Association of the Duration of Antibiotic Therapy With Major Surgical Site Infection in Cochlear Implantation

[Standardized risk-based antibiotic prophylaxis and adhesive film dressing for the prevention of wound infection following cochlear implantation]

BACKGROUND

There is no consensus in the pertinent literature regarding the optimal antibiotic prophylaxis (AP) for cochlear implantation (CI). This study evaluates the implementation of standardized risk-based AP combined with application of an adhesive film dressing.

MATERIALS AND METHODS

All CI cases since September 2019 were retrospectively reviewed for postoperative wound complications. While all patients received preoperative AP with ceftriaxone, postoperative AP after CI in patients older than 7 years was no longer routinely performed in our clinic. Exceptions were made according to predefined criteria for an increased risk of infection. The wound was covered with a transparent adhesive polyurethane film.

RESULTS

In 72% of the 219 cases, we did not perform postoperative AP. The overall wound complication rate was 2.7% (in the groups with and without postoperative AP, 4.9% and 1.9%, respectively). Wound infection did not occur in any of the patients without postoperative AP older than 70 years (n = 32), with controlled diabetes mellitus (n = 19), or with reimplantation due to technical defect (n = 19). The film did not need to be changed until the suture material was removed.

CONCLUSION

Standardized risk-based AP can avoid prolonged administration of antibiotics in selected patients. The film dressing permits continual examination and sufficient wound protection.

An overview of risk factors, management and prevention of cochlear implant infections

PURPOSE OF REVIEW

With cochlear implantation becoming increasingly performed worldwide, an understanding of the risk factors, preventive measures, and management of cochlear implant (CI) infection remains important given the significant morbidity and cost it conveys.

RECENT FINDINGS

At the turn of the 21st century there was a decrease in rates of CI infection, particularly meningitis, following the discontinuation of positioner use for CI. However, in more recent years rates of CI infection have remained largely static. Recently, studies evaluating preventive measures such as pneumococcal vaccination, S. aureus decolonization and surgical antibiotic prophylaxis have emerged in the literature.

SUMMARY

Prompt recognition of CI infection and appropriate investigation and management are key, however at present treatment is largely informed by cohort and case-control studies and expert opinion. Preventive measures including pneumococcal vaccination, S. aureus decolonization and preoperative antibiotic prophylaxis play a role in reducing rates of CI infection. However, there remains a need for well designed clinical trials to provide higher level evidence to better guide preventive measures for, and management decisions of, CI infections in the future.

Revision cochlear implant surgery in adults and children is a safe and effective technique: a retrospective single faculty study in Okayama University Hospital, Japan

BACKGROUND

Cochlear implant (CI) surgery is a safe surgical technique, although some patients require revision CI surgery.

AIMS/OBJECTIVES

This study investigated the cause and underlying reason of revision CI surgery as well as hearing outcomes in a single institution.

PATIENTS AND METHODS

This retrospective study evaluated patients who underwent CI surgery between April 2006 to March 2022 (n = 351). Sex, aetiology of hearing loss (HL), age and period from initial CI surgery to reimplantation, cause of revision, and related factors were examined.

RESULTS

Twelve patients (8 males, 4 females) received CI reimplantation. The revision surgery rate was 2.59% (3.15% children, 1.69% adults); the period from initial surgery to reoperation was 8.60 ± 6.56 years for 9 children with congenital HL and 15.27 ± 5.72 years for 3 adults with progressive HL. Device failure was the most common cause (n = 8), followed by infections (n = 2), advanced facial irritation symptoms (n = 1), and electrode slip-out (n = 1). Mean preoperative and postoperative CI thresholds were 44.0 ± 9.46 dBnHL and 39.19 ± 8.89 dBnHL (p < .068), respectively.

CONCLUSION AND SIGNIFICANCE

Caregiver education, surgical technique advances, flap design, and extensive antibiotic use may decrease the revision surgery rate. The lack of post-revision deterioration of the hearing threshold contributed to well-being in patients with CI.

The Risk of Meningitis After Cochlear Implantation: A Systematic Review and Meta-Analysis

OBJECTIVE

This study aims to estimate the rate of postoperative meningitis (both immediate and long-term) in patients following cochlear implants (CIs). It aims to do so through a systematic review and meta-analysis of published studies tracking complications after CIs.

DATA SOURCES

MEDLINE, Embase, and Cochrane Library.

REVIEW METHODS

This review was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies tracking complications following CIs in patients were included. Exclusion criteria included non-English language studies and case series reporting <10 patients. Bias risk was evaluated using the Newcastle-Ottawa Scale. Meta-analysis was performed through DerSimonian and Laird random-effects models.

RESULTS

A total of 116/1931 studies met the inclusion criteria and were included in the meta-analysis. Overall, there were 112 cases of meningitis in 58,940 patients after CIs. Meta-analysis estimated an overall rate of postoperative meningitis of 0.07% (95% confidence interval [CIs], 0.03%-0.1%; I2  = 55%). Subgroup meta-analysis showed this rate had 95% CIs crossing 0% in implanted patients who received the pneumococcal vaccine, antibiotic prophylaxis, those with postoperative acute otitis media (AOM), and those implanted less than 5 years.

CONCLUSION

Meningitis is a rare complication following CIs. Our estimated rates of meningitis after CIs appear lower than prior estimates based on epidemiological studies in the early 2000s. However, the rate still appears higher than the baseline rate in the general population. The risk was very low in implanted patients who received the pneumococcal vaccine, antibiotic prophylaxis, received unilateral or bilateral implantations, developed AOM, those implanted with a round window or cochleostomy techniques, and those under 5 years.

Predictors of Surgical Site Infection in Pediatric Cochlear Implantation

OBJECTIVE

To determine risk factors for surgical site infection (SSI) after cochlear implantation (CI) in pediatric patients.

STUDY DESIGN

Case-control study.

SETTING

A total of 150 hospitals contributing data to the ACS-NSQIP Pediatric database (American College of Surgeons National Surgical Quality Improvement Program) in North America and worldwide.

METHODS

Pediatric patients (aged <18 years) undergoing CI during the years 2012 to 2017 were identified in the ACS-NSQIP Pediatric database. Uni- and multivariable logistic regression analyses were used to determine the odds ratios (ORs) of SSI (including superficial incisional, deep incisional, organ/space) occurring up to 30 days postoperatively.

RESULTS

A total of 79 SSIs occurred over a 5-year period (n = 5146). Longer operative time significantly increased the odds of SSI (OR, 1.965; 95% CI, 1.205-3.289). Younger age was also found to raise the odds of SSI, with decreased odds associated with each 6-month increase in age (OR, 0.887; 95% CI, 0.814-0.958).

CONCLUSION

Longer operative time and younger age appear to significantly increase the odds of SSI in pediatric CI. Body mass index, recent steroid use, American Society of Anesthesiologists class, bilateral vs unilateral implantation, and hospital length of stay do not appear to significantly influence SSI risk. These findings must be interpreted in the context of the limitations inherent to adverse events reporting, which are mitigated by the stringent manner of data collection by the ACS-NSQIP, and those inherent to the definition of SSI. Future prospective studies should investigate the impact of reducing operative time on the risk of SSI and other complications in pediatric CI.

Comparison of Adult and Pediatric Cochlear Implant Wound Complications: A Meta-Analysis

OBJECTIVE

To compare age-related differences in wound complications following cochlear implantation (CI).

METHODS

We performed a systematic review of PubMed, Cochrane Database, and Web of Science databases to identify original research evaluating the patient-level factors (demographics and medical history) associated with wound complications following CI. Outcomes were expressed as relative risk (RR) with 95% confidence intervals using the inverse variance method. Studies without comparison groups were described qualitatively.

RESULTS

Thirty-eight studies representing 21,838 cochlear implantations were included. The rate of wound complications ranges from 0% to 22%. Patient age (adult versus pediatric) was the only factor with comparison groups appropriate for meta-analysis. The 10 studies (n = 9547 CI's) included in the meta-analysis demonstrated that adults had a higher incidence of overall wound complications (2.94%) than in children (2.44%) (RR 1.31, 95% CI 1.01-1.69). Adults had a higher incidence of general/unclassified wound complications (2.07%) than in children (1.34%) (RR 1.68, 95% CI 1.12-2.52). There was no difference between adults and children for specific complications such as hematoma, infection, or seroma. Elderly patients (over age 75) have wound complication rates that range from 1% to 4%. No studies contained comparison groups regarding other patient-level factors and CI wound complications.

CONCLUSION

CI wound complication rates reported in the literature are low; however, adults have a higher risk of these complications than pediatric patients. The reported complication rate in elderly adults is low. There is a gap in CI research in consistently reporting wound complications and rigorous research investigating the impact of patient-level factors and wound complications.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:218-226, 2023.

Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery

Importance

Use of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized.

Objective

To evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery.

Design, Setting, and Participants

This is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons' Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (<18 years of age) undergoing nonemergent surgical procedures. Exclusion criteria included antibiotic allergies, conditions associated with impaired immune function, and preexisting infections requiring intravenous antibiotics at time of surgery.

Exposures

Continuation of antimicrobial prophylaxis beyond time of incision closure.

Main Outcomes and Measures

Thirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures.

Results

Forty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = -0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85).

Conclusions and Relevance

Use of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

Duration of Antibiotic Prophylaxis for Cochlear Implantation: A Systematic Review

Antibiotic prophylaxis is commonly given to all patients undergoing cochlear implant surgery. However, currently, there is no consensus if pro- phylactic usage of antibiotics in cochlear implantation accords any benefit and if the duration of such use varies according to the surgeon's experience or institutional preference. A systematic review was conducted to gather evidence on ideal duration for antibiotic prophylaxis rec- ommended for patients undergoing cochlear implantation. We registered the protocol in the International Prospective Register of Systematic Reviews (CRD42021235079) and reported the systematic review following the Preferred Reporting Items for Systematic Reviews and Meta- Analysis statement. Of the 278 screened articles, 6 full-text original articles satisfied the inclusion criteria and were included. There were a total of 2081 participants in these 6 retrospective studies and all studies except 1 included both adult and pediatric populations. Antibiotic therapy was given as intervention, either as single dose or multiple doses, and compared with other group(s) receiving either no antibiotic prophylaxis or a different duration of prophylaxis. Three studies did not find any significant difference between infection rates when a different duration of antibiotic prophylaxis was given, while 2 studies found a single dose to be more efficacious, and yet another study concluded that a longer dura- tion of antibiotic prophylaxis was more beneficial. Based on the available data, the ideal duration of post-operative antibiotic therapy to be given after cochlear implant surgery could not be defined. However, administrating a single dose of intraoperative antibiotic seems to be the most consistent practice so far.

Antimicrobial Prophylaxis in Neonates and Children Undergoing Dental, Maxillo-Facial or Ear-Nose-Throat (ENT) Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication in surgical procedures, mainly because clean/contaminated surgery involves organs that are normally colonized by bacteria. Dental, maxillo-facial and ear-nose-throat (ENT) surgeries are among those that carry a risk of SSIs because the mouth and the first respiratory tracts are normally colonized by a bacterial flora. The aim of this consensus document was to provide clinicians with recommendations on surgical antimicrobial prophylaxis in neonates (<28 days of chronological age) and pediatric patients (within the age range of 29 days−18 years) undergoing dental, maxillo-facial or ENT surgical procedures. These included: (1) dental surgery; (2) maxilla-facial surgery following trauma with fracture; (3) temporo-mandibular surgery; (4) cleft palate and cleft lip repair; (5) ear surgery; (6) endoscopic paranasal cavity surgery and septoplasty; (7) clean head and neck surgery; (8) clean/contaminated head and neck surgery and (9) tonsillectomy and adenoidectomy. Due to the lack of pediatric data for the majority of dental, maxillo-facial and ENT surgeries and the fact that the recommendations for adults are currently used, there is a need for ad hoc studies to be rapidly planned for the most deficient areas. This seems even more urgent for interventions such as those involving the first airways since the different composition of the respiratory microbiota in children compared to adults implies the possibility that surgical antibiotic prophylaxis schemes that are ideal for adults may not be equally effective in children.

Infectious Complications Following Cochlear Implant: Risk Factors, Natural History, and Management Patterns

OBJECTIVE

To describe the natural history, detail the treatment patterns, and identify the risk factors for cochlear implant (CI) infections in a large US cohort.

STUDY DESIGN

Retrospective study based on insurance claims.

SETTING

Optum Data Mart database: 6101 patients who received CIs from 2003 to 2019.

METHODS

Infections, treatments patterns, and timelines were described. A multivariable logistic regression model was used to assess the association between postoperative oral antibiotics and CI infection.

RESULTS

The cohort includes 4736 (77.6%) adults and 1365 (22.4%) children. Between adult and pediatric patients, rates of CI infection (5.1% vs 4.5%, P = .18) and explantation (1.2% vs 0.8%, P = .11) were not significantly different. Infections typically occurred within 5 months of surgery. Children were diagnosed with CI infection earlier than adults (median difference, -1.5 months; P = .001). Postoperative oral antibiotic supply was not associated with lower risk of CI infection in either children or adults. However, among adults, otitis media was associated with higher odds of CI infection (odds ratio, 1.41; P < .001), while higher income was associated with lower odds of CI infection (odds ratio, 0.71; P = .03).

CONCLUSIONS

Postoperative oral antibiotics were not associated with lower risk of infection or interventions. Otitis media episodes and lower income were associated with increased risk of infection among adults as well as intervention overall. Infection typically presented within the first 6 months after surgery, with children presenting earlier than adults. Overall, our findings serve as a resource for providers to consider in their care of patients with CIs.

Impact of preoperative antibiotic use in preventing complications of cochlear implantation surgery

OBJECTIVE

To examine the impact of preoperative antibiotic prophylaxis on the occurrence of postoperative complications.

MATERIALS AND METHODS

Data of 491 patients undergoing cochlear implantation were included in a non-randomized retrospective comparative cohort study. Demographic data, cochlear implant and surgical details, use of preoperative antibiotics and occurrence of postoperative complications were analyzed using a binary logistic regression model.

RESULTS

There were 317 patients (64.56%) who did not receive preoperative antibiotic prophylaxis and 174 (35.44%) patients who received preoperative antibiotic prophylaxis with ceftriaxone. The overall rate of complications requiring surgical treatment was 2.85%. Younger patient age was identified as a positive predictive factor for administering preoperative antibiotic prophylaxis (p<0.001, OR 1.05 CI 95% 1.0124-1.0826). No difference in complication rate was observed between the two groups. No correlation between sex, age, manufacturer, surgeon and postoperative complications were noted (p=0.45).

CONCLUSION

There is insufficient evidence to inform decision making regarding preoperative intravenous ceftriaxone use for prevention of infection after cochlear implantation surgery, with data failing to show that administration of preoperative antibiotics leads to a decrease in complication rate. Considering a very low overall complication rate, with few complications related to infection, routine use of preoperative antibiotic prophylaxis should be analyzed further.

Surgical Factors Influencing Wound Complication After Cochlear Implantation: A Systematic Review and Meta-Analysis

OBJECTIVE

To identify perioperative surgical factors associated with wound complications following cochlear implantation (CI).

DATA SOURCES

PubMed, Web of Science, and Cochrane databases.

STUDY SELECTION

Eligible studies included peer-reviewed research in English evaluating wound complications (wound infection, skin flap breakdown/dehiscence, seroma/hematoma) following CI. Studies with paired samples were included in the meta-analysis.

DATA EXTRACTION

Surgical factors (techniques and perioperative management) in CI and reported wound complications were examined. Level of evidence was assessed using the Oxford Centre for Evidence-based Medicine guidelines and bias was assessed using the NIH Quality Assessment Tool.

DATA SYNTHESIS

Twenty-six studies representing 10,214 cochlear implantations were included. The overall wound complications rate was 3.1% (range 0.03-13.9%). Eleven studies contained paired data and were used for meta-analysis regarding three different surgical factors: incision length, implant placement method, and antibiotic usage. Longer incision lengths (≥7 cm) demonstrated a higher risk of wound complications (risk ratio 2.27, p = 0.02, CI 1.16-4.43). Different implant placement techniques (suture fixation versus periosteal pocket) (p = 0.08, CI 0.92-3.69) and postoperative antibiotic regimens (postoperative use versus none) (p = 0.68, CI = 0.28-7.18) were not associated with differences in wound complication rates following CI.

CONCLUSIONS

Overall rate of wound complications following CI is low. Shorter incision length is associated with lower risk of wound complications. Differences in perioperative techniques and practices regarding implant placement and antibiotic use were not associated with differences in wound complication rates. Considering the low number and quality of studies, there is a need for research in CI outcomes using paired sample prospective designs and standardized reporting.