Surgical site infection (SSI) is the most common nosocomial infection among surgical Patients.The impact of these infections in terms of clinical and financial out comes is substantial.
In cardiac surgery, sternal wound infection (SWI) continues to be one of the most serious postoperative complications. Coagulase-negative staphylococci (CoNS) have become the most common causative agents of SWI. Prophylaxis with intravenous beta-lactam antibiotics is routinely practised. However, many CoNS species are resistant to beta-lactam antibiotics. Vancomycin is often the only effective antibiotic available for treatment of these infections, but its use for routine prophylaxis is strongly discouraged because of the risk of increasing the selection of resistant bacteria. The aim of this work was to develop and evaluate a new technique for antibiotic prophylaxis in cardiac surgery consisting of application of drug eluting collagen-gentamicin sponges in the sternal wound in addition to conventional intravenous antibiotics. The antibiotic concentrations in the wound and serum achieved by routine intravenous dicloxacillin prophylaxis and those after application of local collagen-gentamicin in the sternal wound were investigated…
Contents
INTRODUCTION
Incidence of sternal wound infection
Microbiology
Mortality
Cost
Prevention
1. Minimise contamination
a. Reduce bacterial levels in the operating room
b. Pre- and postoperative hygiene routines
2. Surgical technique
a. Avoid necrosis and ischaemia
b. Avoid haematomas, bleeding and dead space
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d. Minimise foreign material
3. Optimise conditions for wound healing
a. Optimise blood supply and pO2 in tissues
b. Reduce oedema
c. Optimise blood glucose control
4. Antibiotic prophylaxis
Aim of the prophylaxis
Intravenous prophylaxis
Rationale for reconsidering the present iv prophylaxis
Local application of antibiotics
AIMS
MATERIALS AND METHODS
Patients
Dicloxacillin concentrations after iv administration (I)
Gentamicin concentrations after local administration (I)
Local Gentamicin for Sternal Wound Infection Prophylaxis (LOGIP) trial (II-V)
Antibiotic prophylactic techniques
Routine iv antibiotic prophylaxis protocol
Local collagen-gentamicin: surgical technique
Study design and data collection
Dicloxacillin concentrations (I)
Gentamicin concentrations (I)
Design of the LOGIP trial (II-V)
General design
End point
Follow-up and data collection
Comment
Risk factors for sternal wound infection (III)
Cost of a sternal wound infection and cost effectiveness of local gentamicin prophylaxis (III)
Model for calculating the cost of a sternal wound infection
Cost effectiveness
Sensitivity analysis
Comment
Comment
of local gentamicin prophylaxis (V)
Comment
Biochemical analyses
Dicloxacillin concentration (I)
Gentamicin concentration (I)
Comment
Microbiological analyses
Bacterial samples (II-IV)
Statistical methods (I-V)
Sample size
Risk factor analysis (III)
General statistical methods
RESULTS AND DISCUSSION
Antibiotic concentration determinations
Dicloxacillin concentrations (I)
Comment
Gentamicin concentrations (I)
Comment
LOGIP trial
Effect of local gentamicin on sternal wound infections (II, IV)
Primary end point (II)
Microbiological agents and clinical presentation (IV)
Comment
General outcome (II)
Adverse reactions
Comment
Risk factors for sternal wound infection (III)
Effect of prophylaxis in risk groups
Comment
Cost of a sternal wound infection (III)
Comment
Cost effectiveness of local gentamicin prophylaxis (III)
Comment
Clinical presentation in relation to microbiological agent (IV)
Cost related to microbiological agent
Symptoms
Time to presentation
Comment
Antibiotic susceptibility (IV)
Comment
Comment
Comment
GENERAL DISCUSSION
Prophylactic effect of local gentamicin
Prophylaxis and antibiotic concentrations
Cost effectiveness
Issues of consideration
The increase in reoperation for bleeding
Future perspectives
Details of the technique
Antibiotic resistance
Applications outside cardiac surgery
CONCLUSIONS
ACKNOWLEDGMENTS
REFERENCES
Author: Friberg, Örjan
Source: Linköping University
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