Infections Associated with Surgical Implants
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《新英格兰医药杂志》
To the Editor: Dr. Darouiche (April 1 issue)1 discusses the treatment of infections associated with surgical implants but does not point out that postherniorrhaphy mesh infections constitute a significant proportion of such infections. Approximately 1 million inguinal and 20,000 ventral herniorrhaphies are performed yearly in the United States, and approximately 95 percent of these repairs involve mesh implants. The infection rate is estimated to be between 3 and 4 percent for inguinal herniorrhaphies and between 6 and 8 percent for ventral herniorrhaphies. Accordingly, some 30,000 to 50,000 postherniorrhaphy infections will occur each year, the majority of them involving mesh implants.2
If they become infected, a significant number of implants will require additional surgery for drainage, with or without mesh explantation. If final healing is achieved, the process has to be followed by a definitive hernia repair. These complications pose a considerable problem for both patients and surgeons. The literature suggests that the incidence of mesh infections has been reduced by the use of modern aseptic and antiseptic procedures and meticulous surgical technique.3,4,5
Maximo Deysine, M.D.
Winthrop University Hospital
Mineola, NY 11501
maxdey@optonline.net
References
Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004;350:1422-1429.
Deysine M. Pathophysiology, prevention, and management of prosthetic infections in hernia surgery. Surg Clin North Am 1998;78:1105-1115.
Deysine M. Hernia infections: pathophysiology, diagnosis, treatment and prevention. New York: Marcel Dekker, 2003.
Salvati EA, Callaghan JJ, Brause BD, Klein RF, Small RD. Reimplantation in infection: elution of gentamycin from cement and beads. Clin Orthop 1986;207:83-93.
Charnley J, Eftekhar N. Postoperative infection in total prosthetic arthroplasty of the hip-joint: with special reference to the bacterial content of the air of the operating room. Br J Surg 1969;56:641-649.
To the Editor: More than 50 percent of the 300,000 patients treated with hemodialysis in the United States have a prosthetic dialysis-access graft made of polytetrafluoroethylene.1 Infected dialysis-access grafts (some studies have reported infection rates as high as 22 percent2) are a major cause of clinical morbidity (sepsis, infective endocarditis, septic emboli, and osteomyelitis) and also a substantial financial burden to the Medicare program for end-stage renal disease. In contrast, rates of infection in primary (native) arteriovenous fistulae are extremely low.2,3,4
The most effective intervention to reduce the clinical morbidity and financial costs associated with dialysis-access grafts in this country is probably a concerted effort to increase our national prevalence rate for the use of native fistula from the current 30 percent to 70 to 90 percent, which is the norm in most European countries.1
Prabir Roy-Chaudhury, M.D., Ph.D.
Rino Munda, M.D.
University of Cincinnati
Cincinnati, OH 45267-0585
References
Pisoni RL, Young EW, Dykstra DM, et al. Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int 2002;61:305-316.
Fong IW, Capellan JM, Simbul M, Angel J. Infection of arterio-venous fistulas created for chronic haemodialysis. Scand J Infect Dis 1993;25:215-220.
Schwab SJ, Besarab A, Brouwer D, et al. DOQI clinical practice guidelines. Am J Kidney Dis 2001;37:Suppl 1:S145-S179.
Butterly DW, Schwab SJ. Dialysis access infections. Curr Opin Nephrol Hypertens 2000;9:631-635.
To the Editor: As a resident in a busy urban emergency department, I often see patients with infectious complications that are associated with surgical implants. By the time such patients arrive in the emergency department, my colleagues and I find ourselves behind the eight ball; antibiotics and ultimately surgical revision are often our only options. Yet, we should all remember the one simple thing that consistently and dramatically reduces the spread of most infections: washing our hands. In the March 25 issue, Dr. Gawande writes about the constant uphill battle that infectious-disease specialists face — the right soap, the right technique, and both for the right length of time.1 Hence, I was surprised to note that in the photograph in Figure 1A of Dr. Darouiche's article, the hand was bare. An oversight, I imagine, but one that we should all strive to correct.
Erica Kreismann, M.D.
Bellevue Hospital
New York, NY 10016
References
Gawande A. On washing hands. N Engl J Med 2004;350:1283-1286.
To the Editor: Human homografts provide excellent material to fill in tissue defects and have been used as a substitute for an infected vascular graft and a cardiac valve. In his review, Darouiche does not mention treatment of prosthetic-valve endocarditis with cryopreserved homografts. Surgical reintervention for prosthetic-valve endocarditis, especially when the infection is caused by Staphylococcus aureus, remains a formidable challenge, with high rates of recurrence and mortality. The cryopreseved aortic homograft is considered to be the valve replacement of choice for aortic-valve endocarditis, even if infections are active. The homografts have advantages with regard to the incidence of reinfection, late mortality, and valve-related complications.1,2 After the perioperative period, homografts provide excellent long-term durability and superior hemodynamic performance, and anticoagulation treatment is not required.3 However, contaminated homografts can cause serious infections in recipients. Adherence to a strict screening protocol is required to prevent microbial contamination.
Kotaro Mitsutake, M.D.
Kazuo Niwaya, M.D.
National Cardiovascular Center
Osaka 565-8565, Japan
kmitsuta@hsp.ncvc.go.jp
References
Niwaya K, Knott-Craig CJ, Santangelo K, Lane MM, Chandarsekaran K, Elkins RC. Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis. Ann Thorac Surg 1999;67:1603-1608.
Donaldson RM, Ross DN. Homograft aortic root replacement for complicated prosthetic valve endocarditis. Circulation 1984;70:Suppl:78-78.
O'Brien MF, Stafford EG, Gardner MAH, et al. Allograft aortic valve replacement; long-term follow up. Ann Thorac Surg 1995;60:Suppl 2:S65-S70.
Dr. Darouiche replies: Dr. Kreismann is an astute observer. The photograph of the infected penile implant was taken in the operating room before the surgical site was prepped because the povidone–iodine could have affected the clarity of the image. The bare — but washed — hand in the photograph belongs to an assistant surgeon who washed his hands again and then gloved before assisting with the surgery. Most agree that hand washing is the simplest and perhaps the most effective strategy for preventing infection, but physicians' compliance with hand washing is not even close to universal. Personal encounters and educational presentations can induce behavioral changes in physicians.1
As Dr. Deysine states, infections associated with hernia mesh are relatively common and cause major morbidity. Since cure of infection often requires removal of the mesh, this clinical scenario vividly illustrates how infection can prevent achievement of the sole objective of surgical implantation — in this case, bridging or buttressing native tissues to obtain better closure of a tissue defect.
I agree with Drs. Mitsutake and Niwaya that the advantages of implanting cryopreserved aortic grafts, as compared with mechanical valves, include the absence of a need for anticoagulation treatment, a lower rate of infection, and superior hemodynamic performance. These advantages help explain why the use of cryopreserved aortic grafts is a generally accepted treatment in patients with prosthetic-valve endocarditis. However, the relative shortage of homografts, the high rate of early calcification, and the inadequate assessment of the durability of cryopreserved aortic grafts more than 10 years after implantation in humans have all contributed to the continued use of prosthetic heart valves in some institutions.2
Drs. Roy-Chaudhury and Munda correctly argue that we should strive to secure dialysis access through arteriovenous fistulae, which are less likely than vascular grafts to become infected. Although surgical implantation and subsequent blood access are sometimes achieved more easily with arteriovenous grafts than with fistulae, repeated infection of vascular grafts depletes the already limited number of sites available for securing long-term hemodialysis access. Treatment of infected arteriovenous grafts is both cumbersome and expensive. An infected prosthetic graft usually must be removed, and a temporary hemodialysis catheter inserted, followed by the reimplantation of a new graft at a different site, often in combination with prolonged antimicrobial therapy. The estimated total cost of medical and surgical treatment combined is $40,000. Therefore, a national strategy that increases the prevalence of native fistulae can most likely improve patient care and save money.
Rabih O. Darouiche, M.D.
Baylor College of Medicine
Houston, TX 77030
rdarouiche@aol.com
References
Salemi C, Canola MT, Eck EK. Hand washing and physicians: how to get them together. Infect Control Hosp Epidemiol 2002;23:32-35.
Hagl C, Galla JD, Lansman SL, et al. Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated? Ann Thorac Surg 2002;74:S1781-S1785.
If they become infected, a significant number of implants will require additional surgery for drainage, with or without mesh explantation. If final healing is achieved, the process has to be followed by a definitive hernia repair. These complications pose a considerable problem for both patients and surgeons. The literature suggests that the incidence of mesh infections has been reduced by the use of modern aseptic and antiseptic procedures and meticulous surgical technique.3,4,5
Maximo Deysine, M.D.
Winthrop University Hospital
Mineola, NY 11501
maxdey@optonline.net
References
Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004;350:1422-1429.
Deysine M. Pathophysiology, prevention, and management of prosthetic infections in hernia surgery. Surg Clin North Am 1998;78:1105-1115.
Deysine M. Hernia infections: pathophysiology, diagnosis, treatment and prevention. New York: Marcel Dekker, 2003.
Salvati EA, Callaghan JJ, Brause BD, Klein RF, Small RD. Reimplantation in infection: elution of gentamycin from cement and beads. Clin Orthop 1986;207:83-93.
Charnley J, Eftekhar N. Postoperative infection in total prosthetic arthroplasty of the hip-joint: with special reference to the bacterial content of the air of the operating room. Br J Surg 1969;56:641-649.
To the Editor: More than 50 percent of the 300,000 patients treated with hemodialysis in the United States have a prosthetic dialysis-access graft made of polytetrafluoroethylene.1 Infected dialysis-access grafts (some studies have reported infection rates as high as 22 percent2) are a major cause of clinical morbidity (sepsis, infective endocarditis, septic emboli, and osteomyelitis) and also a substantial financial burden to the Medicare program for end-stage renal disease. In contrast, rates of infection in primary (native) arteriovenous fistulae are extremely low.2,3,4
The most effective intervention to reduce the clinical morbidity and financial costs associated with dialysis-access grafts in this country is probably a concerted effort to increase our national prevalence rate for the use of native fistula from the current 30 percent to 70 to 90 percent, which is the norm in most European countries.1
Prabir Roy-Chaudhury, M.D., Ph.D.
Rino Munda, M.D.
University of Cincinnati
Cincinnati, OH 45267-0585
References
Pisoni RL, Young EW, Dykstra DM, et al. Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int 2002;61:305-316.
Fong IW, Capellan JM, Simbul M, Angel J. Infection of arterio-venous fistulas created for chronic haemodialysis. Scand J Infect Dis 1993;25:215-220.
Schwab SJ, Besarab A, Brouwer D, et al. DOQI clinical practice guidelines. Am J Kidney Dis 2001;37:Suppl 1:S145-S179.
Butterly DW, Schwab SJ. Dialysis access infections. Curr Opin Nephrol Hypertens 2000;9:631-635.
To the Editor: As a resident in a busy urban emergency department, I often see patients with infectious complications that are associated with surgical implants. By the time such patients arrive in the emergency department, my colleagues and I find ourselves behind the eight ball; antibiotics and ultimately surgical revision are often our only options. Yet, we should all remember the one simple thing that consistently and dramatically reduces the spread of most infections: washing our hands. In the March 25 issue, Dr. Gawande writes about the constant uphill battle that infectious-disease specialists face — the right soap, the right technique, and both for the right length of time.1 Hence, I was surprised to note that in the photograph in Figure 1A of Dr. Darouiche's article, the hand was bare. An oversight, I imagine, but one that we should all strive to correct.
Erica Kreismann, M.D.
Bellevue Hospital
New York, NY 10016
References
Gawande A. On washing hands. N Engl J Med 2004;350:1283-1286.
To the Editor: Human homografts provide excellent material to fill in tissue defects and have been used as a substitute for an infected vascular graft and a cardiac valve. In his review, Darouiche does not mention treatment of prosthetic-valve endocarditis with cryopreserved homografts. Surgical reintervention for prosthetic-valve endocarditis, especially when the infection is caused by Staphylococcus aureus, remains a formidable challenge, with high rates of recurrence and mortality. The cryopreseved aortic homograft is considered to be the valve replacement of choice for aortic-valve endocarditis, even if infections are active. The homografts have advantages with regard to the incidence of reinfection, late mortality, and valve-related complications.1,2 After the perioperative period, homografts provide excellent long-term durability and superior hemodynamic performance, and anticoagulation treatment is not required.3 However, contaminated homografts can cause serious infections in recipients. Adherence to a strict screening protocol is required to prevent microbial contamination.
Kotaro Mitsutake, M.D.
Kazuo Niwaya, M.D.
National Cardiovascular Center
Osaka 565-8565, Japan
kmitsuta@hsp.ncvc.go.jp
References
Niwaya K, Knott-Craig CJ, Santangelo K, Lane MM, Chandarsekaran K, Elkins RC. Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis. Ann Thorac Surg 1999;67:1603-1608.
Donaldson RM, Ross DN. Homograft aortic root replacement for complicated prosthetic valve endocarditis. Circulation 1984;70:Suppl:78-78.
O'Brien MF, Stafford EG, Gardner MAH, et al. Allograft aortic valve replacement; long-term follow up. Ann Thorac Surg 1995;60:Suppl 2:S65-S70.
Dr. Darouiche replies: Dr. Kreismann is an astute observer. The photograph of the infected penile implant was taken in the operating room before the surgical site was prepped because the povidone–iodine could have affected the clarity of the image. The bare — but washed — hand in the photograph belongs to an assistant surgeon who washed his hands again and then gloved before assisting with the surgery. Most agree that hand washing is the simplest and perhaps the most effective strategy for preventing infection, but physicians' compliance with hand washing is not even close to universal. Personal encounters and educational presentations can induce behavioral changes in physicians.1
As Dr. Deysine states, infections associated with hernia mesh are relatively common and cause major morbidity. Since cure of infection often requires removal of the mesh, this clinical scenario vividly illustrates how infection can prevent achievement of the sole objective of surgical implantation — in this case, bridging or buttressing native tissues to obtain better closure of a tissue defect.
I agree with Drs. Mitsutake and Niwaya that the advantages of implanting cryopreserved aortic grafts, as compared with mechanical valves, include the absence of a need for anticoagulation treatment, a lower rate of infection, and superior hemodynamic performance. These advantages help explain why the use of cryopreserved aortic grafts is a generally accepted treatment in patients with prosthetic-valve endocarditis. However, the relative shortage of homografts, the high rate of early calcification, and the inadequate assessment of the durability of cryopreserved aortic grafts more than 10 years after implantation in humans have all contributed to the continued use of prosthetic heart valves in some institutions.2
Drs. Roy-Chaudhury and Munda correctly argue that we should strive to secure dialysis access through arteriovenous fistulae, which are less likely than vascular grafts to become infected. Although surgical implantation and subsequent blood access are sometimes achieved more easily with arteriovenous grafts than with fistulae, repeated infection of vascular grafts depletes the already limited number of sites available for securing long-term hemodialysis access. Treatment of infected arteriovenous grafts is both cumbersome and expensive. An infected prosthetic graft usually must be removed, and a temporary hemodialysis catheter inserted, followed by the reimplantation of a new graft at a different site, often in combination with prolonged antimicrobial therapy. The estimated total cost of medical and surgical treatment combined is $40,000. Therefore, a national strategy that increases the prevalence of native fistulae can most likely improve patient care and save money.
Rabih O. Darouiche, M.D.
Baylor College of Medicine
Houston, TX 77030
rdarouiche@aol.com
References
Salemi C, Canola MT, Eck EK. Hand washing and physicians: how to get them together. Infect Control Hosp Epidemiol 2002;23:32-35.
Hagl C, Galla JD, Lansman SL, et al. Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated? Ann Thorac Surg 2002;74:S1781-S1785.