Is there any data to support antibiotics for endocarditis prophylaxis in patients with ICDs?
No good data. We saw a patient in clinic this week with an ICD who was slated to undergo a big dental procedure, and this question arose. I know this isn’t a group we routinely treat, but, I did not know the data – how often does endocarditis occur in patients with implanted devices from a dental or genitourinary, for example, procedure?
Up to Date says patients with CIEDs (cardiac implantable electronic devices) are at intermediate risk; the 2023 ESC guidelines on endocarditis say they are very low risk. I also learned a lot from this AHA Scientific Statement on CIED infections, which I’ll post in clinic.
While I didn’t find a helpful number to report back, my reading did lead me to the PADIT trial. Attached, this is a study that looked at incremental antibiotic use during initial device implantation for preventing infections. More than 12K high-risk patients (defined as repeat procedure or CRT) were randomized to conventional cefazolin or vancomycin versus the treatment group: cefazolin + vancomycin pre-procedure, pocket bacitracin intra-procedure, and cephalexin post-procedure. This international study did not find a significant difference between the two groups in terms of hospital admission/pocket infection, though perhaps a trend towards better outcomes with more antibiotics:
Central Illustration: Summary of Infection Risks Across Device Platforms in the Prevention of Arrhythmia Device Infection Trial
There are some limitations: it was a center-based cluster study, and the overall rate of infection was lower than anticipated – the authors hypothesize a Hawthorne effect may have been in play. That said, it’s always cool to see a negative study published, and this data reassures me about the limited role of antibiotics for this particular patient population.
Baddour LM, Zerelda Esquer Garrigos, M. Rizwan Sohail, et al. Update on Cardiovascular Implantable Electronic Device Infections and Their Prevention, Diagnosis, and Management: A Scientific Statement From the American Heart Association. Circulation. Published online December 4, 2023. doi:https://doi.org/10.1161/cir.0000000000001187
Delgado V, Nina Ajmone Marsan, Suzanne de Waha, et al. 2023 ESC Guidelines for the management of endocarditis. European Heart Journal. 2023;44(39). doi:https://doi.org/10.1093/eurheartj/ehad193
Krahn AD, Longtin Y, Philippon F, et al. Prevention of Arrhythmia Device Infection Trial. Journal of the American College of Cardiology. 2018;72(24):3098-3109. doi:https://doi.org/10.1016/j.jacc.2018.09.068
