Prevention of biofilm formation on artificial pacemakers: is it feasible?

Literature review, in order to answer the following question: “What antimicrobial agents are applied to prevent biofilm formation on artificial pacemakers?” The databases PubMed, Web of Science, Scopus, Science Direct, Cochrane, CINAHL, Embase, and LILACS were used in all languages and without time restriction.

Results:

The final sample consisted of five primary studies, mostly experimental laboratory ones. The investigations identified agents with promising potential for reduction or inhibition of biofilm formation on pacemakers. An association between physical-chemical agents and pharmacological antimicrobials was highlighted.

Conclusion:

Prevention of biofilm formation on pacemakers is feasible. Among the agents that stood out were rifampicin, AIGIS^®, aqueous neobactrim formulation, and a plasma coating using a combination of trimethylsilane and oxygen for coating deposition.

Keywords
Biofilms; Infection control; Artificial pacemaker; Cardiac implantable device; Infection

Reasons	Excluded (n= 44)
Involved only bacteria in planktonic form	10
Involved artificial devices other than artificial pacemakers	12
Involved biofilm on artificial pacemakers, but addressed treatment, not prevention	13
Review studies	6
Clinical case studies	2
Protocols	1

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[1] Corresponding author Álvaro Francisco Lopes de Sousa Av. dos Bandeirantes, 3900, 14040-902, Ribeirão Preto, SP, Brazil. alvarosousa@usp.br

Article ID
A1	A2	A3	A4	A5
Year
2010	2015	2010	2014	2011
Database
PubMed	PubMed	PubMed	Scopus	PubMed
Title
Time-dependent effects of rifampicin on Staphylococcal biofilms^1.1	Nanoscale plasma coating inhibits formation of Staphylococcus aureus biofilm.¹²12. Xu Y, Jones JE, Yu H, Yu Q, Christensen GD, et al. Nanoscale Plasma Coating Inhibits Formation of Staphylococcus aureus Biofilm. Antimicrob Agents Chemother. 2015;59(12):7308-15.	Efficacy of local rifampin minocycline delivery (AIGIS(RX)^® to eliminate biofilm formation on implanted pacing devices in a rabbi model.¹³13. Hansen LK, Berg K, Johnson D, Sanders M, Citron M. Efficacy of local rifampin/minocycline delivery (AIGIS(RX)® to eliminate biofilm formation on implanted pacing devices in a rabbit model. Int J Artif Organs. 2010;33(9):627-35.	Prevention of pacemaker infections with perioperative antimicrobia treatment: an in vitro study.⁸8. Marsch G, Mashaqi B, Burgwitz K, Bisdas T, Knigina L, Stiesch M, et al. Prevention of pacemaker infections with perioperative antimicrobial treatment: an in vitro study. Europace. 2014; 16(4):604-11.	Implantation success and infection in CIED procedures utilizing an antibacterial envelope.¹⁴14. Bloom HL, Constantin L, Dan D, Lurgio DB, El-Chami M, Ganz LI, et al. Implantation success and infection in cardiovascular implantable electronic device procedures utilizing an antibacterial envelope. Pacing Clin Electrophysiol. 2011; 34(2):133-42.
Aims
Evaluating the effect/time relationship of rifampicin (1.2 mg/mL) on Staphylococcus epidermidis biofilms in patients with contaminated cardiovascula devices.	To demonstrate the effect of oxygen + plasma coating monomeric trimethylsilane (TMS) on nanometer scale to inhibit the formation of S. aureus biofilms.	Determining the potential of AIGIS^® (polypropylene mesh envelope with bioreabsorbable polymer rifampin and minocycline) in reducing biofilm formation on pacemakers.	Evaluating, in vitro, a pretreatment with antiseptic agents (iodinated povidone and Octenidine + phenoxyethanol) and antibiotics (vancomycin, daptomycin cefuroxime, piperacillin + tazobactam, and neomycin) as prophylaxis for perioperative infection in implanted cardiac devices (artificial pacemakers).	Determining the potential of an antibacterial envelope (polypropylene mesh) for releasing minocycline and rifampin in the generator pocket after pacemaker implantation to prevent infections.
Research type
Experimental Laboratory.	Experimental Laboratory.	Experimental Laboratory.	Experimental Laboratory.	Retrospective Cohort Study.
Sample size
30 isolated patients.	Not specified.	Not specified.	96	624 patients
Bacteria belonging to biofilm
S. epidermidis	Staphylococcus aureus	Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus capitis e Escherichia coli	S. epidermidis, S. aureus, E. coli e Pseudomonas aeruginosa	Not applicable.
Analysis techniques employed
Electrophoresis pulsed-field gel.	Spectroscopy of x-ray excited photoelectrons.	Scanning Electron Microscopy and Confocal.	Scanning Electron Microscopy and Confocal.	Presence of infectious signs.
Main findings
1.2 mg/mL rifampicin reduces biofilm formation by S. epidermidis, although it does no present bactericidal activity.	The material showed inhibition of S. aureus biofilms on pacemaker surfaces (stainless steel and titanium). Through this technique protein absorption related to bacteria adhesion was significantly reduced, and consequently, biofilm formation. The results demonstrate that TMS coated with oxygen is a promising agent in the prevention o biofilm formation on artificial pacemakers.	Evidence from the research suggests that AIGIS® usage may prevent biofilm formation and reduce the microbial burden in cardiac devices.	Showed that a pretreatment of artificial pacemakers consisting of simply immersing them in aqueous solutions of antimicrobial agents significantly reduces bacteria adhesion on their surfaces Nebacetin was the most effective agent in terms of bacterial growth and cytotoxicity.	CIED implantation procedures using an antibacterial envelope had a high success rate (> 99%) with only three device-related infections.