Conversations in Cardiology: Do You Use Antibiotics in the Cath Lab?

Morton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.
 

Kern asks:

I received a query from an East Coast cath lab director that his lab is 99% radial first, but one operator is 100% femoral and uses preprocedural antibiotics for his vascular closure device (VCD) placements. A recent anaphylactic reaction prompted this question. I have not seen any data on this issue for the cath lab.

For the group, does anyone in your lab routinely use antibiotics for VCD? I emphasize routinely as some circumstances may warrant antibiotics (eg, emergent access in semi-sterile setting, contamination during a procedure, etc).

I am assuming all will say no to the routine use of antibiotics. Let's see.

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Steven R. Bailey, MD (LSU Shreveport School of Medicine, LA), replies:

We do not routinely use antibiotics.

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George Vetrovec, MD (VCU Pauley Heart Center, Richmond, VA), replies:

I am not aware of routine use. 

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Navin K. Kapur, MD (Tufts Medical Center, Boston, MA), replies:

We do not use antibiotics routinely. How about among post-cardiac transplant or immunosuppressed patients? Are folks using VCDs if groin access is required? And if so, do you use antibiotics then?

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Kirk Garratt, MD, MSc (ChristianaCare, Newark, DE), replies:

I’m not aware of evidence that routine antibiotics provide any benefit. They’re used only if there’s a breach in the sterile field or in the occasional high-risk patient (long procedure with catheters indwelling, diabetic, or immunocompromised, etc).

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David Rizik, MD (HonorHealth Heart Group, Scottsdale, AZ), replies:

Not aware of any data supporting its use.

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David Cohen, MD (St. Francis Hospital, Roslyn, NY), replies:

I remember some discussion of this in the past, but have to say that I have never considered use of prophylactic antibiotics for VCD on a routine basis. That said, even one bad closure device infection will definitely stick with you for a long time and may have colored this individual's practice.

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Vetrovec replies:

Having had a patient with a bad groin infection in the early days of closure devices, I can affirm David's comment about the memory staying with you for a long time!!

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Robert J. Applegate, MD (Wake Forest School of Medicine, Winston-Salem, NC), replies:

I guess I’m the odd man out. Although our lab does not use antibiotics routinely for VCDs, I do. My rationale is that our EP colleagues continue to use them, and have in fact intensified the duration in the past few years after device placement. Certainly not data driven, but that’s what I do.

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Zoltan Turi, MD (Hackensack University Medical Center, NJ), replies:

Can’t justify routine use for everybody due to lack of an evidence base, but I can attest from observations in many labs that it is done more commonly than you might think. Worst of all worlds: antibiotics given during or immediately after device deployment, since there is a pretty strong evidence base that in situations when it might be justifiable giving antibiotics, at least 1 hour before would be required to have sufficient tissue levels to be effective (Classen DC N Engl J Med 1992). The event rate is low—perhaps 0.25%—but with a 6% mortality (Sohail MR Mayo Clin Proc 2005). Cases you have seen do stay with you forever. Morbidly obese patients with diabetes, immune suppressed, etc, need really compulsive groin care at the least, obviously (with or without VCD use), and lacking an evidence base it’s hard to criticize.

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Jeffrey Moses, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), replies:

Nope, no antibiotics. Except in suspected sterility breach.

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Timothy Henry, MD (The Christ Hospital, Cincinnati, OH), replies:

I don’t remember EVER using antibiotics for a VCD….

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Cohen replies:

On the other hand, I'm old enough to remember the early days of stenting when we gave prophylactic antibiotics for every stent....

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Applegate replies:

Mort. Just to broaden this a bit, is anyone routinely using antibiotics for TAVR?

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Cohen replies:

Every TAVR case. MitraClip, too.

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Rizik replies:

Yes, for TAVR.

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Ramon Quesada, MD (Miami Cardiac & Vascular Institute/Baptist Health South Florida), replies:

We don’t use antibiotics for routine VCD, except for TAVR, TMVR, etc.

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Bailey replies:

Agree regarding implanted devices, but antibiotics are for the device (TAVR/TEER etc) not for the vascular closure device.

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Michael Ragosta, MD (UVA Health, Charlottesville, VA), replies:

Yes, we are using routine antibiotics for TAVR.

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William Fearon, MD (Stanford University, CA), replies:

We used to not use VCDs in our posttransplant patients for that reason, but over the past 5 years have been using them without antibiotics and without issue. We do use prophylactic antibiotics in all of our TAVR procedures.

PS: We have a cohort of femoral cases because of the desire to avoid radial cocktail for endothelial function testing that’s being done as part of a study protocol.

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William Suh, MD (Riverside Medical Clinic, CA), replies:

For those of you on Twitter, I created a poll for this question. =)

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Barry Uretsky, MD (UAMS Medical Center, Little Rock, AR), replies:

We do not use antibiotics with VCDs. We reclean the area, use new gloves, and deploy.

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Rajiv Gulati, MD, PhD (Mayo Clinic, Rochester, MN), replies:

Not routine in our lab with VCDs.

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James Blankenship, MD (Geisinger Medical Center, Danville, PA), replies:

Hari Naidu’s 2021 SCAI cath lab best practices document opined: “Antibiotic prophylaxis is not indicated for routine coronary procedures, but is often used before permanent implantations other than coronary stents and, at some institutions, before vascular closure device (VCD) placement in high-risk subsets, such as immunocompromised individuals or those with diabetes.”

A patient of mine 20 years ago got an infected Angio-Seal plug then had two surgeries to clean it out, and they said if a third surgery was needed they would have to disarticulate the leg at the hip. Fortunately that wasn’t needed, but it sure did scare me. As others do, I re-prep, re-glove, re-drape, and for diabetics or immunocompromised patients or breached sterility situations, I give cefazolin or vancomycin.

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Stephen Ramee, MD (Ochsner Medical Center, New Orleans, LA), replies:

We don't have a policy. But after several serious femoral closure device infections in the 1990s from Perclose and Angio-Seal, I have chosen to use prophylactic antibiotics in my patients. We have a high incidence of high-risk patients with obesity, diabetes, and immune compromise in our patient population. I have no data to support using them in everyone, but I also have not seen any infections since doing so.

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Matthew J. Price, MD (Scripps Clinic, La Jolla, CA), replies:

I use antibiotics if VCD. I saw an infection once, and as others have noted, that has colored my practice. 😊

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Mauricio G. Cohen, MD (University of Miami Hospital, FL), replies:

Following a bad and scarring experience, I use antibiotics for Perclose only because it is a permanent suture, even though it is monofilament and supposed to be less likely to be infected. Timing is before the patient goes on the table, following the same principle mentioned by Zoltan Turi.

About 16 years ago, before I had converted to radial, a patient came back with a Perclose infection, even though I gave antibiotics (first-gen cephalosporin) after the procedure. At that time the Perclose instructions for use recommended antibiotics for diabetics and in patients with implantable prostheses (eg, hip replacement). Treating the infection was an ordeal and required several surgeries. The patient filed a complaint and requested compensation. We had a meeting with the hospital epidemiologists and others, and it was noted clearly that giving antibiotics after deploying the suture is useless and that it should be given 1 hour before the procedure. The hospital settled on my behalf, and I was never sued. This experience was one of the reasons I converted to radial. In current practice, I only use VCDs for large-access closure.

I hope this helps.

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Charanjit Rihal, MD (Mayo Clinic), replies:

No antibiotics, but I do rescrub/glove change. I put a dab of Betadine ointment in the track for good luck and have not seen an infection since 😊

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Alan Yeung, MD (Stanford University, CA), replies:

We have developed a policy through the years from large Perclose to ProGlide-ProStyle/Angio-Seal:

1. Transplant patients on immunosuppression: no closure device
2. Structural heart cases needing ProGlide: pretreat with antibiotics
3. Diagnostics: in a quick case using Angio-Seal without track dissection, no antibiotics. If case goes longer (eg, CABG with bilateral IMAs), prep stick and change gloves
4. PCI: prep stick and change gloves for Angio-Seal. If ProGlide is used with track dissection, encourage use of antibiotics (skin flora gain access more easily to blood vessels with track dissection, especially in the old days of large-bore Perclose).

So far (knock on wood), there have been no infections over last decade and a half or so.

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Lloyd Klein, MD (UCSF Medical Center, San Francisco, CA), replies:

I doubt anyone who has used Perclose often hasn’t at least one horrid experience. Prophylactic antibiotics given 1 hour before seem prudent. I don’t let the absence of a study dissuade me from that practice because, frankly, such procedural details usually don’t have double-blinded controlled trials. I wish we had such definitive studies for everything we do, but that isn’t realistic.

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Carl Tommaso, MD, replies:

I used to when reusing the same groin with collagen plug within 48 hours.

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Paul S. Teirstein, MD (Scripps Clinic), replies:

There seems to be an association between antibiotic use and age of the interventionalist. The older docs have had one bad experience, and one infection is enough to convert you to antibiotics.

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J. Stephen Jenkins, MD (Ochsner Medical Center), replies to Teirstein:

Does that mean if you are an old interventionist and you don’t use antibiotics for VCD (change gloves though) that you have dementia, as you have forgot previous bad outcomes? I was taught by mentors that short-term memory loss was the mark of a good interventionist !!

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Bonnie Weiner, MD (Saint Vincent Hospital, Worcester, MA), replies:

LOL. I guess that makes me demented or at least forgetful.

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Steven Goldberg, MD (Community Hospital of the Monterey Peninsula, CA), replies:

In addition to the conditions listed by Zoltan, I would propose antibiotics if an artery is being reaccessed within a couple of weeks, especially if there was a hematoma. That is a petri dish for an infection. And yes, this is based on personal experience (not my case, however). 

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Suh replies:

Here are the results of the Twitter poll as of September 22: 367 votes. 87.2% said no to prophylactic antibiotics.

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David Cohen replies:

Based on our email discussion, I was surprised to see how many people are using prophylactic antibiotics.

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Weiner replies:

I agree, David. I wonder if some were including use with other implants, since that may be the major volume of femoral procedures. Could be a confusing factor.

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Mauricio Cohen replies:

The problem is not all VCDs are created equal. A Mynx is extravascular and stays in for a little while. Perclose is a permanent vascular suture; therefore, the risk of infection is higher. 

Twitter polls are nice, but who knows what the respondents are or what experience they may have. As noted by Paul Teirstein in this email chain, more-experienced (older) interventionalists tend to use antibiotics. The Twitter crowd may be younger and possibly less experienced with femoral access and/or closure devices.

Just some thoughts.

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Suh replies:

Agree on all your points. I am actually surprised that more than 10% give prophylactic antibiotics. I thought it was going to be way lower.

Based on this email discussion, I will give more thought in possibly giving prophylactic antibiotics in patients at higher risk for VCD infection.

Twitter polls are in no way scientific but like observational studies can provide some useful insights into what the crowd is thinking. =)

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Gurpreet S. Sandhu, MD, PhD (Mayo Clinic), replies:

That is a pretty high number on the poll, but I wonder how many of these might have been for structural cases? We use antibiotics for TAVR etc, but no antibiotics for any closures after PCI. Most of our 5- to 7-French femoral sheaths are still removed using manual pressure.

As long as the skin prep has been good, the risk of infection is quite low. The only one that I can personally recall is after an Angio-Seal case about two decades ago, and this device likely got seeded from bacteremia from a nasopharyngeal abscess.

As others have mentioned, it’s probably best to avoid closure device use in immunocompromised/post-transplant patients. Besides the theoretically higher infection risk, they often require repeated access and there is definitely more scar tissue with foreign bodies.

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Mark A. Menegus, MD (Montefiore Medical Center—Einstein Division, Bronx, NY), replies:

You guys are the best! Thanks for this quick poll—much appreciated!!

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Mitchell W. Krucoff, MD (Duke University Medical Center, Durham, NC), replies:

Great example of responder bias, Dave… A community of users taking the time to connect with one another…

On behalf of the aging ones among us, while I don't have enough dementia yet to enjoy it, I do give antibiotics if I drool on the arteriotomy site.

Having a long COVID day today. I am typing this with a smile, not meant to offend anyone.

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Kreton Mavromatis, MD (Emory University School of Medicine, Atlanta VA Medical Center, GA), replies:

I too have been "scarred" by a VCD infection. It was MRSA in a very thin patient, so I will always make sure to access the artery with a long "subcutaneous tunnel" between skin surface and the actual arteriotomy, and to cut the sutures as deep into the tunnel as possible (on the arteriotomy) to reduce the chance that skin flora can later seed the sutures. This is in addition to new gloves and more ChloraPrep, but no antibiotics.

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Jonathan Tobis, MD (UCLA Health, Los Angeles, CA), replies:

On a slightly different topic, I've had three cases of bacteremia following a PFO closure after using ChloraPrep for the scrub instead of Betadine. No vascular devices were used. I know this is anecdotal, but individual cases can scare you and do affect our behavior, as clearly documented in this email chain. So I tell the techs to prep only with Betadine for my procedures from the groin.

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Richard F. Wright, MD (Pacific Heart Institute, Santa Monica, CA), replies:

Jon, I see that the latest “treatment” for COVID is to gargle with Betadine… Are you doing that, too?

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Neal Kleiman, MD (Houston Methodist Hospital, TX), replies:

We don’t, although we do routinely re-prep the groin when using a VCD—another wipe down with a ChloraPrep, fresh towels, device only touches down on the fresh drape.

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The Bottom Line From Mort Kern

The vast majority of interventionalists on this conversation, and in the Twitter poll, do not use antibiotics for VCD but do so for TAVR or other structural interventions. Of course, a breach of sterile technique in the setting of a foreign-body VCD or other device needs antibiotic treatment. PS: For the record, like bleach, Betadine does not treat COVID either (LOL).