Antiseptic Irrigation Research Articles

Effect of Antiseptic Irrigation with 0.05% Chlorhexidine Gluconate (Irrisept) on the Incidence of Cutibacterium acnes in Primary Shoulder Arthroplasty

Effect of Antiseptic Irrigation with 0.05% Chlorhexidine Gluconate (Irrisept) on the Incidence of Cutibacterium acnes in Primary Shoulder Arthroplasty

Comparing 0.05% chlorhexidine gluconate monotherapy to conventional antibiotic irrigation in de-novo penile prosthesis implantation: a two-center prospective randomized controlled non-inferiority study (preliminary results).

Infection remains a significant concern following penile prosthesis (PP) implantation surgery. Published guidelines have indicated the use of pre-operative intravenous (IV) antibiotics but have not provided specific recommendations regarding intra-operative irrigation. For long in our practice, we have been using a combination of antibiotics for irrigation (rifampin 600 mg/L of sterile water, gentamicin 80 mg/L of sterile water). Recently, 0.05% chlorhexidine gluconate (CHG) (Irrisept®) (Irrimax Corp, Lawrenceville, GA, USA), has shown promise as an alternative irrigant, with potential advantages in terms of cost, ease of administration and reduced antibiotic resistance risk. The study aims to assess the non-inferiority of CHG antiseptic irrigation compared to conventional combined antibiotic irrigation in preventing postoperative infections for men undergoing de-novo PP implantation. This is a two-center Institutional Review Board (IRB) approved prospective randomized controlled non inferiority trial, involving men undergoing de-novo PP implantation with a predetermined non-inferiority margin of 4%. Patients were randomly assigned into one of two groups: the CHG irrigation or the group receiving conventional antibiotic irrigation. All patients received IV antibiotics preoperatively and were sent home on oral antibiotics for 2 weeks post-operatively. The primary endpoint of this trial was to evaluate the incidence of PP infections. Secondary objectives encompassed the assessment of simplicity of use and cost-effectiveness. A hundred patients were enrolled in our study so far (50 in each arm). Only one case of PP infection necessitating explanation was reported in each arm. Moreover, the use of CHG irrigation offered the potential advantages of ease of administration and less cost as compared to antibiotic irrigation solutions. Preliminary data from this non-inferiority study demonstrate that CHG irrigation is non-inferior to conventional antibiotic irrigation in preventing postoperative infection following PP implantation. These findings support the consideration of CHG irrigation as a viable alternative during PP implantation, offering both clinical effectiveness and potential cost savings as well as reducing the risk of antibiotic resistance. ClinicalTrials.gov NCT06489431.

Effects of antiseptic irrigation solutions on osseointegration in a cementless tibial implantation mouse model.

Despite the success of standard antiseptic irrigation solutions in reducing periprosthetic joint infection (PJI) rates, there is still a need for more effective solutions. Synergistic use of povidone-iodine (PI) and hydrogen peroxide (H2O2) has shown promising results; however, the optimal solution concentration balancing bactericidal activity and osseointegration remains unknown. This study aims to evaluate the impact of these antiseptic irrigation solutions on osseointegration and the bone-implant interface strength in vivo. Forty C57BL/6 mice underwent bilateral tibial implantation surgery and were randomly allocated into three groups receiving 0.3% PI, 10% PI mixed with 3% H2O2, or saline as irrigation solutions intraoperatively. Assessments were performed on postoperative Days 1 and 28, including plain radiographs, microcomputed tomography (microCT) evaluation, histological analysis, immunohistochemistry, and biomechanical pull-out testing. No wound complications were observed. MicroCT scans revealed no differences in peri-implant trabecular bone parameters. Biomechanical pull-out testing showed no differences in the bone-implant interface strength across groups. Histological analysis indicated no differences in bone and bone marrow percentage areas among treatment groups. Immunohistochemical analysis demonstrated no differences among groups in peri-implant osteocalcin, osterix, or endomucin-positive cells. In conclusion, using either antiseptic irrigation solution showed no differences in osseointegration parameters compared to the control group, demonstrating safety and the absence of toxicity. CLINICAL RELEVANCE: Dilute 0.3% povidone-iodine and a 1:1 combination of 10% povidone-iodine mixed with 3% hydrogen peroxide can be safely used during primary and revision total joint arthroplasty without compromising osseointegration or causing wound complications.

Detrimental Effects of Chlorhexidine on Articular Cartilage Viability, Matrix, and Mechanics

Background: Chlorhexidine gluconate (CHG) solution is commonly used as an antiseptic irrigation for bacterial decontamination during orthopaedic surgery. Although the chondrotoxicity of CHG on articular cartilage has been reported, the full extent of CHG-related chondrotoxicity and its effects on the extracellular matrix and mechanical properties are unknown. Purpose: To investigate the in vitro effects of a single 1-minute CHG exposure on the viability, biochemical content, and mechanics of native articular cartilage explants. Study Design: Controlled laboratory study. Methods: Articular cartilage explants (6 per group) were harvested from femoral condyles of the porcine stifle and sectioned at tidemark. Explants were bathed in CHG solution (0.05% CHG in sterile water) at varying concentrations (0% control, 0.01% CHG, and 0.05% CHG) for 1 minute, followed by complete phosphate-buffered saline wash and culture in chondrogenic medium. At 7 days after CHG exposure, cell viability, matrix content (collagen and glycosaminoglycan [GAG]), and compressive mechanical properties (creep indentation testing) were assessed. Results: One-minute CHG exposure was chondrotoxic to explants, with both 0.05% CHG (2.6% ± 4.1%) and 0.01% CHG (76.3% ± 8.6%) causing a decrease in chondrocyte viability compared with controls (97.5% ± 0.6%; P < .001 for both). CHG exposure at either concentration had no significant effect on collagen content, while 0.05% CHG exposure led to a significant decrease in mean GAG per wet weight compared with the control group (2.6% ± 1.7% vs 5.2% ± 1.9%; P = .029). There was a corresponding weakening of mechanical properties in explants treated with 0.05% CHG compared with controls, with decreases in mean aggregate modulus (177.8 ± 90.1 kPa vs 280.8 ± 19.8 kPa; P < .029) and shear modulus (102.6 ± 56.5 kPa vs 167.9 ± 16.2 kPa; P < .020). Conclusion: One-minute exposure to CHG for articular cartilage explants led to dose-dependent decreases in chondrocyte viability, GAG content, and compressive mechanical properties. This raises concern for the risk of mechanical failure of the cartilage tissue after CHG exposure. Clinical Relevance: Clinicians should be judicious regarding the use of CHG irrigation at these concentrations in the presence of native articular cartilage.

(310) Severe Delayed Skin Reaction to Antiseptic Irrigation Solution Managed with Pinch Skin Grafting After Inflatable Penile Prosthesis Surgery: A Case Report

Abstract Introduction Inflatable penile prosthesis (IPP) surgery is a common procedure for treating erectile dysfunction, and skin preparation with antiseptic solutions is a standard practice to reduce infection risk. However, some antiseptic solutions, such as chlorhexidine-based Irrisept, have been associated with severe skin reactions. Several studies have reported cases of contact dermatitis, blistering, and chemical burns following the use of chlorhexidine-based antiseptic solutions before surgery. Objective This case report aims to highlight the potential risk of severe skin reactions when using Irrisept and other chlorhexidine antiseptic solutions during penile prosthesis surgery. It also explores the novel technique of pinch skin autografting used to salvage the implant and achieve successful wound healing after delayed skin necrosis. Methods 61-year-old male with a history of prostate cancer and erectile dysfunction who underwent insertion of an IPP. Results The patient's penile shaft developed blisters 3 weeks post-implantation, which progressed to full-thickness necrosis despite conservative treatment. The distribution and location of the reaction led to the hypothesis that it was caused by the chlorhexidine-based Irrisept antiseptic. The antiseptic solution used copiously throughout the case and 10CC was injected under pressure into the drain which also may explain the reaction observed. The patient underwent wound debridement and was treated with pinch skin autografts from the bilateral thighs. The autografts resulted in 95% epithelialization with excellent cosmetic outcomes with no other complications. To the best of our knowledge, this is the first reported case of Irrisept-induced delayed skin necrosis and the use of pinch skin grafting to salvage the implant after penile prosthesis surgery. Conclusions Skin reactions to Irrisept antiseptic solution during penile prosthesis surgery are rare but can be severe. Surgeons should be cautious and consider alternative skin preparation methods in patients with a history of skin allergies or sensitivities. This case also highlights the potential of pinch skin autografting as a salvage technique for post-IPP skin reactions. A multidisciplinary approach involving reconstructive burn surgeons and specialty wound care teams may be beneficial in optimizing outcomes in such cases. Disclosure No.

(129) Prophylactic Dips and Irrigation Solutions Can Considerably Alter the Antimicrobial Efficacy of Inflatable Penile Implant Hydrophilic Surface Coatings

Abstract Introduction Inflatable penile prostheses (IPP) experience surface-associated bacterial biofilms, which may contribute to clinical infections. Current attempts to reduce bacterial colonization include antibiotic coatings, altered implant surface binding properties, and mechanical irrigations. 0.05% chlorhexidine gluconate (CHG) has been proposed as a hydrophilic surface coating and mechanical irrigation for IPP surgery. One study demonstrated reduced surface bacterial colonization on an IPP hydrophilic surface dipped and irrigated with CHG 15psi compared to normal saline. However, CHG’s efficacy has not been compared to that of an antibiotic, particularly in preventing colonization by bacteria that are commonly implicated in IPP infections. Objective To characterize the utility of 0.05% chlorhexidine or vancomycin/gentamicin (VG) as both an antibiotic dip and an intraoperative irrigation in reducing bacterial colonization on hydrophilic IPP surfaces. Methods Sterile 8mm diameter IPP pieces (Coloplast, Minneapolis, MN) underwent the following treatment protocols. 1: IPP pieces were split into three groups (10 replicates each) and submerged for 3 minutes in normal saline (NS), 0.05% CHG in sterile water (Irrimax, Lawrenceville, GA), or a solution of 2mg/mL vancomycin and 160μg/mL gentamicin (VG) (Sigma-Aldrich, Burlington, MA) 2: IPP pieces were split into six groups (&amp;gt;14 replicates each) and submerged for 3 minutes in either NS, 0.05% CHG, or VG. Pieces were then rinsed in NS for five seconds and re-submerged in a separate well containing NS, 0.05% CHG, or VG. The pieces were rinsed in NS to remove any unbound solution and then incubated with 1*10^5 CFU/mL of methicillin-sensitive Staphylococcus aureus ATCC25923 in trypticase soy broth (TSB) for 48 hours. Samples were then rinsed with PBS and adherent bacteria were removed by shaking in 0.3% Tween-20. Suspended bacteria were serially diluted, plated onto 3M PetriFilms (Maplewood, MN), and counted. Mann-Whitney U tests were performed to compare outcomes, p&amp;lt;0.05 considered significant. Results Average bacterial counts with 95% CI’s for protocols 1 and 2 are plotted in Figures 1a and 1b respectively. NS controls showed an average of 1.1E7 CFU/mL adherent bacteria. Pre-dipping the implant in 0.05% CHG inhibits bacterial growth with a nearly ~2 log decrease (4.9E5 CFU/mL, p&amp;lt;0.01) in counts. Pre-dipping with VG had greater potency, with a ~5 log decrease (3.7E1 CFU/mL. p&amp;lt;0.01). However, exposure of the previously dipped IPP surface to an antiseptic irrigation solution altered antimicrobial properties (Figure 1b). NS controls showed an average of 6.0E7 CFU/mL adherent bacteria. The introduction of NS or CHG to the VG-coated implant material resulted in a near-complete loss of antimicrobial efficacy, with a 0.5 log decrease (NS) and a slight increase (CHG) in bacterial growth (NS: 5.5E7 CFU/mL, p=0.433; CHG: 6.2E7, p=.983). VG dipping followed by VG irrigation resulted in retention of antimicrobial properties, with a similar 5 log decrease. Conclusions Dipping of the implant surface with VG was more effective than 0.05% CHG. Furthermore, the choice of irrigation solution appears to alter the efficacy of antimicrobials bound to the hydrophilic IPP surface. Surgeons should be cautious using CHG or NS as an irrigation solution, and, if utilized, should take care to limit the contact time with the antibiotic-coated implant. Disclosure Yes, this is sponsored by industry/sponsor: Coloplast (material not financial support). Clarification: Industry funding only - investigator initiated and executed study. Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast and Boston Scientific.

A Review of Surgical Irrigation Solutions for Infection Prevention in Orthopaedic Surgery

» Intraoperative surgical irrigation is a common practice in orthopaedic procedures, although there is no universally established standard of care due to a lack of concrete data supporting an optimal irrigation agent.» Isotonic normal saline has long been considered a safe and cost effective solution for wound irrigation as compared with other antibiotic and antiseptic irrigation solutions.» Currently, the only adjunct to saline that is formally supported by American Academy of Orthopaedic Surgeons, the Centers for Disease Control and Prevention, and World Health Organization is povidone-iodine.» Further in vivo clinical studies are needed to identify the ideal irrigation solution that carries low cytotoxic effects while also exerting optimal antimicrobial properties.

Review of Intra-Articular Use of Antibiotics and Antiseptic Irrigation and Their Systematic Association with Chondrolysis.

Intra-articular antibiotics have been proposed as a treatment for septic arthritis to allow for high local concentrations without subjecting a patient to the toxicity/side effects of systemic therapy. However, there is concern for chondrotoxicity with intra-articular use of these solutions in high concentrations. The purpose of this systematic review was to evaluate the intra-articular use of antibiotics and antiseptic solutions, and to determine their association with chondrolysis following in vitro or in vivo administration. A systematic review was conducted following PRISMA guidelines through PubMed, Clinical Key, OVID, and Google Scholar. Studies in English were included if they evaluated for chondrotoxicity following antibiotic exposure. The initial search resulted in 228 studies, with 36 studies meeting criteria. These 36 studies included manuscripts that studied 24 different agents. Overall, 7 of the 24 (29%) agents were non-chondrotoxic: minocycline, tetracycline, chloramphenicol, teicoplanin, pefloxacin, linezolid, polymyxin-bacitracin. Eight (33%) agents had inconsistent results: doxycycline, ceftriaxone, gentamicin, vancomycin, ciprofloxacin, ofloxacin, chlorhexidine, and povidone iodine. Chondrotoxicity was evident with 9 (38%) agents, all of which were also dose-dependent chondrotoxic based on reported estimated half maximal inhibitory concentrations (est. IC50): amikacin (est. IC50 = 0.31-2.74 mg/mL), neomycin (0.82), cefazolin (1.67-3.95), ceftazidime (3.16-3.59), ampicillin-sulbactam (8.64 - >25), penicillin (11.61), amoxicillin (14.01), imipenem (>25), and tobramycin (>25). Additionally, chondroprotective effects of doxycycline and minocycline were reported. This systematic review identified agents that may be used in the treatment of septic arthritis. Nine agents should be avoided due to their dose-dependent chondrotoxic effects. Further studies are needed to clarify the safety of these medications for human intra-articular use.

Systematic Review of Intra-Articular Use of Antibiotics and Antiseptic Irrigation and their Association with Chondrolysis

Category: Arthroscopy; Other Introduction/Purpose: Intra-articular antibiotics have been proposed as a treatment for septic arthritis to allow for high local concentrations without subjecting a patient to systemic therapy and its associated toxicity/side effects. However, there is concern for chondrotoxicity with intra-articular use of antimicrobials and antiseptic solutions in high concentrations. The purpose of this systematic review was to evaluate the intra-articular use of antibiotics and antiseptic solutions, determine their association with chondrolysis following in vitro or in vivo administration, and identify the dosages at which they become chondrotoxic. Methods: A systematic review was conducted following the PRISMA guidelines through PubMed, Clinical Key, OVID, and Google Scholar. Studies were included if they were written in the English language and evaluated for chondrotoxicity following in vitro or in vivo intra-articular exposure to an antibiotic and antiseptic solutions. All agents, study characteristics, and conclusions were extracted and summarized. Results: The initial search resulted in 228 studies, with 36 meeting full inclusion criteria. Overall, chondrotoxicity was not associated with 7 out of 24 (29%) included agents: minocycline, tetracycline, chloramphenicol, teicoplanin, pefloxacin, linezolid, polymyxin-bacitracin. Inconsistent results were noted with 8 (33%) agents: doxycycline, ceftriaxone, gentamicin, vancomycin, ciprofloxacin, ofloxacin, chlorhexidine, and povidone iodine. Chondrotoxicity was evident with 9 (38%) agents, all of which were also dose-dependently chondrotoxic based on reported estimated half maximal inhibitory concentrations (est.IC50): amikacin (est. IC50 = 0.31-2.74 mg/mL), neomycin (0.82 mg/mL), cefazolin (1.67-3.95 mg/mL), ceftazidime (3.16-3.59 mg/mL), ampicillin- sulbactam (8.64 - &gt;25 mg/mL), penicillin (11.61 mg/mL), amoxicillin (14.01 mg/mL), imipenem (&gt;25 mg/mL), and tobramycin (&gt;25 mg/mL). Additionally, certain studies reported chondroprotective effects of doxycycline and minocycline. Conclusion: This systematic review identified antimicrobial and antiseptic agents that may be used in the treatment of septic arthritis. The following agents should be avoided due to their dose-dependent chondrotoxic effects: amikacin, neomycin, cefazolin, ceftazidime, ampicillin-sulbactam, penicillin, amoxicillin, imipenem, and tobramycin. Further studies, especially in human models, are needed to clarify the safety of these medications for human intra-articular use.

Poster 152: Detrimental Effects of Chlorhexidine on Articular Cartilage Viability, Matrix, and Mechanics

Objectives: Chlorhexidine gluconate (CHG) is commonly used in antiseptic irrigation solutions for bacterial decontamination during orthopaedic surgery. Although the chondrotoxicity of CHG to articular cartilage has been reported, CHG irrigation is utilized by some surgeons to limit surgical site infection and to salvage grafts after accidental contamination during joint surgery. The full extent of CHG irrigation-related chondrotoxicity, as well as its effects on articular cartilage extracellular matrix and mechanical properties, are unknown. The purpose of this study was to determine the in vitro effects of a single one-minute CHG exposure on the viability, biochemical content, and mechanics of native articular cartilage explants. Methods: Articular cartilage explants (n=6 per group) were harvested from the femoral condyles of the porcine stifle and sectioned at the tidemark. Explants were bathed in Irrisept® chlorhexidine solution (0.05% CHG in sterile water) at varying concentrations (0% control, 0.01% CHG, and 0.05% CHG) to stimulate surgical irrigation for 1 minute, followed by complete phosphate-buffered saline wash and culture. After seven days of culture in chondrogenic medium, the explants were analyzed for viability (live/dead assay); collagen content (hydroxyproline assay); glycosaminoglycan (GAG) content (dimethyl methylene blue assay); and compressive mechanical testing (creep indentation testing). Statistical analyses were performed using a one-way ANOVA with post hoc Tukey test. Results: Seven days after CHG exposure, a dose-dependent decrease in mean chondrocyte viability was observed in the CHG groups (p&lt;0.001), with &lt;3% viability observed in the 0.05% CHG group (Figure 1). There was no significant difference in mean collagen content per wet weight among groups. Conversely, 0.05% CHG exposure led to a decrease in mean GAG per wet weight compared to negative control (p=0.029) and 0.01% CHG (p=0.046) (Figure 2). These changes in GAG content corresponded to observed changes in the compressive mechanical properties of the explants. A dose-dependent decrease in mean aggregate modulus and shear modulus was observed after CHG exposure (p&lt;0.029), indicating weakening of the cartilage matrix and increased deformation in response to compressive loads (Figure 3). Conclusions: One-minute CHG exposure to articular cartilage explants led to dose-dependent decreases in chondrocyte viability, GAG content, and compressive mechanical properties. These detrimental effects were observed for both 0.05% and 0.01% CHG concentrations. There is a paucity of literature examining the effects of CHG on articular cartilage matrix and mechanics, and the findings of this study suggest a lack of matrix maintenance following cell death, raising concern for risk of mechanical failure of the cartilage tissue. Clinicians should be judicious regarding the use of CHG irrigation at these concentrations in the presence of native articular cartilage.

Antimicrobial or Antiseptic Cleansers for Wounds

&#x0D; For chronic wound care, the majority of evidence suggested that antiseptic agents do not add additional clinical benefits compared with saline. No differences were observed between antiseptics and saline in the incidence of adverse events.&#x0D; For surgical wound care, irrigation with antibiotic agents is likely associated with lower rates of surgical site infections compared with saline irrigation. Depending on the type of antiseptic agent, type of surgery, and depth of infection, antiseptic irrigation may have superior or similar efficacy compared with saline in surgical site infection and wound healing rates. Indirect evidence suggested antibiotics were not superior to antiseptics for prevention of surgical site infections. No differences were observed between antiseptic irrigation and saline irrigation in the incidence of adverse events and length of hospital stay.&#x0D; For acute traumatic wound care, a limited number of studies provided mixed results on the effectiveness of povidone-iodine compared with saline for preventing infection. The effect of antiseptic agents on bacterial load was unclear. No robust conclusions could be drawn due to very low certainty of the evidence.&#x0D; The economic evaluation study showed that irrigation with hypochlorous acid preserved wound cleanser was a cost-effective strategy in the short term compared with saline for the treatment of severely complex wounds during ultrasonic debridement. However, we have little confidence in the findings due to several limitations in the methods of the study.&#x0D; We did not identify any studies that compared the clinical effectiveness and cost-effectiveness of antimicrobial or antiseptic wound cleansers with antimicrobial dressings or of different types of antimicrobial or antiseptic wound cleansers for the management of wounds.&#x0D; We did not identify any evidence-based guidelines regarding the use of antimicrobial or antiseptic wound cleansers for the management of wounds.&#x0D;

Novel Intra- Operative Wound Irrigation Solution to Manage Infection Prevention in Patients Undergoing Primary Joint Arthroplasty: Retrospective Review of a Case Series of 308 Patients

Introduction Periprosthetic joint infection (PJI) after total hip and total knee arthroplasty is a devastating complication that is known to be associated with costly, resource-intensive interventions that place a significant burden on the US healthcare system. Estimated average hospital costs to treat female patients with PJI after total knee arthroplasty (TKA) or total hip arthroplasty (THA) in 2018 was $27,307, and $32,956 respectively. While the average costs to treat male patients with PJI after TKA or THA was $27,097 and $33,090 respectively. One strategy aimed at preventing PJI after total joint arthroplasty is the use of an intra-operative wound irrigation with an antiseptic solution. This retrospective case review was conducted to assess the incidence of PJI after using a novel wound antiseptic irrigation solution in patients undergoing primary TKA and THA. Methods The CDC defines surgical site infections, (SSI) as infections that occur after the surgery. The infections are further categorized as superficial involving the skin, or deep tissue. These infections are then divided into; superficial incisional SSI, deep incisional SSI, and organ-space SSI. In a study by Kannan et al., SSIs are more commonly seen in patients with more comorbidities. A consecutive series of 308 high-risk patients undergoing primary TKA or THA between January 4, 2021 and August 30, 2021, in whom Prontosan® Wound Irrigation Solution (B. Braun Medical Inc./ Innovice LLC), containing 0.1% Betaine, a surfactant, and 0.1% Polyhexanide (PHMB) was added to the intra-operative procedure, were evaluated for its impact on the incidence of PJI. The CDC’s Surgical Care Improvement Project, (SCIP) guidelines are standard of care and followed with each surgical procedure. The CDC recommends using antimicrobial prophylaxis at a time before skin incision such that the antibiotic concentration reaches the minimum bactericidal concentration at the time of skin incision, Berríos-Torres SI, et al. All data were prospectively submitted to the American Joint Replacement Registry (AJRR) was retrospectively analyzed to measure the incidence of postoperative infection. Results Primary TJA was performed on 308 patients; of these 10 patients were bilateral TKA (205 TKA procedures and 113 THA procedures). The use of Prontosan® Wound Irrigation Solution was associated with zero (0%) incidence of postoperative infection in this population of patients during a 90-day episode of care, nor at any time postoperatively. CMS defines total joint arthroplasty codes as a major surgery, and encounters or procedures within 90 days of the initiating procedure are included in the 90-day episode of care. No patients were lost to follow-up. Conclusion There was no incidence of PJI uncovered in this retrospective analysis. Adding Prontosan® Wound Irrigation Solution to the intra-operative protocol, contributed to the absence of PJI in this population and potentially avoided 1.74 female and 1.34 male TKA as well as .95 female and .75 THA resulting in total hospital-avoided costs of $83,824 and $56,126, respectively totaling $139,950.

ROUTINE SURGICAL ANTISEPTIC AGENTS ARE INEFFECTIVE IN THE ERADICATION OF TYPICAL PJI BIOFILM FORMED ON ORTHOPAEDIC IMPLANT MATERIAL IN VITRO AND THE ABSENCE OF AN ANTISEPTIC NEUTRALIZATION STAGE GIVES THE FALSE IMPRESSION OF EFFICACY

Prosthetic joint infection (PJI) is a serious complication following joint replacement. Antiseptic solutions are often used for intraoperative wound irrigation particularly in cases of revision for PJI. Antiseptic irrigation is intended to eradicate residual bacteria which may be either free floating or in residual biofilm although there is no clear clinical efficacy for its use. Also, reviewing the scientific literature there is discordance in in vitro results where some studies questions antiseptic efficacy whilst others suggest that even at low concentration antiseptic agents are effective at eradicating bacterial biofilms.The aim of this in vitro study was to establish the efficacy of undiluted antiseptic agents at eradication of a typical PJI forming biofilm and determine the importance of an antiseptic neutralisation step in this assessment.Mature Staphylococcus epidermidis biofilms grown on TiAl6V4 discs were submerged in chlorohexidine (CHL) gluconate 4%, povidone-iodine (PI) 10% or phosphate-buffered saline (PBS) control solution. The discs were then rinsed, the biofilm bacteria suspended in solution using sonication and vortexing, and the viable count (CFU/ml) of the bacterial suspensions determined. The rinse/suspension solution was either (a) PBS or (b) Dey-Engley neutralization broth (NB).When PBS was used to rinse/suspend the biofilm a highly significant, 7.5 and 4.1, mean log reduction in biofilm vitality was observed from the control, for CHL 4% and PI 10%, respectively. However, when NB was the rinse/suspension solution the apparent antiseptic biofilm eradication efficacy was replaced with a statistically significant but clinically irrelevant less the one log-reduction in biofilm vitality.Clinical antiseptic agents are ineffective at eradicating S. epidermidis biofilm in an in vitro PJI model and absence of a neutralisation step gives the false impression of efficacy. Antiseptics alone are an ineffective treatment for biofilm related PJI and no substitute for meticulous debridement.

Intradural Extramedullary Pyogenic Abscess: Incidence, Management, and Clinical Outcomes in 45 Patients With a Mean Follow Up of 2 Years.

Retrospective review. Spinal intradural extramedullary abscess (SIEA) is a rare disease with an unknown incidence. In this study, we systematically described the clinical course of SIEA in a large cohort with acute onset of neurological illness, assessed the morbidity and mortality rates, and determined the potential risk factors for mortality. Electronic medical records of patients diagnosed with SIEA at a single institution for the period between September 2005 and December 2020 were retrieved. Over a period of 15years, 881 patients with spinal infections were treated either conservatively or surgically at our center, of whom 45 patients (45/881, 5.1%) had SIEA. The overall mean age was 69.6 ± 5.6years of patients diagnosed with SIEA and all of them underwent posterior decompression via laminectomy. The mean Charlson Comorbidity Index (CCI) was 6.9 ± 2.5, indicating a poor baseline reserve. Progressive neurological decline was observed in all patients (mean motor score, 88.6 ± 9.7). The in-hospital rate and 90-day mortality were 4.4% and 10%, respectively. Mortality was not surgery related. Most importantly, the patients' motor deficits and blood infection parameters significantly improved after surgery. Risk factors for mortality were increased age, comorbidities as measured by CCI, and preoperative motor weakness (MS). Immediate surgical decompression via laminectomy, with antiseptic irrigation and drainage of the subdural space, followed by antibiotic therapy, appears to be the key to ensuring beneficial clinical outcomes to treatment of rare diseases such as SIEA.

Peritoneal antiseptic irrigation to prevent surgical site infection after laparotomy for hepatobiliary or gastrointestinal surgery (PAISI)—protocol for a randomized controlled study

BackgroundPostoperative surgical site infections (SSIs) remain common after laparotomy for resections of the gastrointestinal or hepatobiliary tract. Especially organ/space infections (CDC class III SSI) can be life-threatening, require relaparotomy, intensive care or interventional drainage of intraabdominal abscesses. The PAISI study aims to investigate whether the use of prophylactic peritoneal irrigation with NaOCl/HOCl solution can reduce the SSI rates following laparotomy for resections of the gastrointestinal or hepatobiliary tract, compared to standard irrigation with physiological electrolyte solution (Ringer’s solution). Secondarily, to evaluate whether the use of prophylactic peritoneal irrigation with NaOCl/HOCl solution can reduce postoperative morbidity and mortality as well as the rate of re-operations and length of hospital stay.MethodsPAISI is a prospective, randomized, observer- and patient-blinded, monocentric, two-arm surgical study in an adaptive parallel groups design, comparing peritoneal and wound irrigation with NaOCl/HOCl (50/50ppm) solution to irrigation with Ringer’s solution. The primary endpoint of the study is the SSI rate within 30 days postoperatively. Since there is no data on incidence rates from randomized clinical trials, the rates for sample size calculation were estimated according to the clinical experience at our institution. Therefore, the study design includes one unblinded look at the data by a second statistician, which will be performed after half of the patients reached the primary endpoint. This interim information will be used to check the assumptions and if needed, the sample size will be adjusted. The O’Brien-Fleming spending function is used to determine the efficacy test boundary and the non-binding futility boundary. The one-sided z-test (Group sequential test of two proportions) at the 2.5% significance level with a total of two looks at the data will have overall 80% power.DiscussionThe results of this study will provide high-level evidence for future research and clinical recommendations regarding the use of NaOCl/HOCl solution in abdominal surgery and provide the participating patients the opportunity of a potentially improved treatment.Trial registrationGerman Clinical Trials Register (DRKS) DRKS00028037. Registered on 27 May 2022.

Comparison of Breast Reconstruction Outcomes Using Oxychlorosene versus Triple Antibiotic Solution for Pocket Irrigation.

Background:Breast pocket irrigation with antiseptic solutions is performed to reduce contamination with breast implants. The optimal antiseptic irrigation solution and the efficacy of individual practices are unclear. Oxychlorosene sodium is frequently used at our institution. Oxychlorosene is bactericidal with a mechanism of action of oxidation and hypochlorination. The purpose of our study was to compare the outcomes of oxychlorosene sodium irrigation with triple antibiotic solution (TAS) in implant-based breast reconstruction.Methods:All patients who underwent implant-based reconstruction after mastectomy were reviewed. The primary predictive variable was type of solution used for pocket irrigation (TAS or oxychlorosene). Outcome variables included surgical site infection, device removal, and wound complications.Results:Between 2013 and 2018, 331 implant-based breast reconstructions were performed. Of these, 62% (n = 206) received oxychlorosene for surgical pocket irrigation (group I), and 38% (n = 125) received TAS (group II). Group I had an 11.7% (n = 24) 90-day surgical site infection rate, with 4.9% (n = 10) requiring oral antibiotics, 2.4% (n = 5) requiring intravenous antibiotics without device removal, and 4.4% (n = 9) requiring prosthetic removal. Group II had an 11.2% (n = 14) 90-day infection rate, with 5.6% (n = 7) requiring oral antibiotics, 2.4% (n = 3) requiring intravenous antibiotics without device removal, and 3.2% (n = 4) requiring removal (P = 0.90). When comparing the cost of oxychlorosene irrigation with TAS irrigation, oxychlorosene was less expensive.Conclusions:Oxychlorosene and TAS have similar surgical site infection rates in prosthetic breast reconstruction. Ease of preparation and cost make oxychlorosene a more favorable option for antibiotic irrigation in reconstructive breast surgery with prosthetic devices.

Breast Implant Illness: Surgical, Autoimmune, and Breast Reconstruction Associations

Breast implant illness refers to a combination of different symptoms related to breast implant surgery, including fatigue, brain fog, and arthralgias. This malaise occurs after cosmetic and reconstructive breast surgeries, although it has not been proven to be a disease. Even recent studies have reported concluding statements of the etiology, diagnosis, and treatment as unclear and widely unknown. Therefore, this review aimed to determine the associations between the manifestations of breast implant illness in surgery and breast reconstruction, as well as the autoimmune responses involved. Complications associated with breast implants include breast pain, capsular contracture, infections, as well as other manifestations specific to breast reconstruction. Moreover, patients with implants may present with new-onset systemic sclerosis, Sjögren’s syndrome, and connective tissue diseases. However, the incidence of capsular contracture has steadily decreased with each generation of implants, particularly since the development of textured implants, as well as with the use of antibiotics and antiseptic pocket irrigation. However, the incidence of anaplastic large cell lymphoma has increased with the use of textured implants. Remarkably, the autoimmune response to these implants remains unclear. Therefore, close follow-up, careful observation of any symptom presentation, and evidence-based treatment decisions are necessary for patients with breast implants.

Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty: A Critical Analysis Review.

There are limited data that directly compare the efficacy of antiseptic irrigation solutions used for the prevention and treatment of periprosthetic joint infections in orthopaedic procedures; there is a notable lack of prospective data. For prevention of periprosthetic joint infections, the strongest evidence supports the use of low-pressure povidone-iodine. For the treatment of periprosthetic joint infections, delivering multiple solutions sequentially may be beneficial.

What Is the Duration of Irrigation? An InVitro Study of the Minimum Exposure Time to Eradicate Bacteria With Irrigation Solutions.

Antiseptic irrigation solutions are commonly used by arthroplasty surgeons to reduce intraoperative bacterial colonization with the goal of reducing postoperative infections in the setting of primary total joint arthroplasty. Currently, the minimum irrigation time to eliminate common microbes implicated in periprosthetic joint infection is unknown. We sought to determine the minimum effective exposure time required to prevent growth of Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes with common antiseptic solutions. S aureus, S epidermidis, and C acnes cultures were treated with povidone-iodine (0.35%), chlorhexidine (0.05%), sodium hypochlorite (0.5%), polyhexamethylene biguanide, and an acetic acid-based solution for 15, 30, 60, 90, and 120seconds in triplicate. Bacterial growth was quantified using the drop plate method. Failure to eliminate all bacteria was considered "not effective" at that time point. Povidone-iodine 0.35% (Betadine), sodium hypochlorite 0.5% (HySept), and acetic acid (Bactisure) eradicated all bacterial growth after 90seconds of treatment, and as low as 15seconds in S aureus and C acnes (Betadine) or S epidermidis (Bactisure). Polyhexamethylene biguanide (Prontosan) required 90seconds for elimination of S aureus and S epidermidis, and 120seconds for C acnes. Chlorhexidine 0.05% (Irrisept) did eliminate S epidermidis at 120seconds but did not effectively eradicate S aureus or C acnes. All tested antiseptic solutions demonstrated successful eradication of all bacterial growth in under 2minutes of treatment time except chlorhexidine. Povidone-iodine may require the shortest duration of treatment time to successfully eradicate common bacteria.

Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections.

Irrigation and debridement in the treatment of periprosthetic joint infection (PJI) serve an integral role in the eradication of bacterial burden and subsequent re-infection rates. Identifying the optimal irrigation agent, however, remains challenging, as there is limited data on superiority. Direct comparison of different irrigation solutions remains difficult because of variability in treatment protocols. While basic science studies assist in the selection of irrigation fluids, in vitro results do not directly translate into clinical significance once implemented in vivo. Dilute povidone iodine, hydrogen peroxide, chlorhexidine gluconate, acetic acid, sodium hypochlorite, hypochlorous acid, and preformed combination solutions all have potential against a broad spectrum of PJI pathogens with their own unique advantages and disadvantages. Future clinical studies are needed to identify ideal irrigation solutions with optimal bactericidal properties and low cytotoxicity for PJI treatment.