Risk Factors and Treatment of Pectus Bar Infections

Risk Factors and Treatment of Pectus Bar Infections

Risk Factors and Treatment of
Pectus Bar Infections
Robert J. Obermeyer, M.D., FACS, FAAP
Assistant Professor of Clinical Surgery
Children’s Hospital of The King’s Daughters
Norfolk, Virginia
Goals
1.
2.
3.
Review the expected incidence of pectus bar
infections and bar preservation rate after an infection
Identify variables that may influence the incidence
of pectus bar infections
Highlight a proposed infection prevention and
infection treatment bundle for pectus bar infections
Disclosures

Consultant, Zimmer Biomet
References
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Nuss D, Kelly Jr RE, Croitoru DP, et al. A 10-year review of a minimally invasive
technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-52.
Fonkalsrud EW. Current management of pectus excavatum. World J Surg 2003; 27(5):502-8.
Kelly RE, Shamberger RC, Mellins RB. 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 Amer Coll Surg
2007;205(2):205-216.
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.
Calkins CM, Shew SB, Sharp RJ, Ostlie DJ, et al. Management of postoperative infections
after the minimally invasive pectus excavatum repair. J Pediatr Surg. 2005;40(6).
Van Renterghem KM, Von Bismarck S, Bax NMA, Fleer An, Hollwarth ME. Should an
infected Nuss bar be removed? J Pediatr Surg. 2005;40:670-673.
Sesia SB, Haecker FM, Shah B, Goretsky MJ, et al. J Ped Surg Case Reports I. 2013;152-155.
Shin S, Goretsky MJ, Kelly RE Jr, Gustin T, Nuss D. Infectious complications after the
Nuss repair in a series of 863 patients. J Pediatr Surg. 2007;42;87-92.
Risk Factors and Management of Nuss Bar Infections
in 1717 Patients Over 25 Years
Robert J. Obermeyer, MD1,2, Erin Godbout2, Michael J. Goretsky, MD1,2,
James F. Paulson, Ph.D. 3, Frazier W. Frantz, MD1,2, M. Ann Kuhn, MD1,2,
Michele L. Lombardo, MD1,2, E. Stephen Buescher, MD1,2,
Ashley Deyerle1, Robert E. Kelly Jr., MD
Journal of Pediatric Surgery 51 (2016) 154-158
Study Design
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Retrospective chart review
– IRB #14-03-WC-0034/EVMS
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Outcomes evaluated
–
–
–
–
–
Incidence of Infection
Infection Characteristics
Potential Risk Factors
Management
Bar Preservation Rate
Background
Perceived increased incidence of infections
 Common inquiry regarding management

Comparative Data
Incidence of Bar Infections
Author
Year
Incidence
Van
Renterghem
2005
6.9%
Calkins
2005
3.6%
Shin*
2007
1.5%
St Peter
Tanaka
2010
2012
4.2%
5.6%
*CHKD Early Experience
18 years
(1/1987-9/2005)
Results
Incidence of Bar Infections*
Time Period
No. Patients
Infection Incidence
18 years
13/863
1.5%
8 years
30/854
3.5%
3/237
1.3%
(1/1987-9/2005)
(10/2005-6/2013)
2.5 years
(7/2013-12/2015)
p=.01
p=.07
*Includes cases treated with antibiotics for cellulitis, superficial draining
infection or deep infection regardless of the time of presentation
Results
Infection Characteristics
Time Period
18 years
(1/1987-9/2005)
10 years
(10/2005-12/2015)
TOTALS
Superficial
Deep
Infection Infection
Total
Infections
Cellulitis
13
31%
23%
46%
33
24%
30%
45%
46
26%
28%
46%
Results
2005-2015
Incidence of Infection vs. Potential Risk Factors
Variable
Not Used
Used
p
Preop CHG Cloths
3.8%
1.6%
.025
Variable
Betadine
CHG/IPA
p
Skin Prep
3.7%
1.3%
.045
Variable
<72hr
>72hr
p
Postop Antibiotic
Duration
3.2%
2.7%
.656
Results
2005-2015
Incidence of Infection vs. Potential Risk Factors
Variable
Clindamycin
Cefazolin
p
Preop
Antibiotic
20%
2.5%
<0.001
Variable
Used
Not Used
p
Peri-Incisional
On-Q
Catheters
8.3%
2.1%
<0.001
Infection Prevention Bundle

Preoperative Precautions
– Metal allergy skin testing
– CHG/Alcohol skin wipes day before and day of
surgery
Infection Prevention Bundle
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Intraoperative Precautions
– CHG/Alcohol skin preparation
– Cefazolin IV (30mg/kg up to 2000mg)
– Antibiotic within 30 min of incision and repeat q4
hours
– Penicillin allergic patients (non-anaphylactic): test
dose cefazolin in OR
– NOTE: one of the new deep bar infections occurred
in a patient that received clindamycin
Infection Prevention Bundle
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Operative Precautions
–
–
–
–
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Sterile technique
Double glove
Three layered wound closure
Avoid use of ON-Q catheters near incision
Postoperative Precautions
– Continue IV antibiotics for up to 48 hrs
Infection Treatment
Cellulitis
 Superficial Infection
 Deep Wound Infection

Management
Cellulitis or Superficial Infections
2005-2013
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
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IV antibiotics (56%)
– 15.5 days (2 - 60)
– PICC Line (28%)
– Clindamycin, Cefazolin
PO antibiotics (100%)
– 10 days -> 1 year
No surgical treatment in operating room
Management
Deep Infections
2005-2013
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IV Antibiotics (100%)
– 24 days (1 – 88)
– PICC Line (50%)
Surgical Treatment
– Average # operations = 2.2 (range 1 - 6)
– Early stabilizer removal only = 3
– Early bar removal = 3
Operative Management
•Remove suture
•Irrigate
•Debridement
•Wet-to-Dry
•Wound VAC
•Layered Closure
Results
2005-2015
BarPreservationwithDeepInfections
Deep
Infections
Bar
Preservation
Early Bar
Removals
(months)
Recurrent
Pectus
18 years
6
3 (50%)
3, 18, 18
1
10 years
15
12 (80%)
4, 6, 19
0
Time Period
(1/1987-9/2005)
(10/2005-12/2015)
Results
2005-2015
BarPreservationwithDeepInfections
Author
Year
Calkins
2005
Removed/Deep
Infections
1/5
VanRenterghem
Shin
Tanaka
2005
2007
2012
3/6
3/6
3/4
50%
50%
25%
Obermeyer*
2015
3/15
80%
Preserved
80%
*Unpublished Data
Pectus Bar Infection Treatment
Bundle
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Controlling gross infection
–
–
–
–
–
Drain purulence and culture
Irrigate – consider pulse antibiotic irrigation
Debridement
Remove all non-absorbable suture in field
If gross pus, pack wet-to-dry and irrigate in
operating room daily
Pectus Bar Infection Treatment
Bundle

Gross Infection Controlled
– If wound clean but cannot be closed consider
wound vac type dressing and change every 2-3 days
– If wound clean and can be closed attempt layered
closure with nylon skin suture
Pectus Bar Infection Treatment
Bundle

Antibiotic Therapy
–
–
–
–
–
Initial IV antibiotics 1-2 weeks
Consider PICC line
Modify antibiotics per culture results
Consider repeating skin allergy testing if not improving
Home antibiotics PO clindamycin and rifampin

(CBC & LFT q3 wks)
– After 1-2 months if CBC, ESR, and CRP normal then stop
clindamycin and rifampin
– Consider long-term trimethoprim-sulfamethoxazole
Conclusions
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Infection Prevention
Clindamycin may be an inferior preoperative
antibiotic choice
Peri-incisional ON-Q’s may increase infection rates
Preop and Intraop CHG may decrease infection rates
Infection rates are not decreased by continuing
antibiotics beyond 48 hours
Conclusions
Infection Treatment
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Cellulitis and Superficial infections are unlikely to
necessitate bar removal
Deep infections require aggressive medical and
surgical treatment. Bar preservation is possible with
deep infections in up to 80% of cases.
Attempts to retain the pectus bar help prevent pectus
excavatum recurrence but early removal does not
always result in recurrence
Thank You