A 19-year Study on Pacemaker-related Infections

A Claim for Using Postoperative Antibiotics

Janek M. Senaratne, B.Med.Sc., M.D.; Anushka Jayasuriya, B.Sc.; Marleen Irwin, Sajad Gulamhusein, M.D.; Manohara P.J. Senaratne, M.B.B.S., Ph.D.


Pacing Clin Electrophysiol. 2014;37(8):947-954. 

In This Article

Abstract and Introduction


Background: Although the incidence of pacemaker-related infection (PMINF) is low, it necessitates removal of the pacing system. There is currently no consensus on antibiotics during implantation.

Methods: A prospective database on patients undergoing pacemaker surgery from 1991 to 2009 was reviewed to determine factors associated with PMINF. Specifically, three eras of antibiotic use were compared to elucidate the effect of antibiotics on PMINF: no antibiotics, perioperative antibiotics, and peri- plus postoperative antibiotics.

Results: There were 3,253 procedures with PMINF identified in 46 (1.4%) patients. Over 19 years, PMINF incidence fell from 3.6% (no antibiotics) to 2.9% (perioperative antibiotics), to 0.4% (peri- plus postoperative antibiotics). On univariate analysis, the following were associated with PMINF: nonuse of postoperative antibiotics (3.0% vs 0.4%, P < 0.001), year of implant (P < 0.001), repeat procedures (2.3% vs 1%, P = 0.006), nonuse of perioperative antibiotics (3.6% vs 1.3%, P = 0.027). With postoperative antibiotics, rates were significantly reduced in new implants (1/1,289 = 0.1% vs 22/967 = 2.3%, P < 0.001) and repeat procedures (7/692 = 1.0% vs 16/305 = 5.2%, P < 0.001). On multivariate analysis, the following were significant (standardized coefficients denote relative importance): postoperative antibiotics (0.776), repeat procedures (0.508), year of implant (0.142), perioperative antibiotics (0.088).

Conclusions: The PMINF rate is reduced significantly by perioperative antibiotics with a further significant reduction with postoperative antibiotics. However, the reduction in PMINF rate could be a result of changes in practice in the different time eras. This study suggests consideration of perioperative followed by postoperative antibiotics to minimize pacemaker infections.


The incidence of pacemaker-related infection (PMINF) has been reported between 0.13% and 12.6% in the literature.[1–8] Although the PMINF rate is quite low in most centers, it is never nil and remains a troublesome problem. Furthermore, the occurrence of PMINF necessitates the removal of the entire pacing system for effective management.[6] As such PMINF leads to significant clinical consequences for patients with an attendant risk of complications—including possible death—associated with the need for removal of pacing leads. Complications due to lead extraction have been reported as high as 9% in the literature, and the mortality rate for cardiac device infections as much as 3.7%.[9] In addition, the healthcare costs associated with the management of PMINF can be considerable.[10] In view of the consequences associated with PMINF, it is imperative to minimize their occurrence to the lowest rate possible. A review of the literature does not appear to provide definitive recommendations with regard to the need for the use of antibiotics in order to minimize PMINF. Many studies have advocated the use of one to two doses of perioperative antibiotics.[1–3,7,8,11–15] However, further antibiotic doses for an extended period remain controversial, with limited data in the literature with regard to efficacy.

This 19-year review of a single-center experience was conducted to investigate and elucidate factors associated with PMINF. It examined three eras of antibiotic use within this 19-year period: (1) pacemaker insertion without antibiotic prophylaxis; (2) two doses of intravenous perioperative antibiotics; (3) perioperative antibiotics in conjunction with a 4-day course of postoperative oral antibiotics.