Rates of post procedural prophylactic antibiotic use following cardiac implantable electronic device insertion and the impact on surgical site infections in Alberta, Canada

BACKGROUND: The necessity of post procedural prophylactic antibiotics following clean surgeries is controversial. While most evidence suggests that there is no benefit from these additional antibiotics and guidelines do not support their use, there is a paucity of evidence as to how often they are still being used and their impact on infection outcomes. The current study assessed the use of prophylactic antibiotics following cardiac implantable electronic device (CIED) implantations in the province of Alberta, and their impact on infection and mortality. METHODS: We conducted a population-based cohort study in the province of Alberta. Administrative data was used to link all patients ≥ 18 who underwent outpatient CIED implantation from January 1, 2011 through December 31, 2019 to antibiotics commonly used for surgical prophylaxis which were prescribed within 48 h of implantation. The primary outcome, explored with an adjusted Poisson model, was incidence of complex surgical site infection within one year of device implantation. All-cause mortality was a secondary outcome. RESULTS: Post implantation prophylactic antibiotics were used 41% of the time overall, though the rate has been decreasing over time. The most commonly used prophylactic antibiotic was cefalexin (52%). When adjusted analyses were completed, there was no difference in the outcome of infection between those who did and did not receive post implantation prophylactic antibiotics (Relative Risk 0.74, 95% CI 0.46-1.17) and there was no difference in mortality (Relative Risk 0.8, 95% CI 0.63-1.02). CONCLUSIONS: The use of prophylactic antibiotics following CIED implantation does not correlate to a reduced rate of complex surgical site infection or reduced mortality. The widespread use of these antibiotics, which is not guideline concordant, suggests the need for targeted antimicrobial stewardship interventions for surgical prophylaxis to ensure that antibiotic use is being optimized. Further work should explore other adverse outcomes associated with this antibiotic usage and stewardship programs should explore interventions to educate and reduce antibiotic use for this indication.