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Pacemaker infections. A clinical study with special reference to prophylactic use of some isoxazolyl penicillins
Abstract:
Infection is a major complication of pacemaker treatment. Antibiotic prophylaxis has been used in association with pacemaker surgery with conflicting results, and conclusive prospective trials are lacking. This investigation indicated that systemic antibiotic prophylaxis was of benefit when infections occurred frequently. The effect of local antibiotic prophylaxis was comparable with that of systemic prophylaxis at generator replacements. No serious adverse effects of the prophylaxis were noted. However, with modern surgical methods and hygienic principles, antibiotic prophylaxis did not seem to be necessary at implantation of new cardiac pacemakers. Once infection had developed it was difficult to eradicate and serious complications sometimes occurred. Most infections commenced in the pacemaker pocket. A few cases were cured by antibiotic treatment alone but, particularly if the infection spread along the electrode, surgery was strongly needed and in the presence of endocarditis and/or septicemia all foreign material should be removed if possible. The most common causal microorganisms of pacemaker infections were Staphylococcus aureus and Staphylococcus epidermidis. Routinely performed pre-, per- and postoperative cultures were of no prognostic value. Persistent use of antibiotics could select for methicillin-resistant coagulase-negative staphylococci, therefore bacteriological monitoring of wound infections was considered important. The dosage schedules used for cloxacillin and flucloxacillin gave satisfactory serum concentrations peroperatively. Local treatment with cloxacillin in the pacemaker pocket peroperatively gave adequate concentrations in tissue fluid from the pocket 24 h after the operation, as did systemic administration of flucloxacillin. The pharmacokinetics of flucloxacillin in these elderly patients differed in some respects from that found in healthy volunteers. Plasma elimination half-life was almost twice as long. Despite the high degree of plasma protein binding, flucloxacillin appeared to pass rapidly and efficiently to extravascular compartments, such as a pacemaker pocket.
Insights
Antibiotic prophylaxis for pacemaker surgery showed benefits when infections were frequent, with local and systemic methods being comparable. However, modern techniques may reduce the need for antibiotics during new pacemaker implantation.
Area of Science:
- Cardiology
- Infectious Diseases
- Surgical Infections
Background:
- Pacemaker treatment is associated with significant infection risks.
- Antibiotic prophylaxis use in pacemaker surgery has yielded conflicting results, lacking conclusive prospective trials.
- Understanding optimal antibiotic strategies is crucial for patient outcomes.
Purpose of the Study:
- To evaluate the efficacy and necessity of antibiotic prophylaxis in pacemaker surgery.
- To compare systemic versus local antibiotic prophylaxis effectiveness.
- To analyze factors influencing pacemaker infection development and treatment.
Main Methods:
- Review of infection rates and outcomes associated with antibiotic prophylaxis.
- Comparison of systemic and local antibiotic administration.
- Analysis of common pathogens and treatment strategies for pacemaker infections.
- Pharmacokinetic evaluation of flucloxacillin in elderly patients.
Main Results:
- Systemic antibiotic prophylaxis was beneficial in high-infection-rate scenarios.
- Local antibiotic prophylaxis demonstrated comparable efficacy to systemic prophylaxis during generator replacements.
- Modern surgical practices may render antibiotic prophylaxis unnecessary for new pacemaker implantations.
- Infections often originate in the pacemaker pocket and can be difficult to eradicate, sometimes requiring surgical intervention.
- Staphylococcus aureus and Staphylococcus epidermidis were the most frequent causative agents.
- Pharmacokinetics of flucloxacillin in elderly patients showed a longer elimination half-life compared to healthy volunteers.
Conclusions:
- Antibiotic prophylaxis may be beneficial in specific high-risk pacemaker surgery scenarios.
- Local antibiotic prophylaxis is a viable alternative to systemic prophylaxis for generator replacements.
- Careful consideration of antibiotic use is warranted with advancements in surgical techniques and hygiene.
- Prompt and appropriate treatment, often involving surgery, is essential for managing established pacemaker infections.
- Bacteriological monitoring is important to prevent the selection of resistant strains.