Invasive cardiology procedures in adults - Guideline for Antimicrobial Prophylaxis

Publication: 30/07/2010  --
Last review: 19/07/2019  
Next review: 19/07/2022  
Clinical Guideline
CURRENT 
ID: 2019 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for antimicrobial prophylaxis during invasive cardiology procedures in adults.

  1. Summary table of routine recommendations
  2. Background information
  3. Special antimicrobial prophylaxis recommendations
  4. Appendix

1. Summary table of routine recommendations

Procedure

Prophylaxis recommended?

Evidence level

Prophylaxis aims to reduce

NNT

Antimicrobial dose/route ≤ 1 hour before procedure

Routine and MRSA risk

Allergy to teicoplanin

Allergy to Gentamicin

Cardiac pacemaker and defibrillator insertion

YES

A (1)

Any infection

38

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv plus Gentamicin 2mg/kg IBW iv both single dose

Replace Teicoplanin electronic Medicines Compendium information on Teicoplanin with linezolid 600mg iv or po* single dose

Replace Gentamicin with Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg iv or 500mg po* single dose

Placement of closure devices (e.g. ASD, PFO) and other indwelling cardiac devices (except stents)

YES

D

Device infection

n/k

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv plus Gentamicin 2mg/kg IBW iv both single dose

Replace Teicoplanin electronic Medicines Compendium information on Teicoplanin with Linezolid electronic Medicines Compendium information on Linezolid 600mg iv or po* single dose

Replace Gentamicin with Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg iv or 500mg po* single dose

Percutanous insertion of prosthetic valves (TAVI)

YES

D

Device infection

n/k

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv plus Gentamicin2mg/kg IBW iv both single dose

Replace Teicoplanin electronic Medicines Compendium information on Teicoplanin with Linezolid electronic Medicines Compendium information on Linezolid 600mg iv or po* single dose

Replace Gentamicin with Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin  400mg iv or 500mg po* single dose

Percutaneous valvuloplasty

NO

D

 ?

-

     

Other closed cardiac procedures (angiography, stent placement, ablation)

NO

C

 

-

     

Table 1. Summary of routine antimicrobial prophylaxis recommendations for invasive cardiology procedures. NNT, number needed to treat; *redose Flucloxacillin electronic Medicines Compendium information on Flucloxacillin at 4 hours if operation lasts ≥4 hours. NB. It is the responsibility of the cardiologist to prescribe and administer intravenous prophylactic antibiotics within the hour before incision. IBW, ideal body weight; *give oral agents 1 hour before procedure.


Gentamicin dosing in adult male >16 years

 

Gentamicin dosing in adult female > 16 years

Use height to select 
Gentamicin dose

IBW
from height
(kg)

Use ABW if
less than IBW (kg)

Gentamicin dose (mg)

 

Use height to select 
Gentamicin dose

IBW
from height
(kg)

Use ABW if
less than IBW (kg)

Gentamicin dose (mg)

6’ 3” (1.9m) +

84.5

78 to 82

 160

6’ 3” (1.9m) +

79.5

78 to 82

160

6’ 2” (1.88m)

82.2

6’ 2” (1.88m)

77.2

72 to 77

 150

6’ 1” (1.85m)

79.9

6’ 1” (1.85m)

74.9

6’ (1.82m)

77.6

72 to 77

 150

6’ (1.82m)

72.6

5’ 11” (1.8m)

75.3

5’ 11” (1.8m)

70.3

66 to 71

140

5’ 10” (1.78m)

73

5’ 10” (1.78m)

68

5’ 9” (1.75m)

70.7

66 to 71

 140

5’ 9” (1.75m)

65.7

60 to 65

 130

5’ 8” (1.72m)

68.4

5’ 8” (1.72m)

63.4

5’ 7” (1.7m)

66.1

5’ 7” (1.7m)

61.1

5’ 6” (1.67m)

63.8

60 to 65

130

5’ 6” (1.67m)

58.8

55 to 59

 120

5’ 5” (1.65m)

61.5

5’ 5” (1.65m)

56.5

5’ 4” (1.62m)

59.2

55 to 59

 120

5’ 4” (1.62m)

54.2

5’ 3” (1.6m)

56.9

5’ 3” (1.6m)

51.9

49 to 54

100

5’ 2” (1.57m)

54.6

5’ 2” (1.57m)

49.6

5’ 1” (1.55m)

52.3

49 to 54

100

5’ 1” (1.55m)

47.3

43 to 48

90

5’ (1.52m) or under

50

5’ (1.52m) or under

45

Table 2. Guidance for dosing Gentamicin for prophylaxis. IBW, ideal body weight; ABW, actual body weight.

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Background information

The aim of antimicrobial prophylaxis when used in interventional cardiology is a reduction in surgical site infection (SSI) and device-related infection - a potentially life-threatening complication.

A review of antimicrobial prophylaxis recommendations for cardiac procedures in Leeds has been prompted by several recent infections involving pacing devices, the continued presence of meticillin-resistant Staphylococcus aureus (MRSA) in the Trust and the ongoing problem of Clostridium difficile infection. It is appropriate to use a single pre-operative dose of prophylaxis in most situations to reduce the risks related to antimicrobial use while gaining maximum benefit from prophylaxis (2).

Measures other than antimicrobial prophylaxis can have an impact on infection rates, such as avoiding implantation (wherever possible) in patients with clinical evidence of infection, use of meticulous aseptic technique and control of bleeding (3), but these are not addressed further in this guideline.

These guidelines should be applicable to the majority of patients. Where the recommendations in these guidelines do not seem appropriate for a particular patient the cardiologist is advised to discuss the case with a microbiologist.

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Special antimicrobial prophylaxis recommendations

  1. Pacemaker insertion

    Recent SIGN(4) and NICE guidelines have recommended the use of antimicrobial prophylaxis for permanent pacemaker implantation based on a meta-analysis (1). Recent American Heart Association (AHA) guidelines have also concluded that prophylaxis is required to cover commended (3) We include intra-cardiac defibrillators in this section.

    Choice of systemic antimicrobial agents.
    • Antimicrobial prophylaxis should cover the organisms most likely to cause surgical site infection/device infection.
    • Pacemaker infections involving the pocket are usually caused by Staphylococcus aureus, but Gram negatives including Pseudomonas sp. have caused a number of recent infections.
    • Pacemaker lead infections are most commonly caused by coagulase negative staphylococci, the majority of which are resistant to beta-lactams (penicillins and cephalosporins).
    • Antimicrobial prophylaxis, where advised, should therefore cover these organisms.
    • The majority of MRSA isolates that are tested in Leeds are susceptible to gentamicin (see appendix).
    • Coagulase negative staphylococci are usually resistant to beta-lactams (e.g. Flucloxacillin electronic Medicines Compendium information on Flucloxacillin, cefuroxime). Resistance to gentamicin is variable – see appendix. Resistance to Teicoplanin electronic Medicines Compendium information on Teicoplanin is uncommon.
    • AHA guidelines advise cephalosporins as the preferred prophylactic agent but acknowledge that vancomycin is used as prophylaxis by some experts particularly where oxacillin (meticillin) resistance is high among staphylococci (3) SIGN guidelines recommend use of a glycopeptides for MRSA colonised patients (2).
    • Choice of glycopeptide: Vancomycin electronic Medicines Compendium information on Vancomycin needs to be given by prolonged intravenous infusion and timing of its administration is unlikely to be optimal for prophylaxis, particularly if the infusion is started around the time of induction. Teicoplanin electronic Medicines Compendium information on Teicoplanin can be given as a bolus and achieves satisfactory serum levels (5).
    • Several factors justify the routine addition of Gentamicin to prophylaxis regimen.
      1. The vast majority of staphylococci (tested) in Leeds are gentamicin-susceptible (inc. MRSA).
      2. Not every patient who develops MRSA SSI is identified as at high risk pre-procedure.
      3. Several Gram negative PPM infections have been seen recently.
    • Conclusion: Teicoplanin electronic Medicines Compendium information on Teicoplanin plus Gentamicin provides the antimicrobial spectrum of activity required according to local epidemiology and is generally well tolerated and not likely to promote MRSA or Clostridium difficile infection. A selection pressure for development of glycopeptide resistance is a potential down-side.
      [Evidence level C/D]
    • In patients who are allergic to or intolerant of Gentamicin use ciprofloxacin 400mg iv or 500mg po in place of Gentamicin.
      [Evidence level D]
    • In patients who are allergic to or intolerant of Teicoplanin electronic Medicines Compendium information on Teicoplanin use linezolid 600mg iv or 600mg po in place of Teicoplanin electronic Medicines Compendium information on Teicoplanin.
      [Evidence level D]

Route of administration of antimicrobial prophylaxis
AHA recommends intravenous antimicrobials (3).
[Evidence level C]

In the uncommon situation when peripheral intravenous access cannot be obtained, local consensus is not to site central venous cannulae solely for administration of antimicrobial prophylaxis but to give Teicoplanin electronic Medicines Compendium information on Teicoplanin and Gentamicin by the intramuscular route or, if this is not practicable, oral linezolid 600mg single dose plus oral ciprofloxacin 500mg single dose is an alternative.
[Evidence level D]

Intramuscular and oral agents should be given 1 hour pre-procedure.
[Evidence level D]

There is no indication for topical administration of antimicrobials or antimicrobial wash solutions.

There is no evidence to support pocket irrigation with antimicrobials and this is not recommended.

Povidone iodine irrigation of the pocket offered no advantage over a saline irrigation in terms of infection reduction of infection (6).

Duration of prophylaxis
Multiple dose prophylaxis regimens have been used in Leeds for some time, without evidence of increased effectiveness and with local evidence of adverse consequences for the patient (e.g. RCA reports of Clostridium difficile infection).

Few studies have examined the duration of prophylaxis but one study showed no benefit of a seven day prophylaxis regimen when compared to a 48-hour regimen (7). SIGN and NICE guidelines recommend single dose prophylaxis as a general principle (2, 4); AHA guidelines recommend administration of a single-pre-procedural dose of antimicrobial (3).

  1. Insertion of closure devices and other indwelling cardiac devices.
    We extrapolate from evidence used to justify both prosthetic valve implantation (see LTHT guidelines for cardiac surgery) and pacemaker insertion to support prophylaxis for procedures involving the implantation of other indwelling intracardiac devices.

  2. Coronary artery stent insertion and percutaneous cardiac procedures not involving device insertion.
    Coronary artery stent infections are exceptionally rare and prophylaxis is not recommended.
    [Evidence level D]

  3. Percutaneous implantation of prosthetic valves (TAVI)
    We extrapolate from evidence used to justify and select antimicrobial agents for prosthetic valve implantation (see LTHT guidelines for cardiac surgery) to support prophylaxis for procedures involving the percutaneous implantation of valves. 
    [Evidence level D]

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Appendix.

Graph 1 showing susceptibility of MRSA blood culture isolates to Gentamicin 2006-08.

Graph 2. Susceptibility of all meticillin-susceptible Staphylococcus aureus isolates to Gentamicin 2006-08.

Graph 3. Susceptibility of coagulase-negative staphylococci to Gentamicin 2006-08.

Graph 4. Susceptibility of coagulase-negative staphylococci to Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 2006-08

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Provenance

Record: 2019
Objective:
Clinical condition:

Invasive cardiology procedures

Target patient group: Adults
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

  1. Da Costa A, Kirkorian G, Cucherat M, Delahaye F, Chevalier P, Cerisier A, et al. Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis. Circulation. 1998 May 12;97(18):1796-801.
  2. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2008.
  3. Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010 Jan 26;121(3):458-77.
  4. Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008.
  5. Wilson AP, Taylor B, Treasure T, Gruneberg RN, Patton K, Felmingham D, et al. Antibiotic prophylaxis in cardiac surgery: serum and tissue levels of teicoplanin, flucloxacillin and tobramycin. J Antimicrob Chemother. 1988 Feb;21(2):201-12.
  6. Lakkireddy D, Valasareddi S, Ryschon K, Basarkodu K, Rovang K, Mohiuddin SM, et al. The impact of povidone-iodine pocket irrigation use on pacemaker and defibrillator infections. Pacing Clin Electrophysiol. 2005 Aug;28(8):789-94.
  7. Dwivedi SK, Saran RK, Khera P, Tripathi N, Kochar AK, Narain VS, et al. Short-term (48 hours) versus long-term (7 days) antibiotic prophylaxis for permanent pacemaker implantation. Indian heart journal. 2001 Nov-Dec;53(6):740-2.

Evidence levels
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus [no national guidelines exist, guidelines from different learned bodies contradict each other, or no evidence exists]

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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