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Risk factors and management of Nuss bar infections in 1717 patients over 25years

Published:November 09, 2015DOI:https://doi.org/10.1016/j.jpedsurg.2015.10.036

      Abstract

      Purpose

      An increase in postoperative infections after Nuss procedures led us to seek risks and review management. We report potential risk factors and make inferences for prevention of infections.

      Methods

      An IRB-approved retrospective chart review was used to evaluate demographic, clinical, surgical, and postoperative variables of patients operated on between 10/1/2005 and 6/30/2013. Those with postoperative infection were evaluated for infection characteristics, management, and outcomes with univariate analyses.

      Results

      Over this 8-year period (2005–2013), 3.5% (30) of 854 patients developed cellulitis or infection, significantly more than 1.5% (13) in our previous report of 863 patients, 1987–2005 (p = .007). The most frequent organism cultured was methicillin-sensitive Staphylococcus aureus. Patients who were given clindamycin preoperatively (5 of 26 patients) had higher infection rates than those who received cefazolin (25 of 828) (19% vs 3%, p < .001). Patients treated with a peri-incisional ON-Q (I-Flow, Kimberly-Clark, Irvine, CA) also had higher infection rates (8.3% vs 2.4%, p < .001). Of the 30 patients who developed an infection, eighteen (60%) with cellulitis or superficial infections did not require surgical treatment or early bar removal. The other twelve patients (40%) with deep hardware infections required an average of 2.2 operations (range 1–6), with 3 (25%) requiring removal of their stabilizer and 3 (25%) requiring early bar removal. None of these three patients experienced recurrence of pectus excavatum at 2 to 4 years of follow-up.

      Conclusion

      Preoperative antibiotic selection and use of ON-Q's may influence infection rates after Nuss repair. Nuss bars could be preserved in 90% of all patients with an infection and even 75% of those with a deep hardware infection. Attempts to retain the bar when an infection occurs may help prevent pectus excavatum recurrence.
      Level of Evidence = III.

      Key words

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      References

        • Nuss D.
        • Kelly Jr., R.E.
        • Croitoru D.P.
        • et al.
        A 10-year review of a minimally invasive technique for the correction of pectus excavatum.
        J Pediatr Surg. 1998; 33: 545-552
        • Fonkalsrud E.W.
        Current management of pectus excavatum.
        World J Surg. 2003; 27: 502-508
        • Kelly R.E.
        • Shamberger R.C.
        • Mellins R.B.
        • et al.
        Prospective multicenter study of surgical correction of pectus excavatum: design, perioperative complications, pain, and baseline pulmonary function facilitated by internet-based data collection.
        J Am Coll Surg. 2007; 205: 205-216
        • Ortega G.
        • Rhee D.S.
        • Papandria D.J.
        • et al.
        An evaluation of surgical site infections by wound classification system using the ACS-NSQIP.
        J Surg Res. 2012; 174 ([Epub 2011 Jun 24]): 33-38https://doi.org/10.1016/j.jss.2011.05.056
        • Tanaka K.
        • Kuwashima N.
        • Ashizuka S.
        • et al.
        Risk factors of infections of implanted device after the Nuss procedure.
        Pediatr Surg Int. 2012; 28: 873-876
        • Rightmire E.
        • Zurakowski D.
        • Vrahas M.
        Acute infections after fracture repair: management with hardware in place.
        Clin Orthop Relat Res. 2008; 466: 466-472
        • Van Renterghem K.M.
        • Von Bismarck S.
        • Bax N.M.A.
        • et al.
        Should an infected Nuss bar be removed?.
        J Pediatr Surg. 2005; 40: 670-673
        • Shin S.
        • Goretsky M.J.
        • Kelly Jr., R.E.
        • et al.
        Infectious complications after the Nuss repair in a series of 863 patients.
        J Pediatr Surg. 2007; 42: 87-92
        • Calkins C.M.
        • Shew S.B.
        • Sharp R.J.
        • et al.
        Management of postoperative infections after the minimally invasive pectus excavatum repair.
        J Pediatr Surg. 2005; 40: 1004-1008
        • Wheeless III, Clifford R.
        Wheeless' textbook of orthopaedics.
        (online reference)
      1. Lincosamides, oxazolidinones, and streptogramins.
        Merck manual of diagnosis and therapy. Merck & Co., 2005
        • Campangna J.D.
        • Bond M.C.
        • Schabelman E.
        • et al.
        The use of cephalosporins in penicillin-allergic patients: a literature review.
        J Emerg Med. 2012; 42: 612-620
        • Pichichero M.E.
        Cephalosporins can be prescribed safely for penicillin-allergic patients.
        J Fam Pract. 2006; 55: 106-112
        • American Society of Health-System Pharmacists ASHP
        Therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists.
        Am J Health Syst Pharm. 1999; 56: 1839-1888
        • American Academy of Orthopedic Surgeons
        Information statement, recommendations for the use of intravenous antibiotic prophylaxis in primary total joint arthroplasty.
        2014
        • Fry D.E.
        Surgical site infections and the Surgical Care Improvement Project (SCIP): evolution of national quality measures.
        Surg Infect. 2008; 9: 579-584
        • Johnson A.J.
        • Daley J.A.
        • Zywiel M.G.
        • et al.
        Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty.
        J Arthroplasty. 2010; 25: 98-102
        • Kapadia B.H.
        • Johnson A.J.
        • Daley J.A.
        • et al.
        Pre-admission cutaneous chlorhexidine preparation reduces surgical site infections in total hip arthroplasty.
        J Arthroplasty. 2013; 28: 490-493
        • Sacco Casamassima M.G.
        • Goldstein S.D.
        • Salazar J.H.
        • et al.
        Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience.
        J Pediatr Surg. 2014; 49: 575-582
        • Lee I.
        • Agarwal R.K.
        • Lee B.Y.
        • et al.
        Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection.
        Infect Control Hosp Epidemiol. 2010; 21https://doi.org/10.1086/657134
        • Dumville J.C.
        • McFarlane E.
        • Edwards P.
        • et al.
        Preoperative skin antiseptics for preventing surgical wound infections after clean surgery.
        Cochrane Database Syst Rev. 2013; 3: 1-59
        • Sesia S.B.
        • Haecker F.M.
        • Shah B.
        • et al.
        Development of metal allergy after Nuss procedure for repair of pectus excavatum despite preoperative negative skin test.
        J Pediatr Case Rep I. 2013; : 152-155
        • Shah B.
        • Cohee A.
        • Deyerle A.
        • et al.
        High rates of metal allergy amongst Nuss procedure patients dictate broader pre-operative testing.
        J Pediatr Surg. 2014; 49: 451-454
        • Zheng Z.
        • Stewart P.S.
        Penetration of rifampin through Staphlococcus epidermidis biofilms.
        Antimicrob Agents Chemother. 2002; 46: 900-903