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Haidari Z, Ahmad SU, Knipp S, Turaev I, El Gabry M. Aortic Valve Infective Endocarditis Complicated by Annular Abscess: Antibiotics in the Abscess Cavity. J Cardiovasc Dev Dis 2024; 11:189. [PMID: 39057612 PMCID: PMC11276662 DOI: 10.3390/jcdd11070189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
OBJECTIVES Infective endocarditis of the aortic valve complicated by annular abscess is a challenging problem and often requires patch reconstruction after surgical debridement of the abscess cavity. Filling the remaining cavity with antibiotics is advocated to prevent recurrent endocarditis. This study aimed at evaluating the role of local antibiotics in patients with aortic valve infective endocarditis complicated by annular abscess. METHODS Between January 2012 and December 2021, all consecutive patients with aortic valve infective endocarditis complicated by annular abscess undergoing cardiac surgery and annular patch reconstruction were included. Patients receiving local antibiotics were compared with patients without local antibiotics. The primary endpoints were the incidence of recurrent endocarditis, re-operation, and mortality during two-year follow-up. RESULTS A total of 41 patients with aortic valve infective endocarditis complicated by annular abscess underwent surgical patch reconstruction after radical debridement. In total, 20 patients received local antibiotics in the abscess cavity and 21 patients were treated without local antibiotics. The most common causative microorganisms were the staphylococci species and the most common location of the abscess was the non-coronary annulus. During two-year follow-up, one patient in each group developed recurrent endocarditis (p > 0.99) and both patients were reoperated (p > 0.99). Two-year mortality was 30% in the local antibiotic group and 24% in the control group (p = 0.65). CONCLUSIONS Radical debridement and patch reconstruction of the aortic annulus in patients with aortic valve infective endocarditis complicated by annular abscess is an effective surgical strategy. Filling of the remaining abscess cavity with antibiotic seems not to affect the rate of recurrent endocarditis, reoperation, and mortality during two-year follow-up.
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Affiliation(s)
- Zaki Haidari
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, 45147 Essen, Germany (I.T.)
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Kowalewski M, Kołodziejczak MM, Urbanowicz T, De Piero ME, Mariani S, Pasierski M, Makhoul M, Comanici M, Dąbrowski EJ, Matteucci M, Massimi G, Litwinowicz R, Kowalówka A, Wańha W, Jiritano F, Martucci G, Raffa GM, Malvindi PG, Kuźma Ł, Suwalski P, Lorusso R, Meani P, Lazar H. Regional antibiotic delivery for sternal wound infection prophylaxis a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2024; 14:9690. [PMID: 38678140 PMCID: PMC11055886 DOI: 10.1038/s41598-024-60242-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024] Open
Abstract
Despite evidence suggesting the benefit of prophylactic regional antibiotic delivery (RAD) to sternal edges during cardiac surgery, it is seldom performed in clinical practice. The value of topical vancomycin and gentamicin for sternal wound infections (SWI) prophylaxis was further questioned by recent studies including randomized controlled trials (RCTs). The aim of this systematic review and meta-analysis was to comprehensively assess the safety and effectiveness of RAD to reduce the risk of SWI.We screened multiple databases for RCTs assessing the effectiveness of RAD (vancomycin, gentamicin) in SWI prophylaxis. Random effects meta-analysis was performed. The primary endpoint was any SWI; other wound complications were also analysed. Odds Ratios served as the primary statistical analyses. Trial sequential analysis (TSA) was performed.Thirteen RCTs (N = 7,719 patients) were included. The odds of any SWI were significantly reduced by over 50% with any RAD: OR (95%CIs): 0.49 (0.35-0.68); p < 0.001 and consistently reduced in vancomycin (0.34 [0.18-0.64]; p < 0.001) and gentamicin (0.58 [0.39-0.86]; p = 0.007) groups (psubgroup = 0.15). Similarly, RAD reduced the odds of SWI in diabetic and non-diabetic patients (0.46 [0.32-0.65]; p < 0.001 and 0.60 [0.44-0.83]; p = 0.002 respectively). Cumulative Z-curve passed the TSA-adjusted boundary for SWIs suggesting adequate power has been met and no further trials are needed. RAD significantly reduced deep (0.60 [0.43-0.83]; p = 0.003) and superficial SWIs (0.54 [0.32-0.91]; p = 0.02). No differences were seen in mediastinitis and mortality, however, limited number of studies assessed these endpoints. There was no evidence of systemic toxicity, sternal dehiscence and resistant strains emergence. Both vancomycin and gentamicin reduced the odds of cultures outside their respective serum concentrations' activity: vancomycin against gram-negative strains: 0.20 (0.01-4.18) and gentamicin against gram-positive strains: 0.42 (0.28-0.62); P < 0.001. Regional antibiotic delivery is safe and effectively reduces the risk of SWI in cardiac surgery patients.
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Affiliation(s)
- Mariusz Kowalewski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Wołoska 137, 02-507, Warsaw, Poland.
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland.
| | - Michalina M Kołodziejczak
- Department of Anaesthesiology and Intensive Care, Antoni Jurasz University Hospital No. 1, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Tomasz Urbanowicz
- Cardiac Surgery and Transplantology Department, Poznań University of Medical Sciences, Poznan, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Maria Elena De Piero
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Michał Pasierski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Wołoska 137, 02-507, Warsaw, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Maged Makhoul
- Department of Cardiac Surgery, Harefield Hospital, London, UK
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Maria Comanici
- Department of Cardiac Surgery, Harefield Hospital, London, UK
| | - Emil Julian Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Cardiac Surgery Unit, Department of Medicine and Surgery, ASST dei Sette Laghi, University of Insubria, Varese, Italy
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Giulio Massimi
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Cardiac Surgery Unit, Santa Maria della Misericordia Hospital, Perugia, Italy
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Radosław Litwinowicz
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Adam Kowalówka
- Department of Cardiac Surgery, Faculty of Medical Sciences, Upper-Silesian Heart Center, Medical University of Silesia, Katowice, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Wojciech Wańha
- Department of Invasive Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Federica Jiritano
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo Per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti Delle Marche, Polytechnic University of Marche, Ancona, Italy
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Suwalski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Wołoska 137, 02-507, Warsaw, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Paolo Meani
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Harold Lazar
- Boston University School of Medicine, Boston, MA, USA
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Kowalewski M, Pasierski M, Makhoul M, Comanici M, Dąbrowski EJ, Matteucci M, Litwinowicz R, Kowalówka A, Wańha W, Jiritano F, Fina D, Martucci G, Raffa GM, Malvindi PG, Kuźma Ł, Suwalski P, Lorusso R, Meani P, Lazar H. Topical vancomycin for sternal wound infection prophylaxis. A systematic review and updated meta-analysis of over 40,000 cardiac surgery patients. Surgery 2023; 174:1102-1112. [PMID: 37414589 DOI: 10.1016/j.surg.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/25/2023] [Accepted: 05/24/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Despite guideline recommendations, routine application of topical antibiotic agents to sternal edges after cardiac surgery is seldom done. Recent randomized controlled trials have also questioned the effectiveness of topical vancomycin in sternal wound infection prophylaxis. METHODS We screened multiple databases for observational studies and randomized controlled trials assessing the effectiveness of topical vancomycin. Random effects meta-analysis and risk-profile regression were performed, and randomized controlled trials and observational studies were analyzed separately. The primary endpoint was sternal wound infection; other wound complications were also analyzed. Risk ratios served as primary statistics. RESULTS Twenty studies (N = 40,871) were included, of which 7 were randomized controlled trials (N = 2,187). The risk of sternal wound infection was significantly reduced by almost 70% in the topical vancomycin group (risk ratios [95% confidence intervals]: 0.31 (0.23-0.43); P < .00001) and was comparable between randomized controlled trials (0.37 [0.21-0.64]; P < .0001) and observational studies (0.30 [0.20-0.45]; P < .00001; Psubgroup = .57). Topical vancomycin significantly reduced the risk of superficial sternal wound infections (0.29 [0.15-0.53]; P < .00001) and deep sternal wound infections (0.29 [0.19-0.44]; P < .00001). A reduction in the risk of mediastinitis and sternal dehiscence risks was also demonstrated. Risk profile meta-regression showed a significant relationship between a higher risk of sternal wound infection and a higher benefit accrued with topical vancomycin (ß-coeff. = -0.00837; P < .0001). The number needed to treat was 58.2. A significant benefit was observed in patients with diabetes mellitus (risk ratios 0.21 [0.11-0.39]; P < .00001). There was no evidence of vancomycin or methicillin resistance; on the contrary, the risk of gram-negative cultures was reduced by over 60% (risk ratios 0.38 [0.22-0.66]; P = .0006). CONCLUSION Topical vancomycin effectively reduces the risk of sternal wound infection in cardiac surgery patients.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior, Warsaw, Poland; Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, the Netherlands; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland.
| | - Michał Pasierski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Maged Makhoul
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | - Maria Comanici
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | | | - Matteo Matteucci
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Cardiac Surgery Unit, Azienda Socio Sanitaria Territoriale dei Sette Laghi, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Radosław Litwinowicz
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
| | - Adam Kowalówka
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiac Surgery, Upper-Silesian Heart Center, Medical University of Silesia, Faculty of Medical Sciences, Katowice, Poland
| | - Wojciech Wańha
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Poland
| | - Federica Jiritano
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Experimental and Clinical Medicine, Magna Græcia University, Catanzaro, Italy
| | - Dario Fina
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientific Policlinico, San Donato Milanese, Milan, Italy
| | - Gennaro Martucci
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione, Palermo, Italy
| | - Giuseppe Maria Raffa
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione, Palermo, Italy
| | - Pietro Giorgio Malvindi
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, the Netherlands
| | - Paolo Meani
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientific Policlinico, San Donato Milanese, Milan, Italy
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Miazza J, Vasiloi I, Koechlin L, Gahl B, Reuthebuch O, Eckstein FS, Santer D. Combined Band and Plate Fixation as a New Individual Option for Patients at Risk of Sternal Complications after Cardiac Surgery: A Single-Center Experience. Biomedicines 2023; 11:1946. [PMID: 37509585 PMCID: PMC10377508 DOI: 10.3390/biomedicines11071946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Due to the advent of interventional therapies for low- and intermediate-risk patients, case complexity has increased in cardiac surgery over the last decades. Despite the surgical progress achieved to keep up with the increase in the number of high-risk patients, the prevention of sternal complications remains a challenge requiring new, individualized sternal closure techniques. The aim of this study was to evaluate the safety and feasibility, as well as the in-hospital and long-term outcomes, of enhanced sternal closure with combined band and plate fixation using the new SternaLock® 360 (SL360) system as an alternative to sternal wiring. From 2020 to 2022, 17 patients underwent enhanced sternal closure using the SL360 at our institution. We analyzed perioperative data, as well as clinical and radiologic follow-up data. The results were as follows: In total, 82% of the patients were treated with the SL360 based on perioperative risk factors, while in 18% of cases, the SL360 was used for secondary closure due to sternal instability. No perioperative complications were observed. We obtained the follow-up data of 82% of the patients (median follow-up time: 141 (47.8 to 511.5) days), showing no surgical revision, no sternal instability, no deep wound infections, and no sternal pain at the follow-up. In one case, a superficial wound infection was treated with antibiotics. In conclusion, enhanced sternal closure with the SL360 is easy to perform, effective, and safe. This system might be considered for both primary and secondary sternal closure in patients at risk of sternal complications.
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Affiliation(s)
- Jules Miazza
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Ion Vasiloi
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - Friedrich S Eckstein
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
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The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis. Plast Reconstr Surg Glob Open 2022; 10:e4233. [PMID: 35506023 PMCID: PMC9053136 DOI: 10.1097/gox.0000000000004233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/07/2022] [Indexed: 12/04/2022]
Abstract
Deep sternal wound infection (DSWI) is one of the most complex and devastating complications post cardiac surgery. We present here the modified sternoplasty, a novel surgical technique for treating DSWI post cardiac surgery. The modified sternoplasty includes debridement and sternal refixation via bilateral longitudinal stainless-steel wires that are placed parasternally along the ribs at the midclavicular or anterior axillary line, followed by six to eight horizontal stainless-steel wires that are anchored laterally and directly into the ribs. On top of that solid structure, wound reconstruction is performed by the use of bilateral pectoralis muscle flaps followed by subcutaneous tissue and skin closure. We reported mortality rates and length of hospitalization of patients who underwent the modified sternoplasty. In total, 68 patients underwent the modified sternoplasty. Two of these critically ill patients died (2.9%). The average length of hospitalization from the diagnosis of DSWI was 24.63 ± 22.09 days. The modified sternoplasty for treating DSWI is a more complex surgery compared with other conventional sternoplasty techniques. However, this technique was demonstrated to be more effective, having a lower rate of mortality, and having a length of hospitalization lower than or comparable to other techniques previously reported in the literature.
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Magro PL, Sousa Uva M. Does routine topical antimicrobial administration prevent sternal wound infection after cardiac surgery? Interact Cardiovasc Thorac Surg 2021; 32:452-456. [PMID: 33346346 DOI: 10.1093/icvts/ivaa292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/19/2020] [Accepted: 10/27/2020] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Does routine topical antimicrobial administration prevent sternal wound infection (SWI) after cardiac surgery? Altogether >238 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Several different antimicrobial agents, dosages and application protocols were found in the literature. Regarding topical vancomycin use, a meta-analysis by Kowalewski et al. demonstrated a 76% risk reduction in any SWI. Collagen-gentamicin sponge application was associated with a 38% risk reduction in SWI in another meta-analysis by Kowalewski et al., which included 4 randomized control trials and >23 000 patients. Lower evidence observational studies found benefit in the use of different regimes, including: combination of vancomycin paste and subcutaneous gentamycin; combined cefazoline and gentamicin spray; isolated cefazolin; bacitracin ointment; and rifampicin irrigation. We conclude that, in light of the body of evidence available, topical antibiotic application prevents SWI, including both superficial and deep SWI. The strongest evidence, derived from 2 meta-analyses, is related to the use of gentamicin-collagen sponges and topical vancomycin. Heterogeneity throughout studies regarding antibiotic agents, dosages, application protocols and SWI definition makes providing general recommendations challenging.
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Affiliation(s)
- Pedro Lamares Magro
- Department of Cardio-thoracic Surgery, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Miguel Sousa Uva
- Department of Cardio-thoracic Surgery, Hospital de Santa Cruz, Carnaxide, Portugal
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7
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Kachel E, Moshkovitz Y, Sternik L, Sahar G, Grosman-Rimon L, Belotserkovsky O, Reichart M, Stark Y, Emanuel N. Local prolonged release of antibiotic for prevention of sternal wound infections postcardiac surgery-A novel technology. J Card Surg 2020; 35:2695-2703. [PMID: 32743813 DOI: 10.1111/jocs.14890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Sternal wound infection (SWI) is a devastating postcardiac surgical complication. D-PLEX100 (D-PLEX) is a localized prolonged release compound applied as a prophylactic at the completion of surgery to prevent SWI. The D-PLEX technology platform is built as a matrix of alternating layers of polymers and lipids, entrapping an antibiotic (doxycycline). The objective of this study was to assess the safety profile and pharmacokinetics of D-PLEX in reducing SWI rates postcardiac surgery. METHOD Eighty-one patients were enrolled in a prospective single-blind randomized controlled multicenter study. Sixty patients were treated with both D-PLEX and standard of care (SOC) and 21 with SOC alone. Both groups were followed 6 months for safety endpoints. SWI was assessed at 90 days. RESULTS No SWI-related serious adverse events (SAEs) occurred in either group. The mean plasma Cmax in patients treated with D-PLEX was about 10 times lower than the value detected following the oral administration of doxycycline hyclate with an equivalent overall dose, and followed by a very low plasma concentration over the next 30 days. There were no sternal infections in the D-PLEX group (0/60) while there was one patient with a sternal infection in the control group (1/21, 4.8%). CONCLUSION D-PLEX was found to be safe for use in cardiac surgery patients. By providing localized prophylactic prolonged release of broad-spectrum antibiotics, D-PLEX has the potential to prevent SWI postcardiac surgery and long-term postoperative hospitalization, reducing high-treatment costs, morbidity, and mortality.
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Affiliation(s)
- Erez Kachel
- Department of Cardiac Surgery, Poriya Medical Center, Tiberias, Israel.,Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
| | - Yaron Moshkovitz
- Department of Cardiothoracic Surgery, Assuta Medical Center, Tel Aviv, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
| | - Gideon Sahar
- Department of Cardiothoracic Surgery, Soroka Medical Center, Beer Sheva, Israel
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Phoon PHY, Hwang NC. Deep Sternal Wound Infection: Diagnosis, Treatment and Prevention. J Cardiothorac Vasc Anesth 2020; 34:1602-1613. [DOI: 10.1053/j.jvca.2019.09.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/28/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022]
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9
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An Extended Duration of the Pre-Operative Hospitalization is Associated with an Increased Risk of Healthcare-Associated Infections after Cardiac Surgery. Sci Rep 2020; 10:8006. [PMID: 32409758 PMCID: PMC7224271 DOI: 10.1038/s41598-020-65019-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/04/2020] [Indexed: 11/25/2022] Open
Abstract
Nosocomial infections are a common complication in clinical practice with major impact on surgical success and patient outcome. The probability of nosocomial infections is rapidly increasing during hospitalization. Therefore, we investigated the impact of a prolonged pre-operative hospital stay on the development of post-operative infection. Within this prospective observational study, 200 patients scheduled for elective cardiac surgery were enrolled. Patients were followed during hospital admission and screened for the development of nosocomial infection. Logistic regression analysis was used to assess the impact of a prolonged pre-operative hospital stay on the development of infection. A total of 195 patients were suitable for the final analysis. We found a strong and direct association of the duration of pre-operative hospital stay and the number of patients developing infection (+23.5%; p = 0.006). Additionally, the length of patients’ pre-operative hospital stay was independently associated with the development of post-operative nosocomial infection, with an adjusted OR per day of 1.38 (95%CI: 1.02–1.86; p = 0.036). A prolonged pre-operative hospital stay was significantly associated with the development of nosocomial infection after cardiac surgery. Those findings need to be considered in future clinical patient management in order to prevent unnecessary antibiotic use and potential harm to patients.
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Shahinian JH, Cogliatti L, Gahl B, Berdajs D, Grapow M, Eckstein F, Reuthebuch O. Assessment of compromised parasternal skin perfusion after left internal mammary artery harvesting with a novel laser Doppler imaging. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 60:742-748. [DOI: 10.23736/s0021-9509.19.10832-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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11
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Ramot Y, Nedvetzki S, Rosenfeld S, Emanuel N, Nyska A. Toxicity and Safety Study of D-PLEX 100 in a Sternal Surgical Defect in New Zealand White Rabbits. Toxicol Pathol 2019; 47:504-514. [PMID: 30975045 DOI: 10.1177/0192623319837887] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Bacterial infections are a common complication after surgical procedures. Therefore, local delivery of antibiotics has been developed, including the use of biodegradable polymers. A newly developed product for prevention of surgical site infections is a polymer-lipid encapsulation matrix loaded with doxycycline, named D-PLEX100 (D-PLEX). We evaluated the toxicity and safety of D-PLEX using a sternal surgical defect model in rabbits. D-PLEX was tested with three different concentrations of doxycycline in comparison to sham-operated control after administration into the sternal surgical defect and on the ventral side of the sternum in New Zealand White (NZW) rabbits, following 15 months of exposure. No mortality or abnormal clinical findings were attributed to D-PLEX, and clinical pathology assays were normal. Histological examinations revealed no treatment-related adverse findings in any of the examined tissues, including the osseous and surrounding soft tissues. It has been shown that D-PLEX gradually degraded until complete disappearance after 9 months, and mainly during the first 3 months, in parallel to normal bone formation. In addition, the administration of D-PLEX did not affect sternal bone strength. This study adds to the growing data on preclinical safety studies utilizing biodegradable materials and provides information on the expected normal reaction to biodegradable materials in the sternum of NZW rabbits.
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Affiliation(s)
- Yuval Ramot
- 1 Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | | | | | | | - Abraham Nyska
- 3 Consultant in Toxicologic Pathology, and Tel Aviv University, Timrat, Israel
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Empleo de vancomicina tópica en la profilaxis de infección de herida de esternotomía: experiencia inicial. CIRUGIA CARDIOVASCULAR 2018. [DOI: 10.1016/j.circv.2018.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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13
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Kocher A, Coti I, Laufer G, Andreas M. Minimally invasive aortic valve replacement through an upper hemisternotomy: the Vienna technique. Eur J Cardiothorac Surg 2018; 53:ii29-ii31. [DOI: 10.1093/ejcts/ezx514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 12/25/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alfred Kocher
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Iuliana Coti
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Guenther Laufer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Christina Tampaki E, Lardinois D, Tampakis A. eComment. Management of deep sternal wound infections after cardiac surgery: Towards development of new substrates for sustained multiagent delivery release profiles. Interact Cardiovasc Thorac Surg 2017; 25:11. [PMID: 28881945 DOI: 10.1093/icvts/ivx176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ekaterini Christina Tampaki
- Department of Propaedeutic Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece.,National Organization for the Provision of Healthcare Services, Department of Planning and Monitoring of Medicines Dispensing, Medicines Division, Greece
| | - Didier Lardinois
- Department of Thoracic Surgery, University Hospital of Basel, Vasel, Switzerland
| | - Athanasios Tampakis
- Department of Propaedeutic Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece.,Department of General and Visceral Surgery, University Hospital of Basel, Basel, Switzerland
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