A survey of antibiotic envelope use during insertion of cardiovascular implantable electronic devices among implanters from the United Kingdom

Cardiac implantable electronic device (CIED)-related infections are associated with significant morbidity and mortality, posing substantial burden to healthcare systems. Absorbable antibiotic envelopes have emerged as a proposed solution to reduce infection risk in selected patients undergoing device procedures.

A survey devised by a focus group of CIED implanters was sent to 500 implanting physicians across 159 sites in the United Kingdom, identified from the NICOR (National Institute for Cardiovascular Outcomes Research) Database. Responses were received from 117 participants (79% of whom were consultant cardiologists).

The TYRX absorbable antibiotic envelope was most commonly used for device upgrades, compared to de novo pacemakers, CRT-P/CRT-D implants, and generator replacements. A limited number (13%) of respondents utilised the PADIT score to guide their use of TYRX whilst 31% of respondents were unaware of the score. Several risk factors (early pocket re-intervention previous device infection and procedural duration) were reported as the most important factors in consideration of TYRX use however these are not included in the PADIT score. Key barriers to adoption included cost-effectiveness and lack of compelling clinical data and guidelines. Technical concerns were reported by 27% of respondents; translating into reduced utilisation in clinical practice (on average, these respondents had ~20% lower TYRX utilisation.

This survey provides a snapshot of antibiotic envelope utilisation across device implanters in the United Kingdom. The PADIT score does not reflect the key decision-making factors reported by our surveyed cohort. There remains significant variation in patient selection and practical techniques as well as uncertainty surrounding the clinical evidence and cost-effectiveness of the TYRX envelope.