Salvage rate of infected prosthetic mesh

“Mesh properties and position within the abdominal wall are the primary determinants in the ability to salvage mesh in the event of PMI. Mesh placed in an intraperitoneal position is rarely salvageable. Similarly, microporous, multifilament, and composite mesh constructs required complete mesh removal in most cases. However, macroporous, monofilament PP mesh in an extraperitoneal position can be salvaged in 72.2% of cases, positively impacting both the need for reoperation for mesh removal and subsequent hernia
recurrence.” (Warren)

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Antibiotic irrigation for decreasing the incidence of infection from ventral hernia repair.

“Surgical site infections (SSI) are common complications after open ventral hernia repair (OVHR), potentially requiring further intervention. Incidence of surgical site occurrence was significantly lower after G 1 C irrigation (Grp 1, 28.1%; Grp 2, 35.4%; Grp 3, 19.7%; P < 0.001). Incidence of SSI was significantly lower after G 1 C irrigation, but not G
alone (Grp 1, 16.5%; Grp 2, 15.2%; and Grp 3, 5.4%; P < 0.001). Multivariate logistic regression demonstrated significantly increased SSI with contaminated wounds (OR 2.96; 95% confidence interval (CI) 1.39–6.21), dirty wounds (OR 3.84; 95% CI 1.49–9.69), and chronic obstructive pulmonary disease (OR 3.70; 95% CI 2.16–6.38), as expected. Use of G 1 C was an independent predictor of decreased SSI (OR 0.33; 95% CI 0.16–0.67). Irrigation with a combined G 1 C antibiotic irrigation significantly reduces the incidence of surgical site infection after OVHR with mesh.” (Fatula)

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Article of interest: Role of antibiotic prophylaxis for the prevention of intravascular catheter-related infection

Carratalà J. Role of antibiotic prophylaxis for the prevention of intravascular catheter-related infection. Clin Microbiol Infect. 2001;7 Suppl 4:83-90. Free full-text.

“A plausible explanation for the failure to reduce catheter-related bacteremia with this prophylactic approach probably lies in the mechanism by which catheter-related infection occurs. Thus, it is known that in long-term central venous catheters, bacteria are more likely to be introduced during and following catheter hub manipulation than via spread from the skin insertion site or from tunnel infection. On the other hand, the systemic administration of prophylactic glycopeptides may lead to the emergence of resistant organisms, and Centers for Disease Control and Prevention guidelines recommend against its use [55]. Therefore, the use of systemic glycopeptides to prevent intravascular catheter-related infections is not recommended.” (p. 85)

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Risk of bloodstream infections by intravascular device or insertion site

Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006 Sep;81(9):1159-71. Full-text for Emory users.

Results: Point incidence rates of IVD-related BSI were lowest with peripheral Intravenous catheters (0.1%, 0.5 per 1000 IVD-days) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the Intensive care unit. Surgically implanted long-term central venous devices–cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)–appear to have high rates of Infection when risk Is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodlalysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI.

Maki, et al. p. 1162

Conclusions: Expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies In which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs In use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related Infection have focused on short-term noncuffed CVCs used in Intensive care units, Infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.

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WHO Global Guidelines for the Prevention of SSIs: Antimicrobial prophylaxis in the presence of a drain and wound drain removal

Global Guidelines for the Prevention of Surgical Site Infection. Geneva: World Health Organization; 2018. Web Appendix 27, Summary of a systematic review on antimicrobial prophylaxis in the presence of a drain and wound drain removal.

In conclusion, the available evidence can be summarized as follows:

Prolonged antibiotic prophylaxis in the presence of a wound drain vs. perioperative prophylaxis alone (PICO question 1, comparison 1)

Overall, a low quality of evidence shows that prolonged antibiotic prophylaxis in the presence of a wound drain has neither benefit nor harm in reducing the SSI rate when compared to perioperative prophylaxis alone (single dose before incision and possible intraoperative additional dose/s according to the duration of the operation).

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Article of interest: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2021

Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11): e1063-e1143.

Full-text for Emory users.

Methods: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.

Results: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.

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ISPD peritonitis guideline recommendations: 2022 update on prevention & treatment

Li PK, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022 Mar;42(2):110-153. Free full-text.

Abstract: The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year.

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