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December 2008
Vol. 18 No. 12
Patient Care and Science
EIN: Vancomycin for Pacer Prophylaxis?
Steve Baragona

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN's sponsor), or the Centers for Disease Control and Prevention, which funds the EIN. The reader assumes all risks in using this information.

An EIN member asked whether others were switching from cefazolin to vancomycin as pre-operative prophylaxis for pacemaker insertion due to high rates of methicillin-resistant Staphylococcus aureus (MRSA).

Several respondents said they do use vancomycin, and given the high rate of MRSA at the member’s institution, they recommend it. “The rationale comes from our experience with patients referred for extraction of infected devices,” said a member in Ohio. In those situations, methicillin-resistant coagulase-negative Staphylococcus is the most common isolate at that respondent’s institution.

“If you are having MRSA pacer pocket infections, that probably makes sense, and I would look into preoperative screening and possibly decolonization before placement,” said a respondent in Washington. “However, if overall infection rate is low and the infections are not MRSA, then changing does not make sense.” The respondent referred to a study that found no advantage in vancomycin over cefazolin for open heart surgery. (Finkelstein et al., J Thorac Cardiovasc Surg. 2002;123:326-32).

A respondent in Iowa had recently considered switching to vancomycin and ceftriaxone prophylaxis for pediatric cardiothoracic surgeries. “Since literature on this was very sparse, we reviewed five years of our infection prevention database for bloodstream and surgical-site infections for children undergoing heart surgery. Our data did not support such a move, so our surgeons continue to use cefazolin, including for pacemaker implants.”

"Let data drive the use,” said a respondent in Kentucky. MRSA rates are high at this respondent’s two hospitals with active cardio departments, but between the two there has been only one pacemaker infection in 15 years. “We use cefazolin. Only 1.5 percent of pacer candidates are colonized [with MRSA] pre-operatively in our facilities. Each facility should look at their data and move appropriately.”

The respondent warned that the increase in vancomycin use for Clostridium difficile infection (CDI) and pre-operative prophylaxis may push up rates of vancomycin-resistant enterococci (VRE). “A look at our VRE colonization in those having received vanco for CDI is alarming,” the respondent said.

EIN members have previously discussed vancomycin prophylaxis for prosthetic joints. A searchable archive of EIN discussions can be viewed at: ein.idsociety.org/search/. (You must be logged in to use the search function.)


E-mail the Emerging Infections Network. 

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) and supported by funding from the Centers for Disease Control and Prevention, EIN tracks emerging infectious diseases and keeps the public-health community up to date with issues that are currently affecting or may soon affect members’ clinical practices.The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. The EIN listserve allows members to discuss new disease trends and difficult cases. Click here for more information or to join EIN.


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