School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia. Email:
Pharmacy Department, Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, WA, Australia. Email:
Aust Health Rev. 2021 Dec;45(6):761-770. doi: 10.1071/AH21046.
Objective This study investigated antibiotic prophylaxis (AP) guideline adherence and the cardiac implantable electronic device (CIED) infection rate in two major Australian public teaching hospitals. Methods In a retrospective observational study, the medical records of patients who underwent CIED procedures between January and December 2017 were reviewed (Hospital A, n = 400 procedures; Hospital B, n = 198 procedures). Adherence to AP guidelines was assessed regarding drug, dose, timing, route and frequency. Infection was identified using follow-up documentation. Results AP was administered in 582 of 598 procedures (97.3%). Full guideline adherence was observed in 33.9% of procedures (203/598) and differed significantly between Hospitals A and B (47.3% vs 7.1%, respectively; P < 0.001). Common reasons for non-adherence were the timing of administration (42.3% vs 60.6% non-adherent in Hospitals A and B, respectively; P < 0.001) and repeat dosing (19.3% vs 78.8% non-adherent in Hospitals A and B, respectively; P < 0.001). Twenty infections were identified over 626.6 patient-years of follow-up (mean (±s.d.) follow-up 1.0 ± 0.3 years). The infection rate was 3.19 per 100 patient-years (P = 0.99 between hospitals). Two devices were removed due to infection; no patients died from CIED infection. Conclusions Although the rate of serious CIED infection was low, there was evidence of highly variable and suboptimal antibiotic use, and potential overuse of AP. What is known about the topic? Previous Australian studies have revealed high rates of inappropriate surgical AP. CIED infections are potentially life threatening, but can be avoided through effective use of AP. However, prolonged durations of AP in this setting may also result in complications, including Clostridioides difficile infection. What does this paper add? This study, the first to our knowledge to focus specifically on adherence to Australian guidelines for AP in CIED procedures, highlighted several common issues between AP in this setting and surgical and procedural AP more broadly. 'Early' and 'late' dose administration and extended post-procedural AP were common. Only 34% of prescriptions fully adhered to the guidelines; practices varied significantly between the two hospitals. What are the implications for practitioners? There is a clear need for institution-specific antimicrobial stewardship strategies to optimise AP in CIED procedures, aligned with the Antimicrobial Stewardship Clinical Care Standard. Patients are being placed at potentially avoidable risk of both complications of extended durations of AP and CIED infection, although the rate of serious CIED infection was low. A standardised approach to surveillance of CIED infections and prospective multisite audits of AP in CIED procedures using a validated tool, such as the Surgical National Antimicrobial Prescribing Survey, are recommended to better inform evidence-based practice. Potential strategies to optimise guideline adherence include prescribing support in patients with immediate penicillin hypersensitivity or methicillin-resistant Staphylococcus aureus colonisation, optimising the in-patient location of drug administration to promote timely dosing, limiting inappropriate post-procedural prophylaxis and routine S. aureus screening and decolonisation.
本研究旨在调查两家澳大利亚主要公立教学医院中心脏植入式电子设备（CIED）感染率和抗生素预防（AP）指南的依从性。
在一项回顾性观察研究中，对 2017 年 1 月至 12 月期间接受 CIED 手术的患者的病历进行了回顾（医院 A：400 例；医院 B：198 例）。评估了药物、剂量、时间、途径和频率等方面的 AP 指南依从性。通过随访记录来确定感染。
在 598 例手术中，582 例（97.3%）接受了 AP。598 例手术中，完全遵循指南的比例为 33.9%（203/598），且医院 A 和医院 B 之间差异显著（分别为 47.3%和 7.1%；P<0.001）。不遵循指南的常见原因是给药时间（医院 A 和医院 B 分别为 42.3%和 60.6%不遵循指南；P<0.001）和重复剂量（医院 A 和医院 B 分别为 19.3%和 78.8%不遵循指南；P<0.001）。在 626.6 患者年的随访中，共发现 20 例感染（平均（±s.d.）随访 1.0±0.3 年）。感染率为 3.19/100 患者年（医院间 P=0.99）。有 2 个设备因感染而被移除；无患者因 CIED 感染而死亡。
尽管严重的 CIED 感染发生率较低，但抗生素使用的高度不规范和不理想，以及潜在的过度使用仍有证据。
已知的主题内容是什么？之前的澳大利亚研究表明，抗生素预防性使用不当的情况非常普遍。CIED 感染可能危及生命，但通过有效使用 AP 可以避免。然而，在这种情况下延长 AP 的持续时间也可能导致并发症，包括艰难梭菌感染。
这篇论文增加了什么新内容？本研究首次专门针对澳大利亚 CIED 手术中 AP 指南的依从性进行了研究，突出了这一领域中 AP 与外科和手术 AP 之间的几个共同问题。“早期”和“晚期”剂量给药以及延长术后 AP 是常见的。只有 34%的处方完全符合指南；两所医院的做法差异显著。
这对从业者有什么影响？显然需要制定针对特定机构的抗菌药物管理策略，以优化 CIED 手术中的 AP，与抗菌药物管理临床护理标准保持一致。尽管 CIED 感染的严重发生率较低，但患者仍面临潜在可避免的延长 AP 持续时间和 CIED 感染的风险。建议采用标准化方法监测 CIED 感染，并使用经过验证的工具（如外科国家抗菌药物处方调查）对 CIED 手术中的 AP 进行前瞻性多地点审核，以更好地为循证实践提供信息。优化指南依从性的潜在策略包括在有即刻青霉素过敏或耐甲氧西林金黄色葡萄球菌定植的患者中提供支持性处方、优化药物给药的住院位置以促进及时给药、限制不适当的术后预防和常规金黄色葡萄球菌筛查和去定植。
