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Am Fam Physician. 1998;58(6):1449-1450

Infection is a serious, potentially fatal complication after permanent pacemaker implantation. Because septicemia and endocarditis have been described in patients receiving permanent pacemakers, many physicians routinely prescribe antibiotic prophylaxis at the time of implantation to prevent infectious complications. At present, however, no evidence shows that this strategy is beneficial. To elucidate the effectiveness of antibiotic prophylaxis in reducing infection rates, Da Costa and associates performed a meta-analysis of all available randomized trials.

A total of seven trials met the inclusion criteria; these studies represented the only pertinent data available on antibiotic prophylaxis at the time of pacemaker implantation. A total of 2,023 patients with established permanent pacemaker implantation were included in the studies. Of these patients, 1,011 received systemic antibiotic prophylaxis, and 1,012 did not. There was no difference in the proportion of patients with preexisting disorders likely to predispose them to infection, such as diabetes, malignancy or recent surgery. All procedures were performed in the operating room, and the skin was assiduously disinfected before surgery. In two of the studies, end-point events were a repeat operation for complications from infection, a repeat operation because of signs of inflammation around the pacemaker pocket, fever or septicemia, and abscess or the presence of pus in the generator pocket. Follow-up duration ranged from one month to four years. The delay to infection ranged from five to 356 days.

The incidence of end-point events in the control groups ranged from zero to 12 percent. The meta-analysis suggested a consistent protective effect of antibiotic pretreatment. Antibiotic administration at the time of pacemaker insertion significantly reduced the risk of pacemaker infection. Most commonly, wound infection, inflammation and skin erosion were reduced or prevented. There is some remaining uncertainty about whether antibiotics prevent septicemia or endocarditis. The recommendation that the risk of infection is best reduced when antibiotics were administered two hours before insertion was followed by six of the seven studies included in the meta-analysis.

The authors conclude that systemic antibiotic prophylaxis administered at the time of pacemaker insertion significantly reduces the incidence of infectious complications. In addition to reducing complications, antibiotic prophylaxis can provide cost savings. Results of this meta-analysis support the use of prophylactic antibiotics at the time of pacemaker insertion to prevent short-term pocket infections, skin erosion or septicemia. Their efficacy with regard to late septicemia or endocarditis is unknown.

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