomycin-induced renal toxicity: an update. Ther Adv Endocrinol Metab 2016;7:136147.
28. Kriaras, I, Michalopoulos, A, Turina, M, Geroulanos, S. Evolution of antimicrobial prophylaxis in cardiovascular surgery. Eur J Cardiothorac Surg 2000;18:440446.
29. Remmelts, HH, Meine, M, Loh, P, et al. Infection after ICD implantation: operating room versus cardiac catheterisation laboratory. Neth Heart J 2009;17:95100.
30. Stevens, V, Dumyati, G, Fine, LS, Fisher, SG, van Wijngaarden, E. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis 2011;53:4248.
31. Vardakas, KZ, Trigkidis, KK, Boukouvala, E, Falagas, ME. Clostridium difficile infection following systemic antibiotic administration in randomised controlled trials: a systematic review and meta-analysis. Int J Antimicrob Agents 2016;48:110.
32. Deshpande, A, Pasupuleti, V, Thota, P, et al. Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. J Antimicrob Chemother 2013;68:19511961.
33. Kwon, JH, Olsen, MA, Dubberke, ER. The morbidity, mortality, and costs associated with Clostridium difficile infection. Infect Dis Clin North Am 2015;29:123134.
34. Sohail, MR, Henrikson, CA, Braid-Forbes, MJ, Forbes, KF, Lerner, DJ. Mortality and cost associated with cardiovascular implantable electronic device infections. Arch Intern Med 2011;171:18211828.
35. Mull, HJ, Gellad, ZF, Gupta, RT, et al. Factors associated with emergency department visits and hospital admissions after invasive outpatient procedures in the Veterans Health Administration. JAMA Surg 2018. doi: 10.1001/jamasurg.2018.0874.
36. Mull, HJ, Rosen, AK, O’Brien, WJ, et al. Factors associated with hospital admission after outpatient surgery in the Veterans Health Administration. Health Serv Res 2018. doi: 10.1111/1475-6773.12826.
37. Pindyck, T, Gupta, K, Strymish, J, et al. Validation of an electronic tool for flagging surgical site infections based on clinical practice patterns for triaging surveillance: operational successes and barriers. Am J Infect Control 2018;42:186190.
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