Antiseptic Irrigation Research Articles

Pedicled omental wrapping of ascending aortic graft following mediastinitis

A 51-year-old male patient post-Aortic valve replacement (#25 SJM) underwent redo supra-coronary ascending aorta replacement for ascending aortic aneurysm developed a peri-graft purulent collection 2 months later post surgery. He was successfully treated by debridement of infected tissues, antiseptic irrigation with povidone, and omental wrapping of graft. The patient was discharged after full course of antibiotics. Quick diagnosis with debridement, irrigation, and omental wrapping can be effective in the treatment of mediastinitis following graft replacement of the ascending aorta for preventing catastrophic complications

Adjunctive Antiseptic Irrigation of Periodontal Pockets: Effects on Microbial and Cytokine Profiles.

To evaluate the effect of adjunctive antiseptic irrigation of periodontal pockets on microbial and cytokine profiles. Fifty-nine patients with severe periodontitis were allocated to one of three groups for scaling and root planing facilitated with different adjunctive antiseptics: 1% polyhexamethyleneguanidine phosphate (PHMG-P) (n = 19), 0.2% chlorhexidine (CHX) (n = 21) or distilled water (n = 19). Gingival crevicular fluid and subgingival bacterial samples were collected at baseline, and at 2 weeks, and 1 and 4 months. The levels of interleukin (IL)-1β, IL-8, IL-10, and IL-17A, matrix metalloproteinase (MMP)-8, Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, Fusobacterium nucleatum, Aggregatibacter actinomycetemcomitans, and Prevotella intermedia were determined. There were no intergroup differences in cytokine concentrations and bacterial counts at any follow-up, however, varying patterns were observed. In the PHMG-P and water groups IL-1β expression peaked at 2 weeks and then gradually declined. In all three groups, the dynamics of MMP-8 concentration were non-linear, increasing by 2 weeks and then declining to below baseline (p > 0.05). P. gingivalis and T. forsythia declined within the first month and increased thereafter, not regaining the baseline level. Adjunctive antiseptic treatment was associated with changes in biomarkers and bacterial counts in the course of the study. The effects of adjunctive antiseptic irrigation were limited in the applied protocol.

The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis.

IntroductionRates of osteoarthritis and total joint arthroplasty (TJA) are on the rise globally. Periprosthetic joint infection (PJI) is the most devastating complication of TJA. A number of different intraoperative interventions have been proposed in an effort to reduce infection rates, including antibiotic cements, local antibiotic powder, and various irrigation solutions. The evidence on the importance of irrigation solutions is limited but has gained prominence recently, including the publication of a large randomized controlled trial (RCT). Thus, the purpose of this study was to evaluate the effectiveness of various irrigation solutions and pressures at reducing the rates of PJI.MethodsA systematic review was performed using the electronic databases MEDLINE, Embase, and Web of Science. All records were screened in duplicate. Data collected included basic study characteristics, the details of the intervention and comparison solutions, if applicable, and rates of superficial and deep infection. A meta-analysis of comparative studies was performed to assess for consistency and potential direction of effect. ResultsA total of ten studies were included, of which one was an RCT, eight were retrospective cohorts, and one was a case series. In total, there were 29,630 TJAs in 29,596 patients. The mean age ranged from 61 to 80 years. Six studies compared povidone-iodine (Betadine®) to normal saline, two studies compared chlorhexidine to saline, one study compared “triple prophylaxis” to standard practice, and one study used gentamicin but had no comparison group. The pooled risk ratio for deep infection in studies using Betadine® compared to saline was 0.62 (95% confidence interval [CI]: 0.33-1.19), while for chlorhexidine it was 0.74 (95%CI: 0.33-1.65).DiscussionCurrent evidence on the relative efficacy of irrigating solutions as prophylaxis for infection following TJA remains inconclusive. Imprecision of estimates vindicates the need for a definitive trial to further inform their use in surgical practice. ConclusionAntiseptic irrigation during TJA with solutions (Betadine®, chlorhexidine) may decrease PJI risk in patients undergoing primary and revision total hip and knee arthroplasties. Wide confidence intervals and heterogeneity among studies, however, render conclusions untrustworthy. Well-conducted RCTs are very much needed to help further investigate this issue.

Is There a Role for the Use of Dilute Povidone-Iodine (Betadine) Irrigation or Other Antiseptic Irrigation Solutions During Total Ankle Arthroplasty (TAA) or Other Foot and Ankle Procedures?

With regard to total ankle arthroplasty (TAA), there is a lack of evidence to recommend for or against the use of betadine solution. Consensus. Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

General Assembly, Prevention, Antiseptic Irrigation Solution: Proceedings of International Consensus on Orthopedic Infections

General Assembly, Prevention, Antiseptic Irrigation Solution: Proceedings of International Consensus on Orthopedic Infections

Antiseptic Irrigation as an Effective Interventional Strategy for Reducing the Risk of Surgical Site Infections.

A surgical site infection (SSI) can occur at several anatomic sites related to a surgical procedure: Superficial or deep incisional or organ/space. The SSIs are the leading cause of health-care-associated infection (HAI) in industrialized Western nations. Patients in whom an SSI develops require longer hospitalization, incur significantly greater treatment costs and reduction in quality of life, and after selective surgical procedures experience higher mortality rates. Effective infection prevention and control requires the concept of the SSI care bundle, which is composed of a defined number of evidence-based interventional strategies, because of the many risk factors that can contribute to the development of an SSI. Intra-operative irrigation has been a mainstay of surgical practice for well over 100 years, but lacks standardization and compelling evidence-based data to validate its efficacy. In an era of antibiotic stewardship, with a widespread prevalence of bacterial resistance to multiple antibiotic agents, there has emerged an interest in using intra-operative antiseptic irrigation to reduce microbial contamination in the surgical site before closure and possibly reduce the need for antibiotic agents. This approach has gained added appeal in an era of biomedical device implantation, especially with the recognition that most, if not all, device-related infections are associated with biofilm formation. This review focuses on the limited, evidence-based rationale for the use of antiseptic agents as an effective risk reduction strategy for prevention of SSIs.

Comparison of the Efficacy of Povidone-Iodine and Normal Saline Wash in Preventing Surgical Site Infections in Laparotomy Wounds-Randomized Controlled Trial

Background: Povidone-iodine has been utilized as a broad-spectrum antiseptic irrigation solution in the wound management processes for many years. However, some recent studies showed that the infection rate in laparotomy wounds decreases more by using normal saline. Objective: The study aims to examine the decreasing infection rate in laparotomy wounds by comparing the effectiveness and safety of povidone-iodine solution with normal saline. Method: The patients undergoing elective laparotomies were included and randomly assigned to 2 groups. In the first group (90 patients), incision wounds were flushed with 5% povidone-iodine solution. In the second group (90 patients), incisions were flushed with 0.9% normal saline solution. By comparing the infection rates of the wound outcomes were measured between the two groups. Result: Surgical site infections were seen in 16 of 180 (12.5%) patients 9 in povidone-iodine versus 7 in normal saline groups. The difference in the infection rates in the two studied groups (p=0.6) has no statistical significance. Conclusion: The infection rate in laparotomy wounds did not increase or decreased when the wound was irrigated with 5% Povidone-iodine solution or with 0.9% saline solution.

Continuous betadine-bacitracin irrigation for vascular graft infections: A case series

The aim of the study was to conduct a retrospective chart review of patients who underwent betadine/bacitracin continuous irrigation (BBCI) for vascular graft infections (VGIs) to review its use as a treatment option. A retrospective chart review from 2013 to 2017 was conducted of patients with VGIs that were treated with BBCI postremoval of the infected graft. The BBCI is a continuous infusion of 0.25% betadine in normal saline at 0.3mL/kg/h for 48hours then followed by bacitracin infusion with a concentration of 50,000 units bacitracin/per liter normal saline at 0.3mL/kg/h for 72hours. Descriptive statistics were used to describe the sample. The nine adult patients who received postoperative BBCI had an age range of 30-81years, with average age of 58.8 years. Five of the subjects were females with four males. A total of nine patients with groin infections were identified, with two aortobifemoral bypasses, two axillofemoral bypasses, three femoral-femoral bypasses, one femoral artery pseudoaneurysm repair with Dacron patch, and one common femoral endarterectomy with Dacron patch. VGIs were identified from 10days up to 72months from the original vascular procedure. Six patients had negative wound cultures, while two had wound cultures positive for methicillin-resistant Staphylococcus aureus and one patient had positive culture for Escherichia coli. The length of time of BBCI ranged from 48 to 84hours with average of 57.6hours (standard deviation [SD]=12.7hours). The length of time of the bacitracin irrigation ranged from 30 to 72hours with average of 48.4hours (SD=14.9hours). All patients healed their groin wounds except for an 81-year-old patient with aortobifemoral bypass graft who developed ischemic bowel and expired. Patients received at least 6weeks of intravenous antibiotics followed by oral antibiotic suppression therapy for life. VGIs are a devastating complication associated with a high morbidity. BBCI provides an option for antiseptic irrigation of the vascular graft site postgraft removal to promote wound closure.

Effect of antiseptic irrigation on infection rates of traumatic soft tissue wounds: a longitudinal cohort study.

Acute traumatic wounds are contaminated with bacteria and therefore an infection risk. Antiseptic wound irrigation before surgical intervention is routinely performed for contaminated wounds. However, a broad variety of different irrigation solutions are in use. The aim of this retrospective, non-randomised, controlled longitudinal cohort study was to assess the preventive effect of four different irrigation solutions before surgical treatment, on wound infection in traumatic soft tissue wounds. Over a period of three decades, the prophylactic application of wound irrigation was studied in patients with contaminated traumatic wounds requiring surgical treatment, with or without primary wound closure. The main outcome measure was development of wound infection. From 1974-1983, either 0.04 % polihexanide (PHMB), 1 % povidone-iodine (PVP-I), 4 % hydrogen peroxide, or undiluted Ringer's solution were concurrently in use. From 1984-1996, only 0.04 % PHMB or 1 % PVP-I were applied. From 1997, 0.04 % PHMB was used until the end of the study period in 2005. The combined rate for superficial and deep wound infection was 1.7 % in the 0.04 % PHMB group (n=3264), 4.8 % in the 1 % PVP-I group (n=2552), 5.9 % in the Ringer's group (n=645), and 11.7 % in the 4 % hydrogen peroxide group (n=643). Compared with all other treatment arms, PHMB showed the highest efficacy in preventing infection in traumatic soft tissue wounds (p<0.001). However, compared with PVP-I, the difference was only significant for superficial infections. The large patient numbers in this study demonstrated a robust superiority of 0.04 % PHMB to prevent infection in traumatic soft tissue wounds. These retrospective results may further provide important information as the basis for power calculations for the urgently needed prospective clinical trials in the evolving field of wound antisepsis.

Is 1% povidone-iodine solution superior to normal saline for simple traumatic wound irrigation?

Abstract Background Povidone-iodine is a broad spectrum antiseptic irrigation solution which has been used in wound management processes for decades but some recent studies have questioned its superiority to normal saline and even tap water in decreasing the infection rate in different types of wounds. Objective This study compares the efficacy and safety of diluted povidone-iodine solution with normal saline as in decreasing the infection rate in simple traumatic wounds repaired in emergency department. Method Patients with simple traumatic were included and randomly allocated to 2 groups. In 223 patients, wounds were irrigated with 1% povidone-iodine solution. In the other 223 patients, wounds were irrigated with 0.9% normal saline solution. Wound infection rates were compared by assessing the signs and symptomsof infection including cellulitis, abscess, lymphangitis and pus formation. Result Infectious complications were seen in 29 of 446 (7.4%) patients (15 in povidone-iodine versus 14 in normal saline groups). Nineteen (7.91%) patients in povidone-iodine group and 13 (6.68%) patients in normal saline group showed the evidences of infection in follow up visits. There was no statistically significant difference between infection rates in two studied groups (p = 0.86). Conclusion Irrigation with 1% Povidone-iodine did not increase or decrease the infection rate in traumatic wounds compared to wound irrigation with 0.9% saline solution.

Enterocutaneous fistula and internal hernia

The aim of the present study was to report the treatment of an unusual association of ventriculoperitoneal shunt (VPS). Although a commonly performed paediatric neurosurgical procedure, a VPS is associated with several complications. There are reports on gut perforation by the peritoneal catheter, but an enterocutaneous fistula is very rare. Only two have been previously reported in literature. We report, here, the first case seen in Nigeria involving a 3-year old boy, at our teaching hospital setting, with a history of a fall 18 months after VPS; this was followed by purulent, and, later, faeculent discharge from the right subcoastal region and abdominal wound. He underwent detailed neurological examination. Preoperative evaluation with a fistulogram (as a barium meal and follow-through because the superficial opening was not clearly visible to allow direct injection of contrast) showed a connection between the intestine and the skin over the shunt tunnel. He underwent a laparotomy with thorough antiseptic irrigation and repositioning of the VPS in peritoneal cavity. Postoperatively, the faeculent discharge from the upper anterior abdominal wall ceased. He was discharged home in 2 weeks. There was complete resolution after 6 months. We conclude that there should be a high index of suspicion of an enterocutaneous fistula, although very rare, when faecal discharge is noticed following a VPS and should necessitate a fistulogram. Effective surgical treatment of the intraluminal migration and other possible complications, should involve a multidisciplinary team. Keywords: complications, enterocutaneous fistula, internal hernia, intraluminal migration, multispecialty treatment, ventriculoperitoneal shunt

Chronic Osteomyelitis Due to Streptococcus Suis: First Case Report from India.

Sir, Streptococcus suis is a major porcine pathogen and is also emerging as a zoonotic agent capable of causing severe invasive diseases in humans.[1] It causes meningitis, septicemia, endocarditis, arthritis, and pneumonia in human beings.[2] We report a rare case of chronic osteomyelitis caused by S. suis. A seven-year-old female child presented with swelling over the base of her amputed right index finger, with discharging sinus and intermittent fever since seven months [Figure 1]. The lesion started as a nodule over the base of her right index finger one year back, which was initially nontender, but gradually increased in size and became painful, with discharging sinus. A diagnosis of chronic osteomyelitis was done based on the typical x-ray findings and excision biopsy. Amputation of the right index finger was done and Ampicillin-sulbactam therapy was advised. However, the patient discontinued the treatment. After two months she again developed discharging sinus from the amputed area.Figure 1: Lesion on the amputed right index finger with discharging sinusOn examination, the child was febrile. The local area was swollen, tender with petechiae, and discharging sinuses. She had right axillary lymphadenopathy. Other systemic examinations were normal. The hemogram showed an Hb of 6.25 gm/dl, leukocytosis with neutrophilia, and a total platelet count of 2.5 of lakhs/mm. The erythrocyte sedimentation rate (ESR) was increased (20 mm/first hour) and the C-reactive protein (CRP) was elevated. The Mantoux test was negative. The routine biochemical tests were normal. An x-ray AP view of the right hand showed areas of sclerosis in the amputed stump of the index finger. A Gram stain of the aspirated pus showed numerous polymorphonuclear cells and many gram-positive cocci arranged singly and in pairs. Acid fast staining was negative. Culture on 5% sheep blood agar yielded small, grayish, α-hemolytic colonies, after 24 hours of aerobic incubation at 37°C, which changed to a large, beta-hemolytic type after prolonged incubation for 48 hours. A gram stain of the colonies showed gram-positive cocci arranged in pairs and short chains. It was catalase negative, optochin-resistant, bacitracin-resistant, and Christie, Atkins and Munch-Peterson(CAMP) test-negative. It grew in the presence of 40% bile and hydrolyzed esculin, but was unable to grow in 6.5% Sodium Chloride (NaCl) broth. It was negative for the Voges–Proskauer test. It fermented glucose, sucrose, lactose, maltose, trehalose, and salicin with production of acid, but did not ferment arabinose, sorbitol, raffinose, mannitol, and inositol. Blood and urine culture was negative. The isolate was presumptively identified as S. suis and confirmed by the automated Vitek 2 system (bioMérieux; 99.0% probability) and the API 20 Strep system (bioMérieux; 99.7% probability). The isolate was identified as serotype 2 by the slide agglutination test, using specific antisera (SSI Diagnostica, Denmark). It was susceptible to ceftriaxone, gentamicin, vancomycin, and linezolid, but resistant to clindamycin and amoxyclav. The child was treated with ceftriaxone 1 gm IV q 24 hours for six weeks, with regular antiseptic irrigation of the sinus. The patient showed subsequent improvement. Further enquiry into the potential pig exposure revealed that the father's occupation was in pig rearing. Streptococcus suis is a gram-positive cocci and belongs to the lancefield group R, S, RS or T.[3] On the basis of capsular antigens, 35 serotypes have been described. The most prevalent serotype that causes invasive human infections worldwide is serotype 2.[45] S. suis is usually susceptible to penicillin, ceftriaxone, and vancomycin, and the least active agents are tetracycline, erythromycin, and chloramphenicol.[5] Patients with chronic osteomyelitis usually require a prolonged antibiotic course between four and six weeks. Previous non-adherence to the treatment may be the cause for the relapse in our case. Our case belongs to a non-endemic area and a small amount of data is available for circulation on the epidemiology of S. suis in India. However, S. suis was diagnosed in a private piggery in Kerala. This is perhaps the first case report of S. suis infection in India, presenting as chronic osteomyelitis, which is a rare presentation worldwide. Increased awareness of both clinicians and microbiologists is needed to fully appreciate the importance of S. suis as a human pathogen.

Vacuum‐assisted closure (VAC)‐Instill® with continuous irrigation for the treatment of Mycoplasma hominis mediastinitis

A 56-year-old patient who underwent ascending aorta replacement postoperatively developed mediastinitis with atypical Mycoplasma hominis. We present the first successful treatment of M. hominis mediastinitis after cardiac surgery with vacuum-assisted closure (VAC)-Instill(®) therapy combined with dilute antiseptic irrigation for bacterial eradication.

구강소독제의 적용 시간 및 기계적 세척 여부에 따른 타액 내 세균 수의 감소 효과

Abstract Salivary Bacterial Counts on Application Time of Oral Antiseptic Agents and Mechanical Irrigation Hyoung-Sup Lim, Jae-Jin Kim 1 , Mija Kim 2 , Hak Kyun Kim 1 Department of Oral and Maxillofacial Surgery, School of Dentist ry, Chosun University, 1 Department of Oral and Maxillofacial Surgery, School of Medicine, Chungnam National University, Rese arch Institute for Medical Sciences, Chungnam National University, 2 Department of Nursing, Pai Chai UniversityPurpose: The purpose of this study is to establish the acceptable intraoral application time of antiseptic agents and evaluate the effect of mechanical irrigation. Methods: A total of 80 subjects were selected for this study. Saliva secreted at the resting state was taken. The subjects were divided into 8 experimental groups, and kept 10% povidone- iodine (PVI) or 0.2% chlorhexidine gluconate (CHX) for 20 or 40 seconds in their oral cavity with/without irrigation o f the oral cavity with sterilized normal saline, respectively. Then, the saliva was taken and diluted with phosphate buffered saline and then plated onto 5% sheep blood agar plates, which were incubated. Colony forming unit (CFU) was measured fo r the salivary bacterial counts.Results: After application of PVI and CHX, all the experimental groups showed statistically significant decrease in CFU (P＜0.01). Group 2 (PVI, 40 s) showed more significant reduction rate in C FU than group 4 (CHX, 40 s; P＜0.01). Group 6 (PVI, 40 s, irrigated) showed more significant reduction rate than gr oup 2 (PVI, 40 s; P＜0.01). Group 2 (PVI, 40 s) showed more significant reduction rate than group 1 (PVI, 20 s; P＜0.01). Conclusion: Application of PVI for 40 seconds and mechanical irrigation wi th sterilized normal saline showed the best result among the 8 groups in terms of the reduction rate of sal ivary bacterial counts.Key words:Povidone-iodine, Chlorhexidine, Irrigation, Bacteria

PP176: Osteoradionecrosis of the mandible and its resolution with protocol: Pentoxifylline–tocopherol associated with antibiotic therapy

Introduction One of the worst concerns of a dentist is to ORN (osteoradionecrosis) of the mandible and maxilla. Various treatment techniques are used, but with little chance of success. Examples include various combinations of antibiotics, antiseptic irrigation, hyperbaric oxygenation therapy, Ultrasound, Sequestrectomias, resection + reconstruction with buccal fat pad flap. As the present case, many attempts have been used. One patient in the Hospital Erastus Gaertner Curitiba-PR-Brazil arrived for treatment after exposure of mandibular bone and underwent treatment with pentoxifylline, and Tocoferal with antibiotics Amoxicillin and Metronidazole. Objective Treatment of osteonecrosis of the jaw after radiotherapy protocol pentoxifylline–tocopherol. Methods Patient LSB, male, 64 years old, Caucasian, former smoker and drinker, submitted in 2005 to glossectomy with resection of the floor of the mouth and neck dissection right due to squamous cell carcinoma of the tongue (T3n0m0) and on edge radiotherapy . After 7 years showed exposed bone in bilateral mandibular body involving cortical and medullary areas of the alveolar bone on the left side, the right side had diffuse involvement in the total thickness of the jawbone, including lower border with pathological fracture. Patient underwent dental extractions for 6 months, with exposure of the bone marrow 2x2cm intraoral left. The right side showed pathological fracture with 3x2cm exposure of intra-oral and extra-oral fistula. The proposed treatment consists in removing the bone sequestration, by using 4 weeks of Amoxicillin and metronidazole 500mg, protocol associated with the use of pentoxifylline and tocopherol 400mg 2x/day 1000IU per day for 3 months may extend 6 months. Still was instructed to consume a diet liquid-pasty. Result In August of 2012 began with antibiotics and protocol Petoxifilina and Tocopherol, with three-month program and bone sequestration were removed under local anesthesia. The patient returned to the head and neck clinic to search for possible recurrent tumor in the oral cavity and biopsy was performed on buccal floor, in the area of bone exposure with negative results for malignancy, but confirming ORN. After 3 months back and it was noted epidermalization exposures bone. Conclusion It is believed that the protocol associated with antibiotic therapy and removal of bone sequestration showed positive results and opened a new technique for treatment of ORN, which needs further research.

Does Surgical Technique Affect the Incidence of Spondylodiscitis Post–Lumbar Microdiscectomy? A Retrospective Analysis of 3063 Patients

Retrospective audit in a single center during a period of 7 years operated by 3 groups of surgeons after 3 different surgical techniques. Our study aimed to determine whether surgical technique had any influence on the incidence of spondylodiscitis in patients undergoing lumbar microdiscectomy and to compare this with published rate of incidence of spondylodiscitis. The incidence of spondylodiscitis post-lumbar microdiscectomy ranges from 0.2% to 15%. There is limited evidence to compare different techniques and the incidence of spondylodiscitis. A total of 3063 patients were analyzed from 2005 to 2011 for discitis postoperatively. The first group followed a standard microdiscectomy technique, the second group used antiseptic (Savlon; Novartis Consumer Health UK Limited, Surrey, UK) irrigation at the end of the procedure to irrigate the disc space, and the third group followed standard microdiscectomy along with usage of a separate disc instruments when discectomy was performed. The number of patients operated in the individual groups was 559, 1122, and 1382. The total number of patients who had postoperative discitis was 3 (0.10%), with a range of 0.07% to 0.18%. There was 1 case of discitis in each group. The incidence of spondylodiscitis in groups A, B, and C were 0.18%, 0.09%, and 0.07%, respectively. This study concluded that different techniques used for lumbar microdiscectomy revealed that standard microsurgical technique with usage of antiseptic irrigation for the disc space and usage of separate disc instruments had lesser incidence of spondylodiscitis in comparison with standard microdiscectomy. The overall incidence of postoperative discitis remains less in our series. So far, to our knowledge, this report involves the largest number of patients studied to determine the incidence of discitis in patients undergoing lumbar microdiscectomy. 3.

Disinfection of the Access Orifice in NOTES: Evaluation of the Evidence Base

Introduction. Appropriate prevention of infection is a key area of research in natural orifice translumenal endoscopic surgery (NOTES), as identified by the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). Methods. A review of the literature was conducted evaluating the evidence base for access orifice preparation/treatment in NOTES procedures in the context of infectious complications. Recommendations based on the Oxford Centre for Evidence-Based Medicine guidelines were made. Results. The most robust evidence includes several experimental randomised controlled trials assessing infectious complications in the transgastric approach to NOTES. Transvaginal procedures are long established for accessing the peritoneal cavity following disinfection with antiseptic. Only experimental case series for transcolonic and transvesical approaches are described. Conclusion. Grade C recommendation requiring no preoperative preparation can be made for the transgastric approach. Antiseptic irrigation is recommended for transvaginal (grade C) NOTES access, as is current practice. Further human trials need to be conducted to corroborate the current evidence base for transgastric closure. It is important that future trials are conducted in a methodologically robust fashion, with emphasis on clinical outcomes and standardisation of enterotomy closure and postoperative therapy.

Efficacy of intraoperative surgical irrigation with polihexanide and nitrofurazone in reducing bacterial load after nail removal surgery

A common challenge of nail avulsion surgery is the associated bacterial contamination and infection that can manifest. The toe has a difficult anatomy to antiseptically prepare and properly maintain throughout the surgical procedure, lending to this widespread problem. We conducted a controlled, prospective randomized study to examine the antiseptic efficacy of 3 intraoperative irrigation methods during nail avulsion surgery. We compared intraoperative antiseptic irrigation using 0.9% saline solution (24 patients), 0.2% nitrofurazone (22 patients), and 0.1% polihexanide (25 patients). Swab samples were taken from each patient at 5 distinct stages throughout the surgical procedure, and bacterial culture analysis was performed (positive culture rate, total inocula count, reduction of bacterial load, and identification of specific micro-organisms). All 3 intraoperative irrigation methods reduced the total bacterial load, but polihexanide was significantly more effective. Furthermore, no patient from the polihexanide group developed postoperative infection. The reduction in bacterial load was lost for all 3 methods after partial nail avulsion surgery, returning to similar values as the initial presurgical bacterial load. An intraoperative irrigation step after partial nail avulsion with saline, nitrofurazone, and polihexanide was effective in reducing the bacterial load by 95.2%, 96.6%, and 99.5%, respectively. Our patients underwent phenol-based nail avulsion, resulting in no bacterial load after complete nail removal because of the intrinsic antiseptic nature of the phenol. Intraoperative irrigation with 0.1% polihexanide substantially reduced the bacterial load and subsequent infections, highlighting the importance of an irrigation step in nail avulsion surgery.

A Novel Antibacterial Silicone Implant Material with Short- and Long-Term Release of Copper Ions

Sir: Capsular contracture after silicone implants is still an unresolved and serious complication. The initial adhesion of specific skin bacteria to the implant surface is believed to be the major cause of early or late infection and may also be associated with capsular contracture.1 Studies of patients with breast implants have shown that many implant pockets are germ culture-positive. The predominant isolate germs are from the local skin flora (e.g., coagulase-negative staphylococci, Propionibacterium acnes, and Corynebacterium species). Preventing implant colonization by microorganisms and formation of bacterial biofilm could be effective in improving the outcome.1,2 Various investigations with different strategies with administration of systemic antibiotics and antiseptic irrigation of the implant pocket have been performed to reduce or prevent the bacterial contamination of silicone implants.2 An alternative approach consists of implant surface modification by antimicrobial agents. With all different methods, it is fundamental not to enforce antibacterial properties at the expense of biocompatibility. The toxic effect of metal ions on either tissue cells or bacteria is well known and has been reported in multiple studies.3 Silver (Ag+) has been widely used as an antimicrobial agent in different fields of medicine. The strong antibacterial effect of Ag+ is mainly enforced at the expense of cytocompatibility.3 Heidenau et al. demonstrated in growth inhibition tests with tissue cells and bacteria that, among Al3+, Co2+, Zn2+, Hg2+, Ag+, and Cu2+, the copper ions had by far the best compromise between antibacterial effectiveness and cytotoxicity.3 Consequently, we modified the surface of silicone sheets from implants with covalent linking of 20 chitosan layers dipped in a copper solution for 1 hour (Fig. 1). Chitosan is a linear biodegradable polysaccharide with high biocompatibility. The advantage of our modification technique with chitosan layers and copper ions is that it achieves a combination of short-term and long-term release of copper ions.4Fig. 1.: Scanning electron microscopic image of a silicone surface with chitosan coating and copper additives.For quantification of bacterial adherence and to determine the proportion of live and active bacteria and dead and inactive bacteria, the LIVE/DEAD BacLight bacterial viability kit (Molecular Probes, Eugene, Ore.) was used, which provides a two-color fluorescence assay of bacterial viability.5 The silicone specimens were incubated in a Staphylococcus epidermidis suspension isolated from the human skin for 120 minutes at 4°C. Subsequently, the bacterial suspension was extracted and the silicone sheets were washed with saline to remove nonadhering bacteria. The live or dead stain was prepared in recommended proportions, so that green fluorescent staining was achieved of bacteria with intact cell membranes and red fluorescent staining was achieved of bacteria with damaged membranes. Consequently, the ratio of green to red fluorescence intensities was measured as a quantitative index of bacterial viability. In our in vitro tests, we found a significantly lower amount of adhering bacteria and a higher percentage of dead S. epidermidis on our silicone sheets with copper additive than on our pure silicone sheets (Fig. 2). Despite these preliminary results, an animal study would still be needed to confirm the antibacterial effect of our implants in vivo. Possibly we can also reduce the development and progress of capsular fibrosis.Fig. 2.: Fluorescence microscopic images by live and dead staining. Vital (green) and dead (red) staphylococci on (left) pure silicone material and (right) silicone material with copper additives (original magnification, × 200). Display window, 150 × 188 μm.Lukas Prantl, M.D., Ph.D Ralf Bürgers, D.D.S., Ph.D. Stephan Schreml, M.D. Johannes Zellner, M.D. Department of Plastic and Reconstructive Surgery Martin Gosau, M.D., D.M.D. Department of Craniomaxillofacial Surgery University Medical Center Regensburg Regensburg, Germany DISCLOSURE Dr. Prantl is one of the inventors of the new implant material and is one of the applicants for a patent. Silicone was supplied by the Mentor Corporation (Irving, Texas). ACKNOWLEDGMENTS The authors thank the Friedrich-Baur-Research Institute for Biomaterials, University of Bayreuth, Germany, for the excellent work to modify silicone sheets with copper ions for antibacterial effect. They also thank Mentor Corporation (Irving, Texas) for their generous supply of silicone material.

Penile implant infections: Prevention and treatment

Penile implants remain a mainstay in treating erectile dysfunction (ED). Despite competing therapies, the number of devices implanted has increased each year. Implant infection continues to be a problem, but recent advances in antibiotic-coated devices and copious use of antiseptic irrigation have reduced the incidence. When confronted with an implant infection, a salvage procedure has gained acceptance that involves immediate replacement of the infected implant after antiseptic washing of the implant cavities. This procedure minimizes shortening of the implant erection and facilitates placement of cylinders in corporal bodies. Among patients and health care providers, satisfaction with penile implant remains the highest for all ED treatments.