Westyn Branch-Elliman, MD, MMSc1,2,3; Maggie Stanislawski, MS1,3; MD; Judith Strymish, MD4,5; Howard S. Gold, MD5,6; Kalpana

Gupta MD, MPH4,7; Preston Schneider, MD, MS1,2; Anna Baron, PhD2,3, Paul Varosy, MD1,2, and P. Michael Ho, MD, PhD1,2,3

Cardiac Electrophysiology Laboratories:

A Potential Target for Antimicrobial Stewardship?

Background

Healthcare-associated infections are both common and costly, ranking among the top 10 causes

of death in the US and costing an estimated $10 billion in direct medical costs per year.

Infections complicate approximately 5% of cardiac device implantations, such as pacemakers and

implantable cardioverter-defibrillators, and cost greater than $50,000 per infection. Pre-Implantation antimicrobial prophylaxis can dramatically reduce the incidence of post-procedural

infections, however, routine post-procedural antibiotic use is not proven to reduce infections, and may,

in fact be harmful.

Despite the lack of evidence, anecdotal reports suggest that post-procedural antibiotic use in the

electrophysiology laboratory is common, and may be a potential target for antimicrobial stewardship

programs.

Objectives We sought to characterize antimicrobial utilization patterns following cardiac device infections within

the VA healthcare system, using the VA Clinical Assessment Reporting and Tracking (CART) database.

Methods

All cardiac device implantations entered into the CART database and performed during the period

from 10/1/2007-9/30/3013 were included.

New antibiotic orders lasting for greater than 24 hours following device implantation were identified

using VA administrative databases, and type and duration of antimicrobial therapy were characterized.

Variation in practice patterns was evaluated by examining the incidence of post-procedural

antimicrobial therapy at different medical centers, stratified by quartile of device procedural volume.

1Eastern Colorado VA HCS (Denver, CO) 2University of Colorado School of Medicine (Denver, CO), 3Denver VA Center for Outcomes and Innovations (COIN) (Denver, CO), 4VA Boston

HCS (Boston, MA) 5Harvard Medical School (Boston, MA), 6Beth Israel Deaconess Medical Center (Boston, MA), 7Boston University School of Medicine School of Medicine (Boston, MA)

Contact: Westyn.Branch-Elliman@UCDenver.edu

Results

N= 3,712 device implantations were identified at 34 VA Medical Centers. The mean age of participants was

72.0 (SD, 11.1 years); 98.4% of patients were male. 1211/3712 (32.6%) of implantations were performed on an

ambulatory basis.

Greater than 24 hours of post-procedural antimicrobial prophylaxis was prescribed following 1,579/3,712

(42.5%) of implantation procedures.

The median duration of therapy was 5 days (Interquartile range, 5-7 days) (Figure 1).

The most commonly prescribed antibiotic was cephalexin (1,152/1,579, 73%), followed by doxycycline

(118/1,579, 7.5%), and ciprofloxacin (101/1,579, 6.4%). Vancomycin was used in 73/1579, 4.6%. Other

antimicrobials were used infrequently.

Routine post-procedural antibiotic use varied considerably by facility, with some institutions providing

prolonged prophylaxis the majority of the time, and other facilities never offering routine post-procedural

prophylaxis (Figure 2).

Conclusions Prolonged post-procedural antibiotic prophylaxis is common following cardiac device implantation procedures,

despite the lack of evidence supporting this practice.

Practice patterns vary widely by specific facility and by procedural volume. There appears to be no defined

standard of care regarding duration of antimicrobial prophylaxis in cardiac electrophysiology laboratories.

Based on our findings, post-procedural antibiotic use may be an important target for antimicrobial stewardship

programs that have primarily focused on inpatient and traditional surgical settings.

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Figure 2. Unadjusted Post-Procedural Antibiotic Use Lasting Greater than 24 hours by Quartile of Procedural Volume, FY 2008-13

Quartile 1:

1-2

Procedures

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Figure 1. Duration of Prolonged Post-Procedural Antimicrobial Use Following Cardiac Device Implantation

The median duration of post-procedural

antimicrobial prophylaxis is 5 days.

The most commonly prescribed agent

is cephalexin.

Research supported by: The Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care