Tailored antibiotic prophylaxis in patients undergoing CIED implantation: One size does not fit all the principle

I have read the article by Madadi et al.1 with a great interest. In this single-blinded controlled study, the authors randomized a total of 450 patients into three groups who underwent cardiovascular implantable electronic device (CIED) implantation, generator replacement, or upgrade as: (1) no antibiotic, (2) intravenous (iv) antibiotic (cefazolin) for 1 day, and (3) 1-day iv cefazolin + 7 days per oral antibiotic (ciprofloxacin) therapy. The rate of both early and late devicerelated infection rate was low and similar between groups and defibrillator implantation was found as the single predictor of CIED infection. As a result, they concluded that therewas no beneficiary effect of postprocedural antibiotic therapy on infection prevention. As CIED-related infections are related with an increased morbidity andmortality for patients and require therapies and interventionswith a higher cost than implantation, there are several preventivemeasures that should be considered during both index implantation, revision, replacement, or upgrade.2 In previous studies, several risk factors have been found to be associated with CIED infections including patient, procedure, and device characteristics. Although iv antibiotic prophylaxis andantimicrobial containing solution for pocket cleansing are recommended routinely at the time of CIED placement in expert consensus document, there was no routine recommendation regarding postprocedural antibiotic administration because of the inconsistent study results and scarce data.2 However, such a prophylaxis issue after CIED implantation should be managed like infective endocarditis prophylaxis. There should be a tailored antibiotic therapy after CIED implantation, replacement, or upgrade according to the presence of related risk factors. Imean thatone size antibiotic prophylaxis doesnot fit to all CIED implantationprocedures toprevent further infections. In the current study, the rate of anticoagulation therapy, particularly for novel oral anticoagulants, was too low and the periprocedural continuation or discontinuation has not been mentioned. As hematoma formation after CIED implantation or replacement was found to be associated withpreprocedural anticoagulationuse andmanagement strategyduring intervention and the hematoma formation was significantly associated with the occurrence of CIED infection,3 the authors may also comment on the incidence of pocket hematoma formation. Although the generator replacement procedure is accepted as a simple intervention for physicians in the field and performed by fellows most of the time, according to our experience, it should be performed by most experienced physicians asmost of the CIED infections occur after generator replacement. Thus, the experience of each operator should be mentioned appropriately as a predictor of CIED infections previously.3 Last, the patientswith impaired renal functions should be included and emphasized because of the immune compromised condition of these patients,whichwas also knownas a predictor of futureCIED infections appropriately.2 Finally, although the study by Madadi et al.1 as a randomized design highlights some parts more clearly, it should be interpreted carefully. It may be suggested that there should be a risk score in whom antibiotic prophylaxis should be given after CIED implantation, replacement, or upgrade. Otherwise, antibiotic prophylaxis after device implantation as a routine in all patients does not fit all groups!