Local collagen-gentamicin for prevention of sternal wound infections: the LOGIP trial

Fast Curing Multifunctional Tissue Adhesives of Sericin-Based Polyurethane-Acrylates for Sternal Closure

The use of wire cerclage after sternal closure is the standard method because of its rigidity and strength. Despite this, they have many disadvantages such as tissue trauma, operator-induced failures, and the risk of infection. To avoid complications during sternotomy and promote tissue regeneration, tissue adhesives should be used in post-surgical treatment. Here, we report a highly biocompatible, biomimetic, biodegradable, antibacterial, and UV-curable polyurethane-acrylate (PU-A) tissue adhesive for sternal closure as a supportive to wire cerclage. In the study, PU-As were synthesized with variable biocompatible monomers, such as silk sericin, polyethylene glycol, dopamine, and an aliphatic isocyanate 4,4'-methylenebis(cyclohexyl isocyanate). The highest adhesion strength was found to be 4322 kPa, and the ex vivo compressive test result was determined as 715 kPa. The adhesive was determined to be highly biocompatible (on L-929 cells), biodegradable, and antibacterial (on Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus bacteria). Finally, after opening the sternum of rats, the adhesive was applied to bond the bones and cured with UV for 5 min. According to the results, there was no visible inflammation in the adhesive groups, while some animals had high inflammation in the cyanoacrylate and wire cerclage groups. These results indicate that the adhesive may be suitable for sternal fixation by preventing the disadvantages of the steel wires and promoting tissue healing.

Antibiotic Powder Reduces Surgical Site Infections in Children After Single-Incision Laparoscopic Appendectomy for Acute Appendicitis

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) has a higher rate of wound infection than the multiport technique. The purpose of this project was to determine whether the use of topical antibiotic powder reduces surgical site infections (SSIs) in pediatric patients who undergo SILA.

METHODS

Patients aged 0-21 years who underwent SILA for acute appendicitis from April 2015 to November 2016 were included in this quality improvement initiative. Cefoxitin powder was placed in the umbilical wound before skin closure. Data were prospectively collected and outcome measures were compared with a historical cohort who underwent SILA before the implementation of antibiotic powder.

RESULTS

There were 108 patients in the historical group (HIST) and 126 in the powder group (POWD). The groups were similar in age (HIST: 11.5 ± 3.6 versus POWD: 12.2 ± 3.7 years, P = .15) and body mass index percentile (HIST: 57.6 ± 30.7 versus POWD: 58.8 ± 27.8, P = .84). Operative time was longer in the powder group (HIST: 26.5 ± 7.5 versus POWD: 29.7 ± 8.9 minutes, P = .004). Length of stay (HIST: 0.2 ± 0.4 versus POWD: 0.1 ± 0.4 days, P = .06), 30-day return to emergency department (HIST: 7% versus POWD: 8%, P = 1.0), and hospital readmissions (HIST: 5% versus POWD: 2%, P = .8) were similar. There was a significantly lower rate of superficial SSIs in the powder group (HIST: 4.6% versus POWD: 0%, P = .02).

CONCLUSIONS

In pediatric patients undergoing SILA for acute appendicitis, the use of cefoxitin powder in the umbilical wound is a simple intervention to reduce the incidence of superficial SSIs.

Antimicrobial Formulation and Delivery in the Prevention of Surgical Site Infection

BACKGROUND

A number of adjunct antimicrobial measures have been studied in an attempt to reduce surgical site infection (SSI) rates. In addition to parenteral antibiotic prophylaxis, these measures include oral antibiotics in bowel preparation for colorectal surgery, antiseptic/antimicrobial irrigation, antimicrobial sutures, local antibiotics, skin incision antibacterial sealants, and antimicrobial dressings. It is the purpose of this review to study the evidence behind each of these measures and to evaluate relevant data for recommendations in each area.

METHODS

A systematic review of the literature through PubMed was performed.

RESULTS

Need for adequate dosing and re-dosing of intravenous peri-operative antibiotics, duration of antibiotic usage past wound closure, and the use of antibiotic bowel preparation in colorectal surgery are well defined in the published literature. However, data on local antimicrobial measures remain controversial.

CONCLUSIONS

Proper dosing and re-dosing of prophylactic intravenous antibiotics should become standard practice. Continuation of intravenous antibiotic prophylaxis beyond wound closure is unnecessary in clean cases and remains controversial in clean-contaminated and complex cases. Oral antibiotic bowel preparation is an important adjunct to intravenous antibiotic prophylaxis in colorectal surgery. The use of topical antimicrobial and antiseptic agents such as antibacterial irrigations, local antimicrobial application, antimicrobial-coated sutures, antibacterial wound sealants, and antimicrobial impregnated dressings in the prevention of SSI is questionable.

Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure

OBJECT

The application of concentrated topical antibiotic powder directly to surgical wounds has been associated with a reduction in wound infection in cardiac, spinal, and deep brain stimulator surgery. As a result of these findings, the corresponding author began systematically applying concentrated bacitracin powder directly to wounds during shunt surgery more than 5 years ago. The object of this study was to evaluate the effectiveness of concentrated bacitracin powder applied directly to wounds prior to closure during cranial shunt surgery and to evaluate the association between shunt infection and other risk factors. A single surgeon's cranial shunt surgery experience, equally divided between periods during which antibiotic powder was and was not applied, was studied to assess the effect of concentrated bacitracin powder application on shunt infection rates.

METHODS

This retrospective cohort study included all patients who underwent a cranial shunting procedure at All Children's Hospital performed by a single surgeon (G.F.T.) from 2001 to 2013. The surgeon applied bacitracin powder to all shunt wounds prior to closure between 2008 and 2013, whereas no antibiotic powder was applied to wounds prior to 2008. Both initial and revision shunting procedures were included, and all procedures were performed at a large children's hospital (All Children's Hospital). The primary outcome measure was shunt infection, which was defined using clinical criteria previously used by the Hydrocephalus Clinical Research Network. The association between bacitracin powder use and shunt infection was estimated using hazard ratios (HRs) and 95% CIs from Cox proportional hazard regression models.

RESULTS

A total of 47 infections out of 539 shunt operations occurred during the study period, resulting in an overall infection rate of 8.7%. Procedures performed before the use of concentrated bacitracin powder was instituted resulted in a 13% infection rate, whereas procedures performed after systematic use of bacitracin powder had been adopted experienced a 1% infection rate. Bacitracin powder use was associated with a reduced risk of shunt infection in univariate analysis (HR 0.11, 95% CI 0.03-0.34, p = 0.0002) and also in multivariate analysis (HR 0.12, 95% CI 0.04-0.41, p = 0.0006) when controlling for covariates that were associated with infection from the univariate analysis. The presence of a tracheostomy or a gastrostomy tube was also found to be independently associated with shunt infection in multivariate analysis (HR 3.15, 95% CI 1.05-9.50, p = 0.04, and HR 2.82, 95% CI 1.33-5.96, p = 0.007, respectively).

CONCLUSIONS

This study suggests, for the first time, that the systematic application of concentrated bacitracin powder to surgical wounds prior to closure during shunt surgery may be associated with a reduction in cranial shunt infection. This initial finding requires validation in a large prospective study before widespread application can be advocated.

Complications associated with bacitracin powder in surgical wounds

OBJECT

There has been renewed interest in the application of concentrated antibiotic powder to surgical wounds as a method to decrease infection rates. While there is substantial medical literature describing the effectiveness and complications associated with vancomycin and gentamycin powders, very little has been reported regarding the safety and effectiveness of bacitracin powder in surgical wounds. In this paper the authors report their detailed analysis of potential bacitracin powder-related complications in a population of pediatric patients who underwent shunt surgery.

METHODS

A detailed retrospective analysis was completed of all CSF shunt surgeries performed by the corresponding author at a large children's hospital between 2001 and 2013. This cohort consisted of many patients who were the subject of a previous report that showed the use of bacitracin powder in shunt wounds potentially decreased infection rates. Data were collected regarding the most common known complications of bacitracin, i.e., anaphylaxis, wound healing difficulties, and renal dysfunction. Data were stratified by typical demographic, medical, and surgical variables, including whether bacitracin powder was applied to wounds prior to closure.

RESULTS

A total of 597 patients were reviewed in the analysis: 389 underwent surgery without bacitracin powder and 208 had concentrated bacitracin powder applied to the wounds prior to closure. The application of bacitracin powder was not associated with anaphylaxis (n = 0 both groups) or with an increase in wound breakdown (n = 5 in the control group, n = 0 in the bacitracin powder group) or renal dysfunction (creatinine/estimated glomerular filtration rate) using both comparative and multivariate analyses between the 2 groups. The sample size evaluating renal function was significantly lower (range 6-320) than that of anaphylaxis and wound breakdown analysis because only clinical values acquired during the routine care of these patients were available for analysis. The only significant difference in demographics was the more frequent use of intrathecal vancomycin and gentamycin in patients who received bacitracin powder (n = 1 for controls, n = 21 for bacitracin powder). In the multivariate analysis, only 1 factor, surgery performed on a premature infant within the first 3 months of life, was independently associated with a change in creatinine at 3 months (creatinine decreased by 0.18) compared with the level before surgery (p < 0.0001). Bacitracin powder was not a significant factor.

CONCLUSIONS

To the authors' knowledge, this is the first study to systematically analyze the potential complications of concentrated bacitracin powder applied to surgical wounds. The use of topical bacitracin powder in CSF shunt wounds was not associated with anaphylaxis, wound breakdown, or renal dysfunction. Further study using standardized protocols is necessary before widespread use can be recommended.

Novel Method of Infection Prophylaxis in Heart Transplantation by Retrosternal Gentamycin Sponge Application

BACKGROUND

Surgical wound infections are more frequent in patients undergoing heart transplantation than in other heart surgery patients. There is a wide spread of sternal wound infection incidence in transplant patients ranging from 4% to 40%. It is first study describing local gentamicin sponge application during heart transplantation procedure.

MATERIALS AND METHODS

We enrolled 75 patients in a retrospective, single-center study, including 25 patients who underwent orthotopic heart transplantation (heart transplant group) and 50 in the cardiac surgery group. They were in mean age of 49 ± 12 years and 51 ± 13 years in heart transplantation and cardiac surgery group, respectively. A gentamicin sponge was inserted intraoperatively between sternal borders before chest closure in all heart transplantation patients.

RESULTS

There was 1 early death (4%) on postoperative day 7 owing to Clostridium difficile infection in the heart transplant group. There was 1 death (2%) in the cardiac surgery group owing to multiorgan failure secondary to perioperative heart ischemia. There was neither bacterial sternal wound infection nor sternal instability in the heart transplant group. None of the patients who had gentamicin sponge applied had wound healing problems. Two patients (4%) had a deep sternal wound infection in the cardiac surgery group, who had no sponge application; 1 (2%) was treated by surgical debridement and active drainage and 1 (2%) by vacuum therapy. There were 11 patients (44%) discharged on insulin therapy in the heart transplant group and 21 (21%) in the cardiac surgery group. Mean overall postoperative hospital stay was 35 ± 19 days in the heart transplant group and 10 ± 4 days in the cardiac surgery group.

CONCLUSIONS

Gentamicin sponge is an effective local infection prophylaxis in heart transplant patients.

Gentamicin-impregnated collagen sponge for preventing sternal wound infection after cardiac surgery

The frequency of sternal wound infection (SWI) after cardiac surgery ranges from 0.5% to 8% and is associated with significant morbidity, mortality, and treatment cost. Perioperative antibiotic prophylaxis is not sufficient to fully prevent the contamination of the surgical access site. One of the most effective methods for the prevention of wound infection seems to be the use of gentamicin-impregnated collagen sponge, which is successfully used in abdominal and orthopedic surgery. Surgically implantable topical antibiotics can reduce wound infection in cardiac patients as well, but the efficacy of SWI prevention in cardiac surgery still raises many questions.

Update on new medicinal applications of gentamicin: evidence-based review

Gentamicin (GM) was discovered in 1963 and was introduced into parenteral usage in 1971. Since then, GM has been widely used in medicinal applications. The Food and Drug Administration of the United States approved the routine prescription of GM to treat the following infectious disorders: infection due to Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, Citrobacter spp., Enterobacteriaceae spp., Pseudomonas spp.; Staphylococcus infectious disease; bacterial meningitis; bacterial sepsis of newborns; bacterial septicemia; infection of the eye, bone, skin and/or subcutaneous tissue; infective endocarditis; peritoneal dialysis-associated peritonitis due to Pseudomonas and other gram-negative organisms; peritonitis due to gastrointestinal tract infections; respiratory tract infections; and urinary tract infectious disease. GM is an old antibiotic and is used widely beyond its FDA-labeled indications as follows: actinomycotic infection; Staphylococcus saprophyticus bacteremia with pyelonephritis; appendicitis; cystic fibrosis; diverticulitis; adjunct regimen for febrile neutropenia; female genital infection; uterine infection; postnatal infection; necrotizing enterocolitis in fetus or newborn; osteomyelitis; pelvic inflammatory disease; plague; gonorrhea; tularemia; prophylaxis of post-cholecystectomy infection, transrectal prostate biopsy, and post-tympanostomy-related infection; malignant otitis externa; and intratympanically or transtympanically for Ménière's disease. GM is also used in combination regimens, such as with beta-lactam antibiotics to treat mixed infection and with bacteriophage to treat Staphylococcus aureus infections. It is also added to medical materials, such as GM-loaded cement spacers for osteomyelitis and prosthetic joint-associated infections. Overall, there are many medicinal applications for GM. To reduce the development of GM-resistant bacteria and to maintain its effectiveness, GM should be used only to treat or prevent infections that are proven or strongly suspected as being caused by susceptible bacteria. In the future, we believe that GM will be used more widely in combination therapy and applied to medical materials for clinical applications. A definitive, appropriately powered study of this antibiotic and its clinical applications is now required, especially in terms of its effectiveness, safety, and cost.

Incidence of sternal wound infection after reexploration in the intensive care unit and the use of local gentamycin

BACKGROUND

Reoperation for bleeding is a known emergency complication after cardiac operations. When performed in the intensive care unit (ICU), sterility issues arise. Our aim was to examine the incidence of sternal wound infection (SWI) after reexploration in the ICU for bleeding with routine use of local gentamycin.

METHODS

From January 2003 until December 2009, 4,863 patients underwent cardiac operations through a median sternotomy at our institution. We conducted a retrospective database review identifying all patients who required reoperations. The occurrence of SWI in this group was compared with the general cardiac surgical population. Reoperations for bleeding during this period were conducted routinely in the ICU with prophylactic application of a gentamycin sponge between the sternal halves before closure in all cases.

RESULTS

Reexploration for bleeding was necessary in 302 patients (6.2%), and SWI occurred in 11, for a rate of 3.6%. SWI occurred in 174 of the 4,561 non-reexplored patients, for a similar rate of 3.8% (p>0.9). These values are similar to our overall rate of SWI of 3.8% (n=185) in the total cohort of 4,863 patients.

CONCLUSIONS

The incidence of SWI was not increased in our study group after emergency reoperation for bleeding in the ICU after the local use of gentamycin. Our data suggest that reexploration in an ICU setting for bleeding does not pose a sterility challenge and that life-threatening delays due to transfer to the operating theater may be avoided.

The possibility of using fibrin-based collagen as an antibiotic delivery system

PURPOSE

Collagen and fibrin are known to have potential use as a local drug-delivery system. This experimental study was designed to evaluate whether a fibrinogen-based collagen (FBC) fleece, coated with thrombin and aprotinin, can be used as an antibiotic delivery system.

METHODS

In an in vitro study, gentamicin, fosfomycin, ampicillin, ciprofloxacin and dibekacin were absorbed by the FBC, Kirby-Bauer disks (KBDs), and expanded polytetrafluoroethylene. After washing with saline or phosphate buffer saline (PBS) 3 times for 6, 12 and 24 h, each sample was analyzed for antibiotic retention. In an in vivo study, we implanted the FBC onto mouse livers and dripped gentamicin and ciprofloxacin onto the FBC. The FBCs were subsequently collected and analyzed for their antibiotic activities.

RESULTS

After irrigation with saline, each antibiotic showed different activities. After PBS washing, the FBC impregnated with each antibiotic had higher activity than the KBDs, and inhibited the bacterial growth by 60-80 % compared to the control. Gentamicin dripped onto the FBC could inhibit bacterial growth after 48 h in vivo without affecting the hemostatic properties of the FBC. However, the FBC treated with ciprofloxacin exhibited antibacterial activity for only 3 h.

CONCLUSIONS

Some bases, including FBC, can retain antibacterial activities dependent on the ingredients of the base and the type of antibiotic. Gentamicin, but not ciprofloxacin, was retained in the FBC in vivo. These results suggest that absorbent FBC might be useful not only as hemostatic material, but also as a local drug-delivery system.

Prevention of early infective complications after laparoscopic splenectomy with the Garamycin sponge

Introduction

Surgical site infection (SSI) appear to be more frequent in splenectomized patients than might be expected and its incidence can be explained neither by the extent of surgery nor by the risk of bacterial contamination of the operating field.

Aim

Evaluation the local antibiotic prophylaxis using a gentamicin surgical implant in order to reduce SSI, particularly subphrenic abscesses.

Material and methods

We conducted a prospective, randomized study of two groups of patients undergoing laparoscopic splenectomy who were considered at high risk of infective complications: patients with idiopathic thrombocytopenic purpura (ITP) pre-treated chronically with systemic steroids and patients with non-Hodgkin lymphoma (NHL). Out of 98 laparoscopic splenectomies performed during the study period, 40 patients with ITP and 20 with NHL met the inclusion criteria and were enrolled in the study. In 20 randomly selected patients with ITP and 10 with NHL, a gentamicin-collagen implant was left in the splenic bed.

Results

Infective complications occurred in 4 (6.67%) among 60 patients from the entire study group; 2 in patients with ITP and a gentamicin implant who developed fever of unknown cause which resolved after systemic antibiotics, and 2 in patients with NHL and gentamicin prophylaxis who developed a subphrenic abscess. In all patients operated on without a gentamicin implant, the postoperative course was uncomplicated.

Conclusions

Gentamicin surgical implants not only fail to reduce the risk of subphrenic abscesses in splenectomized patients, but may contribute to the increase in its incidence, which puts into question the possible benefits of this form of prophylaxis.

The role of topical antibiotics used as prophylaxis in surgical site infection prevention

Compared with systemic antibiotic therapy, the topical or local delivery of an antibiotic has many potential advantages. However, local antibiotics at the surgical site have received very limited approval in any of the surgical prophylaxis consensus guidelines that we are aware of. A review of the literature was carried out through searches of peer-reviewed publications in PubMed in the English language over a 30 year period between January 1980 and May 2010. Both retrospective and prospective studies were included, as well as meta-analyses. With regard to defining 'topical' or 'local' antibiotic application, the application of an antibiotic solution to the surgical site intraoperatively or immediately post-operatively was included. A number of surgical procedures have been shown to significantly benefit from perioperative topical prophylaxis, e.g. joint arthroplasty, cataract surgery and, possibly, breast augmentation. In obese patients undergoing abdominal surgery, topical surgical prophylaxis is also proven to be beneficial. The selective use of topical antibiotics as surgical prophylaxis is justified for specific procedures, such as joint arthroplasty, cataract surgery and, possibly, breast augmentation. In selective cases, such as obese patients undergoing abdominal surgery, topical surgical prophylaxis is also proven to be beneficial. Apart from these specific indications, the evidence for use of topical antibiotics in surgery is lacking in conclusive randomized controlled trials.

Effect of local gentamicin application on healing and wound infection in patients with modified radical mastectomy: a prospective randomized study

This study investigated the effects of Gentacoll implants on healing in patients (n = 44) undergoing modified radical mastectomy and axillary dissection. Group I, the Gentacoll group (n = 22), underwent surgery followed by insertion of 10 × 10 × 0.5 cm Gentacoll implants (280 mg collagen sponge plus 200 mg gentamicin sulphate) into the axillary area and under the flap area of the breast before wound closure. Group II, the control group (n = 22), underwent surgery without the application of Gentacoll. Neither group received oral or parenteral post-operative antibiotic therapy. Outcome measures included wound infection, seroma formation, total drainage volumes, drain removal time and duration of hospital stay. Post-operative infection rate, seroma formation, drainage volumes and duration of hospital stay were significantly reduced in the Gentacoll group compared with the control group. In conclusion, the application of Gentacoll significantly improved post-operative outcomes in patients undergoing modified radical mastectomy.

Nanofiber micro-dispersed oxidized cellulose as a carrier for topical antimicrobials: first experience

BACKGROUND

Micro-dispersed oxidized cellulose, already used for hemostasis, might be helpful for introduction of an antimicrobial drug.

AIM

To examine the effect of topically applied gentamicin attached to a new biodegradable carrier formed by micro-dispersed oxidized cellulose in microfiber and nanofiber form for treatment of acute wound infection and to assess the influence of this carrier on healing.

MATERIALS AND METHODS

A model of a full-thickness infected dermal wound was created in 12 female domestic pigs. The effectiveness of topical gentamicin delivered with micro-dispersed oxidized cellulose carrier was tested in acute wound infections caused by Staphylococcus aureus, Pseudomonas aeruginosa, or Escherichia coli.

RESULTS

The effectiveness of nanofiber micro-dispersed oxidized cellulose with gentamicin was proved according to culture findings. When assessed macroscopically, 100% of wounds treated by the nanofiber product had no signs of local infection. When microfiber micro-dispersed oxidized cellulose was used, cultures demonstrated residual bacteria in 94.4% of treated incisions despite the absence of clinically recognized infection.

CONCLUSIONS

Micro-dispersed oxidized cellulose carrier with a sufficient concentration of an attached antibiotic appears to be effective for the treatment of full-thickness skin infections. The positive influence of the product on the healing of a dermal incision was shown, and a good hemostatic effect was confirmed.

Elution kinetics, antimicrobial efficacy, and degradation and microvasculature of a new gentamicin-loaded collagen fleece

Management of bone and soft tissue infections generally includes surgical procedures as well as attendant treatment and prevention with gentamicin-loaded fleeces. Conventional gentamicin-containing collagen fleeces currently in use are strongly acidic and exhibit limited biocompatibility thereby adversely affecting wound healing. To improve the antibiotic delivery system, a new phosphate-buffered, gentamicin-loaded fleece with pH-neutral properties has been developed (Jason G). This study aimed at comparing the elution kinetics of gentamicin release and the antimicrobial efficacy of conventional fleeces with the newly developed fleece in vitro. In addition, degradation and microvasculature of implanted fleeces were examined in a rat model and assessed using histology, as well as detection of ED-1 and PECAM-expression using immunohistochemistry. We show that the phosphate-buffered fleeces have reduced release (p < 0.05) of the integrated gentamicin. However, all of the fleeces tested had a significant antimicrobial effect on the growth of Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa strains (p < 0.01). Among the fleeces tested, the new Jason G fleece had the weakest but nevertheless sufficient antimicrobial effectiveness. Evaluation of the antibiotic effect in the prevention of an infection showed no differences between the applied fleeces. Following surgical implantation of fleece in the backs of Wistar rats we observed, on day 5 after implantation, an increase in cell infiltration and microvascularization with the phosphate-buffered fleece as compared with conventional fleeces, which show necrotic cells on their surface. Unlike the acidic fleeces, on day 15 after implantation the pH-neutral fleece was resorbed widely. Here, we show that the new, pH-neutral, gentamicin-containing fleece Jason G exhibits good overall antimicrobial effectiveness against both gram-positive and gram-negative bacteria in vitro with improved degradation properties and microvasculature formation in vivo.