Use of skin barrier to reduce cardiac device infection: a single center experience

BACKGROUND Cardiovascular implantable electronic devices (CIED) infection is associated with significant morbidity and devastating sequelae for the patients. The use of incremental perioperative antibiotics, as well as use of an antibiotic impregnated pouch to reduce periprocedural device infections have recently been investigated. Trials investigating these additive interventions have shown only modest benefit, in addition these interventions carry a high cost to the system. Cost of antibiotic pouches can be greater than $1000 per use and use of additive antibiotics in all comers was shown to be neutral in Canadian centers. We sought to determine the effect of skin barrier use at reducing the risk of CIED infection as a simple, low cost intervention at time of device implantation. METHODS AND RESULTS We conducted an audit of all CIED implant procedures completed between Jan 2007 and April 2020 by 17 experienced operators in a shared procedure practice model. All device infections requiring reoperation or extraction were collected prospectively and diagnosis reconfirmed by an infectious disease specialist. A skin barrier was used as per physician preference and operations were retrospectively evaluated for use of skin barrier. Antibiotic use and periprocedural care were consistent in all procedures as per institutional protocol. Over a 13-year period 14,607 procedures were completed (mean age 72 +/- 14 years, female 35%). A total of 7816 pacemakers, 3292 ICDs, 1482 CRTs, and 1635 device upgrade or lead revision procedures were performed. 3913 procedures were completed with skin barrier and 10693 without. There were 90 infections in the no barrier group vs. 19 infections in the barrier group (0.84% vs. 0.48%, p=0.02). After a sensitivity analysis adjusting for the number of procedures, procedure type (ILR, PPM, ICD, CRT, de novo vs. upgrade vs. revision vs. generator replacement), the difference remained statistically significant. CONCLUSION Our data suggests that skin barrier use may be protective against infection. Considering low cost of skin barrier and catastrophic sequelae of device infection, the use of skin barrier during the procedure may be considered as an additional preventative measure to reduce device related infection. The low rates of infection in the barrier group are likely due to operator experience, use of standardized guideline directed perioperative care, and likely reduction of skin flora translocation during the procedure. Re-evaluation after transition to use of skin barrier for all cases will help further confirm these findings.