- Email: [email protected]
Should an infected Nuss bar be removed?
Journal of Pediatric Surgery (2005) 40, 670 – 673
www.elsevier.com/locate/jpedsurg
Should an infected Nuss bar be removed? Katrien M. Van Renterghema, Silvester von Bismarckc, Nikolaas M.A. Baxa,*, Andre Fleerb, Michael E. Ho¨llwarthc a
Department of Pediatric Surgery, Wilhelmina Children’s Hospital, University Medical Center, PO Box 85090, 3508AB Utrecht, The Netherlands b Department of Microbiology, University Medical Center, Utrecht, The Netherlands c Department of Pediatric Surgery, University Medical Center, Graz, Austria Index words: Pectus excavatum; Nuss procedure; Bar infection
Abstract Background: The Nuss procedure is a minimally invasive procedure for correction of pectus excavatum. It involves insertion of a substernal metal bar. A feared complication of any implanted device is infection, which often necessitates removal. The purpose of this report is to describe the authors’ experience with infectious complications after the Nuss procedure. Methods: From February 2000 to July 2002, 102 patients underwent the Nuss procedure in 2 pediatric surgical centers. In a retrospective way, the files of those patients in whom a postoperative infection developed were studied. Results: Seven patients suffered postoperative infectious complications. Only one bar needed to be removed. Conclusion: The authors’ experience indicates that there is no need for immediate removal of an infected Nuss bar. Most of these infections can be managed conservatively. However, early antibiotic treatment is warranted to ensure salvage of the bar. D 2005 Elsevier Inc. All rights reserved.
In 1998, the Nuss procedure [1] was introduced as a minimally invasive alternative to the standard open Ravitch technique for the correction of pectus excavatum. This technique gained easily popularity because of its apparent simplicity and good results [3,4]. As with any new operation, a number of problems have been reported [1-6]. A much dreaded complication of any implanted device is infection, which often necessitates removal, particularly when infected by Staphylococcus aureus, gram-negative bacilli, and Candida sp [7].
1. Materials and methods From February 2000 to July 2002, 102 patients underwent a pectus excavatum correction according to the Nuss method in 2 pediatric surgical departments. The bar was inserted under thoracoscopic control in all patients. Antibiotic prophylaxis (amoxicillin/clavulanate or cefuroxim) was given to all patients. Seven (6.8%) patients developed a postoperative infection. Their postoperative course is described in the following case reports.
1.1. Case 1 4 Corresponding author. Tel.: +31 30 2504004; fax: +31 30 2505348. E-mail address: [email protected] (N.M.A. Bax). 0022-3468/05/4004-0011$30.00/0 D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2004.12.005
This 7-year-old boy went home on postoperative day (POD) 6 after an uneventful postoperative course. On POD 8, he had fever (39.38C) and showed inflammation of both
Should an infected Nuss bar be removed? thoracic wounds without drainage. Oral antibiotics were started (amoxicillin/clavulanate). Despite antibiotic treatment, fever persisted the next 2 days and pus drained from the left thoracic wound. For this reason, he was rehospitalized on POD 10 and intravenous broad spectrum antibiotics (amoxicillin/clavulanate and gentamycin) were started. At that moment, he had a white cell count of 16,000/lL and a C-reactive protein (CRP) of 157 mg/L. Culture of the pus yielded methicillin-sensitive S aureus and on POD 14, antibiotics were switched to flucloxacillin. A 14-day course of intravenous antibiotics was completed. Fever disappeared, drainage of pus stopped, and inflammatory parameters normalized during hospitalization. He was discharged on POD 24. At that moment, the left thoracic wound again showed some drainage. Flucloxacillin was continued orally for another 4 weeks. The left thoracic wound eventually healed. Since that time he did not have any infection anymore. At 1 year postoperatively, the stabilizer of the bar was removed because of displacement. At 2 years the bar is still in place but will be removed after another year.
1.2. Case 2 This 15-year-old adolescent boy developed some serous drainage from the right thoracic incision on POD 4. Oral antibiotic treatment (amoxicillin/clavulanate) was started on an outpatient basis. Culture of the fluid yielded methicillinsensitive S aureus. Antibiotic treatment was continued for 3 weeks. Drainage halted and the thoracic incision healed. Three months postoperatively, he is doing well, without any further infectious complications and the bar is still in place.
1.3. Case 3 This 17-year-old adolescent boy was discharged home on POD 5. On POD 9, he showed erythema of the left thoracic wound without drainage. C-reactive protein was 48 mg/L and white cell count 28,000/lL. Oral antibiotic treatment (amoxicillin/clavulanate) was initiated. At POD 11, he was rehospitalized with fever, general malaise, retrosternal pain, and drainage of pus from both thoracic wounds. On the left side, one of the extremities of the metal bar was visible in the open wound. The CRP had risen to 340 mg/L and white cell count was 17,300/lL. Intravenous antibiotic therapy (flucloxacillin and clindamycin) was started. An ultrasound ruled out endo- and/or pericarditis. Chest x-ray showed normal lungs and no pleural fluid. From the pus, methicillinsensitive S aureus was isolated. Flucloxacillin was continued as monotherapy for another 10 days. He was discharged on POD 19 with flucloxacillin orally. C-reactive protein was 17 mg/L and white cell count was 14,400/lL. On POD 21 he was rehospitalized because of severe retrosternal pain requiring intravenous morphine. At the some time, antibiotics were again administered intravenously. He was finally discharged on POD 34. Antibiotics were continued
671 for another 2 weeks orally, so in total he completed a 6week course of antibiotic treatment. At follow-up 1 month later, the thoracic wounds were healed without signs of infection and he was doing well. At 6 months postoperatively, the bar is still in place and the patient is doing well.
1.4. Case 4 On POD 5, this 16-year-old adolescent boy developed fever (38.58C). Clinical examination was unremarkable. At that moment, his CRP was 420 mg/L and white cell count 12,000/lL. Chest x-ray was normal. Under suspicion of a subclinical wound and/or bar infection, intravenous amoxicillin/clavulanate was started. Blood cultures remained sterile. On POD 7, clinical examination did not reveal an infectious focus yet and CRP had dropped to 166 mg/L. He was discharged the same day with oral amoxicillin/ clavulanate. At home, he again developed fever and on POD 9, pus drained from the left thoracic incision. He was seen in the outpatient clinic on POD 15. At that moment, fever had subsided but the left thoracic incision still showed some redness. Culture of the wound was sterile. Amoxicillin/clavulanate was continued for another 2 weeks and the wound healed without any further complications. At 4 months postoperatively, he is doing well and the bar is still in place.
1.5. Case 5 This 16-year-old adolescent boy developed erythema of both thoracic wounds on POD 2. C-reactive protein was 123 mg/L. Intravenous antibiotics were switched to meropenem and metronidazole; on POD 3, fosfomycine was added because of a rising CRP (148 mg/L). On POD 9, he complained of dyspnea. Chest x-ray showed bilateral pleural effusions. Pleural tab revealed 1 L of old blood. Moreover, CRP had risen again to 168 mg/L and white cell count was 13,500/lL. Antibiotics were switched to vancomycin and piperacillin/tazobactam. On POD 13, he complained of retrosternal pain. Ultrasound demonstrated a pericardial effusion, another chest x-ray showed displacement of the Nuss bar. During reoperation for repositioning of the bar, drainage of pus was noticed along the Nuss bar that was removed. Culture of the pus yielded methicillinresistant Staphylococcus epidermidis. Intravenous antibiotics were continued for another week. On POD 27, he was discharged. Oral antibiotic treatment was continued for 3 more weeks. Two months postoperatively, he is doing well but refuses further attempts for correction of his funnel chest.
1.6. Case 6 This 17-year-old adolescent boy underwent thoracoscopic lung biopsy for multiple lung spots before his funnel chest operation. Histologic examination of the lung biopsy revealed postinfectious changes. On POD 2 after the Nuss procedure, he suffered pain and had fever (38.48C). White
672 cell count was normal and CRP was 235 mg/L. Ultrasound demonstrated bilateral pleural effusions. Intravenous cefuroxime and fosfomycine were started and continued till POD 13. At discharge on POD 14, white cell count was normal, CRP was 45 mg/L, and ultrasound showed less pleural fluid. Oral amoxicillin/clavulanate was administered. On POD 31, he was rehospitalized because of clinical deterioration. He had a subfebrile temperature, a CRP of 65 mg/L, and a chest x-ray showed an increase in pleural effusions. Intravenous clindamycin was initiated. A computed tomography scan of the thorax showed reactive pleural effusions and an infiltrate of the right middle lobe. He was finally discharged on POD 38 with oral clindamycin. Antibiotic treatment was continued for another 5 weeks. Subsequently, the patient’s course was uneventful and the bar is still in place.
1.7. Case 7 This 18-year-old man had fever (38.88C) on POD 1. White cell count was normal and CRP was 59 mg/L. Intravenous cefuroxim was started. Despite this, fever persisted and CRP increased to 157 mg/L on POD 4. Ultrasound demonstrated bilateral pleural effusions and clindamycin was started. Fever disappeared and CRP normalized the following days. Intravenous antibiotic treatment was continued until discharge on POD 10. Oral clindamycin was continued for another week. At 1 month postoperatively, he is doing well and the bar is still in place.
2. Discussion Wound infection is a feared postoperative complication after implantation of a prosthetic device. Bacterial colonization and subsequent infection of prosthetic material can lead to implant failure, often requiring removal of the device. Prosthetic joint infection is a well-known and dreaded complication in orthopedic surgery [8]. In a series of 26,505 patients who received total hip or total knee replacements, 1.8% of patients developed this complication [9]. Prosthetic joint infection has been shown to highly correlate with superficial surgical site infection [9], occurring in 3.4% [10] to 14.3% [11] of patients undergoing hip or knee arthroplasty. The treatment of such infections usually is prolonged and difficult to complete for the patient. Treatment commonly consists of removal of the prosthesis, a long course of antibiotics, and if possible implantation of a new device [8]. It is obvious that these patients consume a considerable amount of health care resources [12]. The reported incidence of wound infection after the Nuss procedure amounts to 2.3% [2,3], resulting in bar infection and eventual bar removal in 0.7% [2]. However, the number of literature reports of patients that underwent a Nuss procedure is still small [1-5] and the details of infectious complications are lacking in most of these reports. Potentially, this might lead to an underestimation of the incidence of postoperative wound infections. Because the extremities
K.M. Van Renterghem et al. of the Nuss bar are located immediately underneath the skin incisions, one would expect a higher rate of bar infections once wound infection occurs. Fortunately, most of these wound infections can be managed conservatively and without any significant sequelae [2,3]. Nevertheless, major complications such as mediastinitis, bacterial pericarditis, and bilateral thoracic empyema have been described [5,6]. The patients of the last 2 case reports did not have any wound infection but presented with pneumonia and reactive pleural effusions. Because of the intrathoracic positioning of the Nuss bar, pulmonary infections are also feared because of the risk of bar infection [13]. The 7 infections (3 documented S aureus infections, 1 documented S epidermidis infection) in our series lead to removal of the bar one patient only. In the short term (mean follow-up, 6.6 months), no slipping occurred nor was there a need to remove the bar prematurely in the remaining 6 patients. Two patients could be treated on an outpatient basis but 5 patients required prolonged hospitalization. This is remarkable, because with other prosthetic devices, particularly intravascular catheters and prosthetic joints, S aureus infection usually requires removal of the device to prevent serious complications [14,15]. Explanations for this discrepancy may lie in the patient populations: patients with pectus excavatum are usually young and healthy without any underlying disease, whereas the reverse is true for patients with intravascular catheters (intensive care unit, hematology-oncology patients, usually with compromised host defenses) and patients with prosthetic joints (elderly patients with debilitating underlying diseases). Since the occurrence of these complications, we have changed our policy of antibiotic prophylaxis. Instead of one preoperative dose of amoxicillin/clavulanate (Utrecht) or cefuroxim (Graz), the same combination is now continued for 24 hours. Moreover, if during the postoperative course any suspicion of wound or pulmonary infection arises, antibiotic therapy is started immediately. Since this policy change no further infectious complications have been encountered. Our experience indicates that there is no need for immediate removal of an infected Nuss bar. However, it should be stressed that when wound infection occurs, early antibiotic treatment is warranted to ensure salvage of the implanted bar.
References [1] Nuss D, Kelly RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545 - 52. [2] Croitoru DP, Kelly RE, Goretsky MJ, et al. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37: 437 - 45. [3] Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 2000;35:252 - 8.
Should an infected Nuss bar be removed? [4] Miller KA, Woods RK, Sharp RJ, et al. Minimally invasive repair of pectus excavatum: a single institution’s experience. Surgery 2001;130: 652 - 9. [5] Mollik KA, Engum SA, Rescorla FJ, et al. Pectus excavatum repair: experience with standard and minimally invasive techniques. J Pediatr Surg 2001;36:324 - 8. [6] Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: case reports. J Pediatr Surg 2001;36:155 - 8. [7] Printzen G. Relevance, pathogenicity and virulence of microorganisms in implant related infections. Injury 1996;27:C9-C15. [8] Tobin EH. Prosthetic joint infections: controversies and clues. Lancet 1999;353:770 - 1. [9] Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998; 27:1247 - 54.
673 [10] Poon PC, Rennie J, Gray DH. Review of total hip replacement. The Middlemore Hospital experience, 1980-1991. N Z Med J 2001;114: 254 - 6. [11] Gaine WJ, Ramamohan NA, Hussein NA, et al. Wound infection in hip and knee arthroplasty. J Bone Joint Surg Br 2000;82: 561 - 5. [12] Saleh K, Olson M, Resig S, et al. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. J Orthop Res 2002;20:506 - 15. [13] Nuss D, Croitoru DP, Kelly Jr RE, et al. Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 2002;12:230 - 4. [14] Schierholz JM, Beuth J. Implant infections: a haven for opportunistic bacteria. J Hosp Infect 2001;49:87 - 93. [15] Raad I. Intravascular-catheter–related infections. Lancet 1998;351: 893 - 8.
www.elsevier.com/locate/jpedsurg
Should an infected Nuss bar be removed? Katrien M. Van Renterghema, Silvester von Bismarckc, Nikolaas M.A. Baxa,*, Andre Fleerb, Michael E. Ho¨llwarthc a
Department of Pediatric Surgery, Wilhelmina Children’s Hospital, University Medical Center, PO Box 85090, 3508AB Utrecht, The Netherlands b Department of Microbiology, University Medical Center, Utrecht, The Netherlands c Department of Pediatric Surgery, University Medical Center, Graz, Austria Index words: Pectus excavatum; Nuss procedure; Bar infection
Abstract Background: The Nuss procedure is a minimally invasive procedure for correction of pectus excavatum. It involves insertion of a substernal metal bar. A feared complication of any implanted device is infection, which often necessitates removal. The purpose of this report is to describe the authors’ experience with infectious complications after the Nuss procedure. Methods: From February 2000 to July 2002, 102 patients underwent the Nuss procedure in 2 pediatric surgical centers. In a retrospective way, the files of those patients in whom a postoperative infection developed were studied. Results: Seven patients suffered postoperative infectious complications. Only one bar needed to be removed. Conclusion: The authors’ experience indicates that there is no need for immediate removal of an infected Nuss bar. Most of these infections can be managed conservatively. However, early antibiotic treatment is warranted to ensure salvage of the bar. D 2005 Elsevier Inc. All rights reserved.
In 1998, the Nuss procedure [1] was introduced as a minimally invasive alternative to the standard open Ravitch technique for the correction of pectus excavatum. This technique gained easily popularity because of its apparent simplicity and good results [3,4]. As with any new operation, a number of problems have been reported [1-6]. A much dreaded complication of any implanted device is infection, which often necessitates removal, particularly when infected by Staphylococcus aureus, gram-negative bacilli, and Candida sp [7].
1. Materials and methods From February 2000 to July 2002, 102 patients underwent a pectus excavatum correction according to the Nuss method in 2 pediatric surgical departments. The bar was inserted under thoracoscopic control in all patients. Antibiotic prophylaxis (amoxicillin/clavulanate or cefuroxim) was given to all patients. Seven (6.8%) patients developed a postoperative infection. Their postoperative course is described in the following case reports.
1.1. Case 1 4 Corresponding author. Tel.: +31 30 2504004; fax: +31 30 2505348. E-mail address: [email protected] (N.M.A. Bax). 0022-3468/05/4004-0011$30.00/0 D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2004.12.005
This 7-year-old boy went home on postoperative day (POD) 6 after an uneventful postoperative course. On POD 8, he had fever (39.38C) and showed inflammation of both
Should an infected Nuss bar be removed? thoracic wounds without drainage. Oral antibiotics were started (amoxicillin/clavulanate). Despite antibiotic treatment, fever persisted the next 2 days and pus drained from the left thoracic wound. For this reason, he was rehospitalized on POD 10 and intravenous broad spectrum antibiotics (amoxicillin/clavulanate and gentamycin) were started. At that moment, he had a white cell count of 16,000/lL and a C-reactive protein (CRP) of 157 mg/L. Culture of the pus yielded methicillin-sensitive S aureus and on POD 14, antibiotics were switched to flucloxacillin. A 14-day course of intravenous antibiotics was completed. Fever disappeared, drainage of pus stopped, and inflammatory parameters normalized during hospitalization. He was discharged on POD 24. At that moment, the left thoracic wound again showed some drainage. Flucloxacillin was continued orally for another 4 weeks. The left thoracic wound eventually healed. Since that time he did not have any infection anymore. At 1 year postoperatively, the stabilizer of the bar was removed because of displacement. At 2 years the bar is still in place but will be removed after another year.
1.2. Case 2 This 15-year-old adolescent boy developed some serous drainage from the right thoracic incision on POD 4. Oral antibiotic treatment (amoxicillin/clavulanate) was started on an outpatient basis. Culture of the fluid yielded methicillinsensitive S aureus. Antibiotic treatment was continued for 3 weeks. Drainage halted and the thoracic incision healed. Three months postoperatively, he is doing well, without any further infectious complications and the bar is still in place.
1.3. Case 3 This 17-year-old adolescent boy was discharged home on POD 5. On POD 9, he showed erythema of the left thoracic wound without drainage. C-reactive protein was 48 mg/L and white cell count 28,000/lL. Oral antibiotic treatment (amoxicillin/clavulanate) was initiated. At POD 11, he was rehospitalized with fever, general malaise, retrosternal pain, and drainage of pus from both thoracic wounds. On the left side, one of the extremities of the metal bar was visible in the open wound. The CRP had risen to 340 mg/L and white cell count was 17,300/lL. Intravenous antibiotic therapy (flucloxacillin and clindamycin) was started. An ultrasound ruled out endo- and/or pericarditis. Chest x-ray showed normal lungs and no pleural fluid. From the pus, methicillinsensitive S aureus was isolated. Flucloxacillin was continued as monotherapy for another 10 days. He was discharged on POD 19 with flucloxacillin orally. C-reactive protein was 17 mg/L and white cell count was 14,400/lL. On POD 21 he was rehospitalized because of severe retrosternal pain requiring intravenous morphine. At the some time, antibiotics were again administered intravenously. He was finally discharged on POD 34. Antibiotics were continued
671 for another 2 weeks orally, so in total he completed a 6week course of antibiotic treatment. At follow-up 1 month later, the thoracic wounds were healed without signs of infection and he was doing well. At 6 months postoperatively, the bar is still in place and the patient is doing well.
1.4. Case 4 On POD 5, this 16-year-old adolescent boy developed fever (38.58C). Clinical examination was unremarkable. At that moment, his CRP was 420 mg/L and white cell count 12,000/lL. Chest x-ray was normal. Under suspicion of a subclinical wound and/or bar infection, intravenous amoxicillin/clavulanate was started. Blood cultures remained sterile. On POD 7, clinical examination did not reveal an infectious focus yet and CRP had dropped to 166 mg/L. He was discharged the same day with oral amoxicillin/ clavulanate. At home, he again developed fever and on POD 9, pus drained from the left thoracic incision. He was seen in the outpatient clinic on POD 15. At that moment, fever had subsided but the left thoracic incision still showed some redness. Culture of the wound was sterile. Amoxicillin/clavulanate was continued for another 2 weeks and the wound healed without any further complications. At 4 months postoperatively, he is doing well and the bar is still in place.
1.5. Case 5 This 16-year-old adolescent boy developed erythema of both thoracic wounds on POD 2. C-reactive protein was 123 mg/L. Intravenous antibiotics were switched to meropenem and metronidazole; on POD 3, fosfomycine was added because of a rising CRP (148 mg/L). On POD 9, he complained of dyspnea. Chest x-ray showed bilateral pleural effusions. Pleural tab revealed 1 L of old blood. Moreover, CRP had risen again to 168 mg/L and white cell count was 13,500/lL. Antibiotics were switched to vancomycin and piperacillin/tazobactam. On POD 13, he complained of retrosternal pain. Ultrasound demonstrated a pericardial effusion, another chest x-ray showed displacement of the Nuss bar. During reoperation for repositioning of the bar, drainage of pus was noticed along the Nuss bar that was removed. Culture of the pus yielded methicillinresistant Staphylococcus epidermidis. Intravenous antibiotics were continued for another week. On POD 27, he was discharged. Oral antibiotic treatment was continued for 3 more weeks. Two months postoperatively, he is doing well but refuses further attempts for correction of his funnel chest.
1.6. Case 6 This 17-year-old adolescent boy underwent thoracoscopic lung biopsy for multiple lung spots before his funnel chest operation. Histologic examination of the lung biopsy revealed postinfectious changes. On POD 2 after the Nuss procedure, he suffered pain and had fever (38.48C). White
672 cell count was normal and CRP was 235 mg/L. Ultrasound demonstrated bilateral pleural effusions. Intravenous cefuroxime and fosfomycine were started and continued till POD 13. At discharge on POD 14, white cell count was normal, CRP was 45 mg/L, and ultrasound showed less pleural fluid. Oral amoxicillin/clavulanate was administered. On POD 31, he was rehospitalized because of clinical deterioration. He had a subfebrile temperature, a CRP of 65 mg/L, and a chest x-ray showed an increase in pleural effusions. Intravenous clindamycin was initiated. A computed tomography scan of the thorax showed reactive pleural effusions and an infiltrate of the right middle lobe. He was finally discharged on POD 38 with oral clindamycin. Antibiotic treatment was continued for another 5 weeks. Subsequently, the patient’s course was uneventful and the bar is still in place.
1.7. Case 7 This 18-year-old man had fever (38.88C) on POD 1. White cell count was normal and CRP was 59 mg/L. Intravenous cefuroxim was started. Despite this, fever persisted and CRP increased to 157 mg/L on POD 4. Ultrasound demonstrated bilateral pleural effusions and clindamycin was started. Fever disappeared and CRP normalized the following days. Intravenous antibiotic treatment was continued until discharge on POD 10. Oral clindamycin was continued for another week. At 1 month postoperatively, he is doing well and the bar is still in place.
2. Discussion Wound infection is a feared postoperative complication after implantation of a prosthetic device. Bacterial colonization and subsequent infection of prosthetic material can lead to implant failure, often requiring removal of the device. Prosthetic joint infection is a well-known and dreaded complication in orthopedic surgery [8]. In a series of 26,505 patients who received total hip or total knee replacements, 1.8% of patients developed this complication [9]. Prosthetic joint infection has been shown to highly correlate with superficial surgical site infection [9], occurring in 3.4% [10] to 14.3% [11] of patients undergoing hip or knee arthroplasty. The treatment of such infections usually is prolonged and difficult to complete for the patient. Treatment commonly consists of removal of the prosthesis, a long course of antibiotics, and if possible implantation of a new device [8]. It is obvious that these patients consume a considerable amount of health care resources [12]. The reported incidence of wound infection after the Nuss procedure amounts to 2.3% [2,3], resulting in bar infection and eventual bar removal in 0.7% [2]. However, the number of literature reports of patients that underwent a Nuss procedure is still small [1-5] and the details of infectious complications are lacking in most of these reports. Potentially, this might lead to an underestimation of the incidence of postoperative wound infections. Because the extremities
K.M. Van Renterghem et al. of the Nuss bar are located immediately underneath the skin incisions, one would expect a higher rate of bar infections once wound infection occurs. Fortunately, most of these wound infections can be managed conservatively and without any significant sequelae [2,3]. Nevertheless, major complications such as mediastinitis, bacterial pericarditis, and bilateral thoracic empyema have been described [5,6]. The patients of the last 2 case reports did not have any wound infection but presented with pneumonia and reactive pleural effusions. Because of the intrathoracic positioning of the Nuss bar, pulmonary infections are also feared because of the risk of bar infection [13]. The 7 infections (3 documented S aureus infections, 1 documented S epidermidis infection) in our series lead to removal of the bar one patient only. In the short term (mean follow-up, 6.6 months), no slipping occurred nor was there a need to remove the bar prematurely in the remaining 6 patients. Two patients could be treated on an outpatient basis but 5 patients required prolonged hospitalization. This is remarkable, because with other prosthetic devices, particularly intravascular catheters and prosthetic joints, S aureus infection usually requires removal of the device to prevent serious complications [14,15]. Explanations for this discrepancy may lie in the patient populations: patients with pectus excavatum are usually young and healthy without any underlying disease, whereas the reverse is true for patients with intravascular catheters (intensive care unit, hematology-oncology patients, usually with compromised host defenses) and patients with prosthetic joints (elderly patients with debilitating underlying diseases). Since the occurrence of these complications, we have changed our policy of antibiotic prophylaxis. Instead of one preoperative dose of amoxicillin/clavulanate (Utrecht) or cefuroxim (Graz), the same combination is now continued for 24 hours. Moreover, if during the postoperative course any suspicion of wound or pulmonary infection arises, antibiotic therapy is started immediately. Since this policy change no further infectious complications have been encountered. Our experience indicates that there is no need for immediate removal of an infected Nuss bar. However, it should be stressed that when wound infection occurs, early antibiotic treatment is warranted to ensure salvage of the implanted bar.
References [1] Nuss D, Kelly RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545 - 52. [2] Croitoru DP, Kelly RE, Goretsky MJ, et al. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37: 437 - 45. [3] Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 2000;35:252 - 8.
Should an infected Nuss bar be removed? [4] Miller KA, Woods RK, Sharp RJ, et al. Minimally invasive repair of pectus excavatum: a single institution’s experience. Surgery 2001;130: 652 - 9. [5] Mollik KA, Engum SA, Rescorla FJ, et al. Pectus excavatum repair: experience with standard and minimally invasive techniques. J Pediatr Surg 2001;36:324 - 8. [6] Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: case reports. J Pediatr Surg 2001;36:155 - 8. [7] Printzen G. Relevance, pathogenicity and virulence of microorganisms in implant related infections. Injury 1996;27:C9-C15. [8] Tobin EH. Prosthetic joint infections: controversies and clues. Lancet 1999;353:770 - 1. [9] Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998; 27:1247 - 54.
673 [10] Poon PC, Rennie J, Gray DH. Review of total hip replacement. The Middlemore Hospital experience, 1980-1991. N Z Med J 2001;114: 254 - 6. [11] Gaine WJ, Ramamohan NA, Hussein NA, et al. Wound infection in hip and knee arthroplasty. J Bone Joint Surg Br 2000;82: 561 - 5. [12] Saleh K, Olson M, Resig S, et al. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. J Orthop Res 2002;20:506 - 15. [13] Nuss D, Croitoru DP, Kelly Jr RE, et al. Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 2002;12:230 - 4. [14] Schierholz JM, Beuth J. Implant infections: a haven for opportunistic bacteria. J Hosp Infect 2001;49:87 - 93. [15] Raad I. Intravascular-catheter–related infections. Lancet 1998;351: 893 - 8.