Mediastinitis in pediatric cardiac surgery: treatment and cost-effectiveness in a low-income country

Alternative Antimicrobial Irrigation Strategies for the Treatment of Infections in Children: A Review of the Existing Literature

As a synergistic treatment approach with systemic antimicrobial therapy or a systemic antibiotic-sparing strategy, the local administration of antimicrobial agents has been proposed as an alternative route for complicated infections. With the rationale of concentrating the active principle in the desired target site, avoiding potentially toxic systemic levels and bypassing anatomical and physiological barriers, local irrigation or infusion of antibiotics may effectively shorten the antimicrobial therapy course and reduce both infection-related and systemic therapy-related complications. Although evidence from the adult population supports its use in selected patients with an acceptable safety profile, data specifically focused on the pediatric population are limited. To provide a rapid and easily accessible tool for clinical practice, we synthesized the most relevant evidence on the use of local antimicrobial agents in common severe infections in children: meningitis, mediastinitis, pleural infections, recurrent urinary infections, and peritonitis. A literature search was performed using predefined combined keywords through an electronic research database (PubMed). Described molecules, dosages, routes, treated age groups, and related efficacy have been summarized for prompt application to clinical practice. It should, however, be noted that the evidence for the pediatric population remains limited, and the local administration of several molecules remains off-label. A careful multidisciplinary and patient-tailored evaluation, as well as a rational use of available guidelines, should always be the basis of clinical decision making in settings where local administration of antibiotics may be considered.

Doubly committed subarterial ventricular septal defect closure through tricuspid approach: a clinical analysis

BACKGROUND

The research was to introduce the experience of doubly committed subarterial ventricular septal defect (DCVSD) repaired through tricuspid approach.

METHODS

From January, 2015 to September, 2019, 86 consecutive DCVSD paediatrics underwent repair via right subaxillary vertical incision (RAVI) through tricuspid approach. Perioperative and follow-up data were collected.

RESULTS

The age and weight at operation were 28.1 ± 18.5 (range: 7-101) months and 12.2 ± 4.2 (6-26.5) kg. There were two patients combined with discrete subaortic membrane, two patients with patent ductus arteriosus, one patient with atrial septal defect, and two patients with abnormal muscle bundle in right ventricular outflow tract. The mean size of ventricular septal defect was 7.0 ± 2.4 (3-13) mm. The defect was repaired with a piece of Dacron patch in 68 patients or directly with 1-2 pledgetted polypropylene sutures in 18 patients. The cardiopulmonary bypass time and aortic cross-clamp time were 46.2 ± 13.3 (23-101) minutes and 29.2 ± 11.5 (12-84) minutes. After 3.1 ± 2.4 (0-14) hours' ventilator assist and 23.2 ± 32.1 (0-264) hours' ICU stay, all patients were discharged safely. At the latest follow-up (27.9 ± 14.6 months), echocardiography showed trivial residual shunt in two patients. There was no malignant arrhythmia occurred and there was no chest deformity or asymmetrical development of the breast was found.

CONCLUSIONS

DCVSD repaired via right subaxillary vertical incision through tricuspid approach was safe and feasible, providing a feasible alternative to median sternotomy, and it can be performed with favourable cosmetic results.

Antibiotic Management for Delayed Sternal Closure Following Pediatric Cardiac Surgery: A Systematic Review of Recent Literature

Delayed sternal closure after pediatric cardiac surgery is a management option for the treatment of patients with severely impaired heart function. The optimal antimicrobial treatment strategy for this condition is unknown. The aim of this systematic review was to evaluate the current antibiotic administration attitudes in pediatric cardiac surgery patients needing an open chest in terms of infection with a focus on surgical site infection rate. The authors performed a systematic review and meta-analysis of all articles, which described the antibiotic administration strategy and surgical site infection rate in pediatric patients with an open chest after cardiac surgery. The authors performed a subgroup analysis on "standard" versus "non-standard" (defined as any antimicrobial drugs different from the adult guidelines recommendations) therapy for one-proportion meta-analysis with a random effect model. The authors identified 12 studies published from January 1, 2000 to July 1, 2019 including a total of 2,203 patients requiring an open chest after cardiac surgery, 350 of whom (15.9%) developed infections and 182 (8.3%) developed a surgical site infection. The surgical site infection rate in patients with "non-standard" strategy was higher than in patients with "standard" strategy: 8.8% (140 reported infections/1,582 patients) versus 6.8% (42 reported infections/621 patients), p = 0.001. The "standard" antibiotic management proposed by guidelines for adult cardiac surgery patients could be used an acceptable strategy to treat pediatric patients with an open chest after cardiac surgery.

Perioperative infections in congenital heart disease

BACKGROUND

Perioperative infections have significant consequences for children with congenital heart disease (CHD), which can manifest as acute or chronic infection followed by poor growth and progressive cardiac failure. The consequences include delayed or higher-risk surgery, and increased postoperative morbidity and mortality.

METHODS

A systematic search for studies evaluating the burden and interventions to reduce perioperative infections in children with CHD was undertaken using PubMed.

RESULTS

Limited studies conducted in low- to middle-income countries demonstrated the large burden of perioperative infections among children with CHD. Most studies focussed on infections after surgery. Few studies evaluated strategies to prevent preoperative infection or the impact of infection on decision-making around the timing of surgery. Children with CHD have multiple risk factors for infections including delayed presentation, inadequate treatment of cardiac failure, and poor nutrition.

CONCLUSIONS

The burden of perioperative infections is high among children with CHD, and studies evaluating the effectiveness of interventions to reduce these infections are lacking. As good nutrition, early corrective surgery, and measures to reduce nosocomial infection are likely to play a role, practical steps can be taken to make surgery safer.

Economic Analysis of Children's Surgical Care in Low- and Middle-Income Countries: A Systematic Review and Analysis

Background

Understanding the economic value of health interventions is essential for policy makers to make informed resource allocation decisions. The objective of this systematic review was to summarize available information on the economic impact of children’s surgical care in low- and middle-income countries (LMICs).

Methods

We searched MEDLINE (Pubmed), Embase, and Web of Science for relevant articles published between Jan. 1996 and Jan. 2015. We summarized reported cost information for individual interventions by country, including all costs, disability weights, health outcome measurements (most commonly disability-adjusted life years [DALYs] averted) and cost-effectiveness ratios (CERs). We calculated median CER as well as societal economic benefits (using a human capital approach) by procedure group across all studies. The methodological quality of each article was assessed using the Drummond checklist and the overall quality of evidence was summarized using a scale adapted from the Agency for Healthcare Research and Quality.

Findings

We identified 86 articles that met inclusion criteria, spanning 36 groups of surgical interventions. The procedure group with the lowest median CER was inguinal hernia repair ($15/DALY). The procedure group with the highest median societal economic benefit was neurosurgical procedures ($58,977). We found a wide range of study quality, with only 35% of studies having a Drummond score ≥ 7.

Interpretation

Our findings show that many areas of children’s surgical care are extremely cost-effective in LMICs, provide substantial societal benefits, and are an appropriate target for enhanced investment. Several areas, including inguinal hernia repair, trichiasis surgery, cleft lip and palate repair, circumcision, congenital heart surgery and orthopedic procedures, should be considered “Essential Pediatric Surgical Procedures” as they offer considerable economic value. However, there are major gaps in existing research quality and methodology which limit our current understanding of the economic value of surgical care.

Rigid sternal fixation in the management of pediatric postmedian sternotomy mediastinitis: A 20-year study

BACKGROUND AND AIM

Pediatric patients are at a risk of mediastinitis, a life-threatening complication of median sternotomy, following cardiac surgery for congenital conditions. Our experience with rigid internal sternal fixation in pediatric patients with postmedian sternotomy mediastinitis is presented.

METHODS AND MATERIALS

A retrospective chart review was performed of patients <18 years of age diagnosed with postoperative mediastinitis between January 1, 1990 and December 31, 2009. Charts were reviewed for demographic data, cardiac history, causative microorganism, and infectious risk factors. The methods of surgical intervention including flap coverage and use and type of sternal plating (resorbable and/or titanium) were also recorded. The primary end point of interest was overall survival.

RESULTS

Twenty-five pediatric patients were diagnosed with postoperative mediastinitis. Rigid fixation of the sternum following debridement was performed in 20 patients (age range: 1 month-18 years), all of whom successfully tolerated the procedure. Resorbable plates were used in 13 patients. Five patients did not undergo rigid fixation due to either serious ill-health or lack of adequate sternal bone stock. No patient experienced recurrent sternal wound infection. A total of 20 patients (80%) survived to discharge. Three patients succumbed to their heart condition prior to rigid fixation, one died following sternal closure from unrelated causes, and one patient was lost to follow-up.

CONCLUSIONS

Post-sternotomy mediastinitis in pediatric patients may be addressed using wide debridement, rigid sternal fixation, and flap coverage. In our series of 25 patients with pediatric mediastinitis, none died from mediastinitis. Placement of hardware did not adversely affect patient survival. This study demonstrates the feasibility of rigid sternal fixation.

Postoperative differences between colonization and infection after pediatric cardiac surgery-a propensity matched analysis

Background

The objective of this study was to identify the postoperative risk factors associated with the conversion of colonization to postoperative infection in pediatric patients undergoing cardiac surgery.

Methods

Following approval from the Institutional Review Board, patient demographics, co-morbidities, surgery details, transfusion requirements, inotropic infusions, laboratory parameters and positive microbial results were recorded during the hospital stay, and the patients were divided into two groups: patients with clinical signs of infection and patients with only positive cultures but without infection during the postoperative period. Using propensity scores, 141 patients with infection were matched to 141 patients with positive microbial cultures but without signs of infection. Our database consisted of 1665 consecutive pediatric patients who underwent cardiac surgery between January 2004 and December 2008 at a single center. The association between the patient group with infection and the group with colonization was analyzed after propensity score matching of the perioperative variables.

Results

179 patients (9.3%) had infection, and 253 patients (15.2%) had colonization. The occurrence of Gram-positive species was significantly greater in the colonization group (p = 0.004). The C-reactive protein levels on the first and second postoperative days were significantly greater in the infection group (p = 0.02 and p = 0.05, respectively). The sum of all the positive cultures obtained during the postoperative period was greater in the infection group compared to the colonization group (p = 0.02). The length of the intensive care unit stay (p < 0.001) was significantly longer in the infection group compared to the control group.

Conclusions

Based on our results, we uncovered independent relationships between the conversion of colonization to infection regarding positive S. aureus and bloodstream results, as well as significant differences between the two groups regarding postoperative C-reactive protein levels and white blood cell counts.

Mediastinitis in pediatric cardiac surgery: Prevention, diagnosis and treatment

In spite of advances in the management of mediastinitis following sternotomy, mediastinitis is still associated with significant morbidity. The prognosis is much better in pediatric surgery compared to adult surgery, but the prolonged hospital stays with intravenous therapy and frequent required dressing changes that occur with several therapeutic approaches are poorly tolerated. Prevention includes nasal decontamination, skin preparation, antibioprophylaxis and air filtration in the operating theater. The expertise of the surgical team is an additional factor that is difficult to assess precisely. Diagnosis is often very simple, being made on the basis of a septic state with wound modification, while retrosternal puncture and CT scan are rarely useful. Treatment of mediastinitis following sternotomy is always a combination of surgical debridement and antibiotic therapy. Continued use of numerous surgical techniques demonstrates that there is no consensus and the best treatment has yet to be determined. However, we suggest that a primary sternal closure is the best surgical option for pediatric patients. We propose a simple technique with high-vacuum Redon's catheter drainage that allows early mobilization and short term antibiotherapy, which thus decreases physiological and psychological trauma for patients and families. We have demonstrated the efficiency of this technique, which is also cost-effective by decreasing intensive care and hospital stay durations, in a large group of patients.

Major infection after pediatric cardiac surgery: a risk estimation model

BACKGROUND

In pediatric cardiac surgery, infection is a leading cause of morbidity and mortality. We created a model to predict risk of major infection in this population.

METHODS

Using the Society of Thoracic Surgeons Congenital Heart Surgery Database, we created a multivariable model in which the primary outcome was major infection (septicemia, mediastinitis, or endocarditis). Candidate-independent variables included demographic characteristics, comorbid conditions, preoperative factors, and cardiac surgical procedures. We created a reduced model by backward selection and then created an integer scoring system using a scaling factor with scores corresponding to percent risk of infection.

RESULTS

Of 30,078 children from 48 centers, 2.8% had major infection (2.6% septicemia, 0.3% mediastinitis, and 0.09% endocarditis). Mortality and postoperative length of stay were greater in those with major infection (mortality, 22.2% versus 3.0%; length of stay >21 days, 69.9% versus 10.7%). Young age, high complexity, previous cardiothoracic operation, preoperative length of stay more than 1 day, preoperative ventilator support, and presence of a genetic abnormality were associated with major infection after backward selection (p < 0.001). Estimated infection risk ranged from less than 0.1% to 13.3%; the model discrimination was good (c index, 0.79).

CONCLUSIONS

We created a simple bedside tool to identify children at high risk for major infection after cardiac surgery. These patients may be targeted for interventions to reduce the risk of infection and for inclusion in future clinical trials.