Local application of gentamicin collagen implants in the prophylaxis of surgical site infections following gastrointestinal surgery: a review of clinical experience

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Electro-microenvironment modulated inhibition of endogenous biofilms by piezo implants for ultrasound-localized intestinal perforation disinfection

Endogenous bacterial infections from damaged gastrointestinal (GI) organs have high potential to cause systemic inflammatory responses and life-threatening sepsis. Current treatments, including systemic antibiotic administration and surgical suturing, are difficult in preventing bacterial translocation and further infection. Here, we report a wireless localized stimulator composed of a piezo implant with high piezoelectric output serving as an anti-infective therapy patch, which aims at modulating the electro-microenvironment of biofilm around GI wounds for effective inhibition of bacterial infection if combined with ultrasound (US) treatment from outside the body. The pulsed charges generated by the piezo implant in response to US stimulation transfer into bacterial biofilms, effectively destroying their macromolecular components (e.g., membrane proteins), disrupting the electron transport chain of biofilms, and inhibiting bacterial proliferation, as proven by experimental studies and theoretical calculations. The piezo implant, in combination with US stimulation, also exhibits successful in vivo anti-infection efficacy in a rat cecal ligation and puncture (CLP) model. The proposed strategy, combining piezo implants with controllable US activation, creates a promising pathway for inhibiting endogenous bacterial infection caused by GI perforation.

Collagen fleece in orthopaedic infections

Collagen fleece is a relatively new development. It represents another option in the battle against infection. It is a cheap, biocompatible, and resorbable local antibiotic delivery mechanism with favorable drug release kinetics and low risk of adverse effects or toxicity. Benefit may be conferred when used in contaminated cases. Significantly more research is still needed before the adoption of collagen fleece as the standard of care. However, we can likely conclude that there are no major adverse effects and it can be safely used as an adjunct in addition to conventional therapies for the prophylaxis and treatment of infections.

Targeted Drug Delivery via the Use of ECM-Mimetic Materials

The use of drug delivery vehicles to improve the efficacy of drugs and to target their action at effective concentrations over desired periods of time has been an active topic of research and clinical investigation for decades. Both synthetic and natural drug delivery materials have facilitated locally controlled as well as targeted drug delivery. Extracellular matrix (ECM) molecules have generated widespread interest as drug delivery materials owing to the various biological functions of ECM. Hydrogels created using ECM molecules can provide not only biochemical and structural support to cells, but also spatial and temporal control over the release of therapeutic agents, including small molecules, biomacromolecules, and cells. In addition, the modification of drug delivery carriers with ECM fragments used as cell-binding ligands has facilitated cell-targeted delivery and improved the therapeutic efficiency of drugs through interaction with highly expressed cellular receptors for ECM. The combination of ECM-derived hydrogels and ECM-derived ligand approaches shows synergistic effects, leading to a great promise for the delivery of intracellular drugs, which require specific endocytic pathways for maximal effectiveness. In this review, we provide an overview of cellular receptors that interact with ECM molecules and discuss examples of selected ECM components that have been applied for drug delivery in both local and systemic platforms. Finally, we highlight the potential impacts of utilizing the interaction between ECM components and cellular receptors for intracellular delivery, particularly in tissue regeneration applications.

Ultralow anterior resection with implantation of gentamicin-collagen sponge and no defunctioning stoma: anastomotic leakage and local cancer relapse

Background Anterior resection with total mesorectal excision (TME) of ultralow rectal cancer may result in the increased risk of the anastomotic leakage (AL). The aim of this study was to evaluate the usefulness of the gentamicin-collagen sponge (GCS) for the protection against symptomatic AL and investigate association between AL and local relapse (LR). Patients and methods A series of 158 patients with ultralow rectal cancer was studied. All the patients underwent R0 sphincter-saving TME with anastomosis wrapping using GCS. In none of the cases a temporary protective stoma was constructed. Results AL rate was 3.2% (5/158) while median time to AL diagnosis was 5 days following surgery (range 3-15). There was no postoperative and leakage-related mortality. Patient age > 75 years and smoking were independent risk factors related to significantly increased AL rate: 12.5% vs. 0.8% (P = 0.0004) and 5.7% vs. 0% P = 0.043), respectively. LR was observed in 12% of cases. It was highly significantly more common and developed earlier in patients who have had AL when compared with non-AL group: 80% vs. 9% (P = 0.00001) and 8.5 vs. 17 months (P = 0.014), respectively. Conclusions Anastomosis wrapping with GCS after anterior resection with TME is a safe procedure resulting in the low incidence of anastomotic leakage which may be also associated with decreased risk of local relapse.

Effective Treatment of Chronic Proliferative Cholangitis by Local Gentamicin Infusion in Rabbits

Background

Hepatolithiasis is highly prevalent in East Asia characterized by the presence of gallstones in the biliary ducts of the liver. Surgical resection is the potentially curative treatment but bears a high risk of stone recurrence and biliary restenosis. This is closely related to the universal presence of chronic proliferative cholangitis (CPC) in the majority of patients. Recent evidence has indicated the association of bacterial infection with the development of CPC in hepatolithiasis. Thus, this study aims to investigate the feasibility and efficacy of local infusion of gentamicin (an antibiotic) for the treatment of CPC in a rabbit model.

Methods

The rabbit CPC model was established based on previously published protocols. Bile duct samples were collected from gentamicin-treated or control animals for pathological and molecular characterization.

Results

Histologically, the hyperplasia of biliary epithelium and submucosal glands were inhibited and the thickness of the bile duct wall was significantly decreased after gentamicin therapy. Consistently, the percentage of proliferating cells marked by ki67 was significantly reduced by the treatment. More importantly, this treatment inhibited interleukin 2 production, an essential inflammatory cytokine, and the enzyme activity of endogenous β-Glucuronidase, a key factor in the formation of bile pigment.

Conclusions

Local gentamicin infusion effectively inhibits the inflammation, cell proliferation, and lithogenesis in a rabbit model of CPC. This approach represents a potential treatment for CPC and thus prevents recurrent hepatolithiasis.

Design and evaluation of antibiotic releasing self- assembled scaffolds at room temperature using biodegradable polymer particles

Biodegradable polymer-based drug-eluting implants offer many advantages such as predictable drug release kinetics, safety, and acceptable drug loading under ambient conditions. Herein, we describe fabrication and evaluation of antibiotic loaded scaffolds for localized delivery and tissue engineering applications. PDLLA particles entrapping gentamycin were formulated using solvent evaporation method and used for scaffold fabrication. Optimization of formulation parameters such as pH of the internal aqueous phase and combination of excipients like glycerol, polyvinyl alcohol (PVA) resulted in high entrapment efficiencies up to 96% of gentamicin in particles with drug load of 16-18μg/mg of polymer particles. These microparticles were fused in presence of methanol at ambient temperatures to form scaffolds of different geometry having reasonable mechanical strength. Porosity of these scaffolds was found to be more than 80%. Antibiotic released from the scaffolds was found to be bioactive as tested against Staphylococcus aureus and the release pattern was biphasic over a period of one week. The scaffolds were found to be non-toxic to murine fibroblasts cultures in vitro as well as to mice upon subcutaneous implantation. This method provides a novel and easy way of fabricating antibiotic loaded polymer scaffolds for varieties of applications.

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Antimicrobial Formulation and Delivery in the Prevention of Surgical Site Infection

BACKGROUND

A number of adjunct antimicrobial measures have been studied in an attempt to reduce surgical site infection (SSI) rates. In addition to parenteral antibiotic prophylaxis, these measures include oral antibiotics in bowel preparation for colorectal surgery, antiseptic/antimicrobial irrigation, antimicrobial sutures, local antibiotics, skin incision antibacterial sealants, and antimicrobial dressings. It is the purpose of this review to study the evidence behind each of these measures and to evaluate relevant data for recommendations in each area.

METHODS

A systematic review of the literature through PubMed was performed.

RESULTS

Need for adequate dosing and re-dosing of intravenous peri-operative antibiotics, duration of antibiotic usage past wound closure, and the use of antibiotic bowel preparation in colorectal surgery are well defined in the published literature. However, data on local antimicrobial measures remain controversial.

CONCLUSIONS

Proper dosing and re-dosing of prophylactic intravenous antibiotics should become standard practice. Continuation of intravenous antibiotic prophylaxis beyond wound closure is unnecessary in clean cases and remains controversial in clean-contaminated and complex cases. Oral antibiotic bowel preparation is an important adjunct to intravenous antibiotic prophylaxis in colorectal surgery. The use of topical antimicrobial and antiseptic agents such as antibacterial irrigations, local antimicrobial application, antimicrobial-coated sutures, antibacterial wound sealants, and antimicrobial impregnated dressings in the prevention of SSI is questionable.

Surgical site infections following short-term radiotherapy and total mesorectal excision: results of a randomized study examining the role of gentamicin collagen implant in rectal cancer surgery

BACKGROUND

Despite the findings of several randomized clinical studies, the role of gentamicin collagen implant (GCI) in rectal cancer surgery is unclear. Local pelvic application of GCI following preoperative radiotherapy and total mesorectal excision (TME) was evaluated to determine the risk of surgical site infections (SSI).

METHODS

In this single-center trial, 176 patients with rectal cancer after preoperative, short-term radiotherapy (5 × 5 Gy) were randomized either to the study group in which GCI was used or in the control group without GCI. Prior to surgery and intraoperatively five patients were excluded from the study. The remaining 171 patients were analyzed; 86 were in the study group and 85 in the control group.

RESULTS

There were no statistically significant differences in the overall rate of early postoperative complications between the study and control group: 25.6 and 34.1 % respectively; p = 0.245, relative risk (RR) 0.750 [95 % confidence interval (CI) 0.471-1.195]. The reoperation rate was similar in both groups: 12.8 versus 9.4 %; p = 0.628; RR 1.359; (95 % CI 0.575-3.212). The total rate of SSI and organ space SSI were 22.2 and 15.8 % without differences between the study and control group. In patients without anastomotic leakage, the risk of organ space SSI was significantly reduced in patients who received GCI: 2.6 versus 13.0 %; p = 0.018.

CONCLUSIONS

Application of GCI in the pelvic cavity after short-term preoperative radiotherapy and TME may reduce the risk of organ space SSI but only in the absence of anastomotic leakage.

Gentamicin/collagen sponge use may reduce the risk of surgical site infections for patients undergoing cardiac operations: a meta-analysis

OBJECTIVE

A meta-analysis of all published randomized controlled trials of the effectiveness of gentamicin/collagen sponges for preventing surgical site infections (SSIs).

BACKGROUND

Despite routine use of systemic prophylactic antimicrobial agents, SSIs continue to be associated with substantial morbidity. RESULTS conflict of studies of the efficacy of gentamicin/collagen sponges for preventing SSIs. However, many of these studies have assessed sponge use in only a single specific type of operation. The general effect of sponge use among different types of operations has not been previously assessed.

METHODS

The PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched for articles appearing from 1990 through January 2012 that were related to gentamicin/collagen sponge use and SSIs. Summary estimates were obtained through a random effects model. After reviewing 714 article abstracts and reviewing 22 articles in detail, we pooled the odds ratios (OR) for 13 independent study populations (cardiac, n=4; colorectal, n=4; pilonidal sinus, n=2; hernia, n=2; gastrointestinal, n=1) in which the association between prophylactic use of gentamicin/collagen sponges and SSIs was assessed.

RESULTS

Pooling of the results of all studies included in the review in a random effects model showed a significant protective effect of prophylactic use of gentamicin/collagen sponges against SSI (pooled OR: 0.66; 95% confidence interval [CI]: 0.45, 0.97; n=13). However, when the data were stratified by type of operation, a significant protective effect was observed in cardiac procedures (pooled OR: 0.59; 95% CI: 0.37, 0.96; n=4) but not in colorectal procedures (pooled OR: 0.74; 95% CI: 0.29-1.92; n=4).

CONCLUSION

Use of gentamicin/collagen sponges was associated with a reduced risk of SSI following cardiac operations but not following colorectal procedures.

Strategies to prevent surgical site infections in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,”1 published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.2

Randomized clinical trial of intestinal ostomy takedown comparing pursestring wound closure vs conventional closure to eliminate the risk of wound infection

BACKGROUND

The use of temporary stomas has been demonstrated to reduce septic complications, especially in high-risk anastomosis; therefore, it is necessary to reduce the number of complications secondary to ostomy takedowns, namely wound infection, anastomotic leaks, and intestinal obstruction.

OBJECTIVE

To compare the rates of superficial wound infection and patient satisfaction after pursestring closure of ostomy wound vs conventional linear closure.

DESIGN

Patients undergoing colostomy or ileostomy closure between January 2010 and February 2011 were randomly assigned to linear closure (n = 30) or pursestring closure (n = 31) of their ostomy wound. Wound infection within 30 days of surgery was defined as the presence of purulent discharge, pain, erythema, warmth, or positive culture for bacteria. Patient satisfaction, healing time, difficulty managing the wound, and limitation of activities were analyzed with the Likert questionnaire.

RESULTS

The infection rate for the control group was 36.6% (n = 11) vs 0% in the pursestring closure group (p < 0.0001). Healing time was 5.9 weeks in the linear closure group and 3.8 weeks in the pursestring group (p = 0.0002). Seventy percent of the patients with pursestring closure were very satisfied in comparison with 20% in the other group (p = 0.0001).

LIMITATIONS

This study was limited by the heterogeneity in the type of stoma in both groups.

CONCLUSION

The pursestring method resulted in the absence of infection after ostomy wound closure (shorter healing time and improved patient satisfaction).

The gentamicin-collagen sponge for surgical site infection prophylaxis in colorectal surgery: a prospective case-matched study of 606 cases

PURPOSE

Surgical site infection (SSI) is a major concern in colorectal surgery (CRS). It accounts for 60 % of all postoperative complications and has an incidence of between 10 and 30 %. The gentamicin-collagen sponge (GCS) was developed to help avoid SSI. The aim of this study was the evaluation of the efficacy of a GCS in preventing SSI after CRS.

METHOD

This study was a retrospective analysis of data collected in a prospective database. Six hundred six CRS patients were enrolled in the study and prospectively assigned to one of two groups. From January 2007 to December 2008, all procedures were performed without the use of GCS (forming the non-GCS group). From January 2009 to July 2011, all procedures included a GCS (forming the GCS group). The primary endpoint was the presence or absence of SSI at postoperative day 30.

RESULTS

The incidence of SSI was 29.7 and 20.8 % in the non-GCS and GCS groups, respectively (p = 0.019). By using a stepwise logistic regression, the predictors of SSI were found to be ASA grade (p < 0.001), operating time (log-transformed value, p < 0.001), gender (p = 0.021), and GCS use (p < 0.001). By adjusting on these variables, a mean reduction in postoperative hospitalization of 8.3 days was found in the GCS group. The proportions of Clavien IIIB-V were 16.6 and 8.9 % for the non-GCS and GCS groups, respectively (p = 0.041).

CONCLUSIONS

This study provides additional evidence of the efficacy of the GCS in reducing SSI rates and shortening hospitalization after CRS.

Impact of Gentamicin-Collagen Sponge (Collatamp) on the Incidence of Sternal Wound Infection in High-Risk Cardiac Surgery Patients: A Propensity Score Analysis

<p>Objective: Local delivery of prophylactic antibiotic to the wound site with an implanted, reabsorbable, gentamicin-containing collagen sponge (Collatamp) is a strategy that has been claimed to prevent sternal wound infection after cardiac surgery. The purpose of this study was to review our experience with Collatamp in cardiac surgery patients deemed at high risk for sternal wound infection.</p><p>Methods: From January 2007 to December 2010, Collatamp was used in 107 patients deemed at high risk for sternal wound infection. Applying the propensity score, we matched 97 patients with Collatamp (group I) with 97 patients who did not receive Collatamp (group II). All individuals received routine intravenous antimicrobial prophylaxis. Postoperative wound-infection rates as well as routine outcomes were compared. Information for the study was obtained from the cardiac surgical Patients Analysis and Tracking System (PATS) database and from hospital records.</p><p>Results: The superficial sternal wound infection rate was 2.1% (2/97) in group I and 6.2% (6/97) in group II (<i>P</i> = .01). The rates of deep sternal wound infection rate were similar (2.1% versus 3.1%, <i>P</i> = .87). There was no mediastinitis in the study population. In addition, more patients in group II received an intra-aortic balloon pump (5.2% versus 2.1%, <i>P</i> = .04) and underwent hemofiltration (7.2% versus 3.1%, <i>P</i> = .02). No side effects were noted.</p><p>Conclusion: Gentamicin-containing collagen sponge (Collatamp) is a useful adjunct to meticulous surgical technique and postoperative wound care in reducing the incidence of sternal wound infection in high-risk cardiac surgery patients. An adequately powered study is needed, however, to validate the safety and efficacy of this strategy.</p>

Surgical site infections and their prevention

PURPOSE OF REVIEW

Recent studies have assessed interventions and bundles of interventions to prevent surgical site infections (SSIs). We reviewed numerous studies to identify those with the strongest evidence supporting interventions for preventing SSIs.

RECENT FINDINGS

Bundles that included more than one intervention to decrease the risk of Staphylococcus aureus wound contamination, such as chlorhexidine bathing and nasal application of mupirocin, had the strongest supporting evidence. However, bundles should be tested to ensure that their components are not antagonistic. Vancomycin prophylaxis and extended antimicrobial prophylaxis should not be used routinely, but should be reserved for high-risk populations such as patients who carry methicillin-resistant S. aureus (MRSA). Novel interventions to prevent SSIs (e.g., topical or oral antimicrobial agents, skin sealant, and antimicrobial sutures) need further evaluation before surgeons implement them routinely.

SUMMARY

There is some evidence that bundled interventions can reduce SSIs. However, more research should be done evaluating the effectiveness of these interventions. Future studies of bundles should use robust methodologies, such as randomized controlled trials, cluster randomized trials, or quasi-experimental studies analyzed by time series analysis.