Antimicrobial Stewardship in Cardiac Device Surgery: Impact of Behavioural Change Interventions on Extended Prophylaxis Practices

Background/Objectives: Single-dose pre-operative antibiotic prophylaxis for cardiac-device implantation is recommended but extending antibiotic prophylaxis is common. Locally, 50–60% of patients had extended prophylaxis after pacemaker insertion or generator change. Our antimicrobial stewardship program (ASP) incorporated behavioral change strategies in implementing a multi-pronged intervention bundle to address this and evaluated its effectiveness and safety. Methods: This single-centre, retrospective cohort study included patients aged 21 years old or older, undergoing uncomplicated pacemaker insertion or generator change at Singapore General Hospital (SGH) from October 2022 to March 2025. To improve antibiotic use, ASP interventions incorporating behavior change strategies were implemented, namely: (1) data-driven feedback, (2) targeted education, (3) identification and engagement of ASP champion, a (4) clinical pathway revision.Results: There were 779 patients evaluated; 380 (48.8%) received standard prophylaxis while 399 (51.2%) received extended prophylaxis with oral antibiotics (mean duration, 3.3 ± 0.8 days). Following ASP interventions, the practice of extended prophylaxis declined significantly from 43.8% to 24.0% (p < 0.01). The incidence of surgical site infections was low and similar in both groups (0.8%, p = 1.000); all infections were superficial. There was also significant reduction in proportion of patients on all antibiotics from 20.7% to 16.3% (p < 0.01). Identification and engagement of ASP champion proved pivotal in changing prescribing behavior through peer influence and credibility.Conclusions: The bundled ASP interventions, incorporating behavioral change strategies, have effectively and safely reduced the use of extended prophylaxis post cardiac device implantation. Behavioral change interventions are essential to achieve sustained stewardship success.