The value of suction drainage fluid culture during aseptic and septic orthopedic surgery: a prospective study of 901 patients

Early Biofilm Formation on the Drain Tip after Total Knee Arthroplasty Is Not Associated with Prosthetic Joint Infection: A Pilot Prospective Case Series Study of a Single Center

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication of arthroplasties that could occur during the surgery. The purpose of this study was to analyze the biofilm formation through microbiological culture tests and scanning electron microscopy (SEM) on the tip of surgical drainage removed 24 h after arthroplasty surgery.

METHODS

A total of 50 consecutive patients were included in the present prospective observational study. Drains were removed under total aseptic conditions twenty-four hours after surgery. The drain tip was cut in three equal parts of approximately 2-3 cm in length and sent for culture, culture after sonication, and SEM analysis. The degree of biofilm formation was determined using a SEM semi-quantitative scale.

RESULTS

From the microbiological analysis, the cultures of four samples were positive. The semi-quantitative SEM analysis showed that no patient had grade 4 of biofilm formation. A total of 8 patients (16%) had grade 3, and 14 patients (28%) had grade 2. Grade 1, scattered cocci with immature biofilm, was contemplated in 16 patients (32%). Finally, 12 patients (24%) had grade 0 with a total absence of bacteria. During the follow-up (up to 36 months), no patient showed short- or long-term infectious complications.

CONCLUSIONS

Most of the patients who underwent primary total knee arthroplasty (TKA) showed biofilm formation on the tip of surgical drain 24 h after surgery even though none showed a mature biofilm formation (grade 4). Furthermore, 8% of patients were characterized by a positivity of culture analysis. However, none of the patients included in the study showed signs of PJI up to 3 years of follow-up.

Suction drainage fluid culture during septic orthopaedic surgery, a retrospective study

We evaluated the usefulness of suction drainage fluid culture after septic orthopaedic surgery to predict early surgical reintervention. We conducted a retrospective observational study, at the Groupe Hospitalier Paris Saint-Joseph between 2014 and 2019. All the patients undergoing septic orthopaedic surgery, with perioperative samples and a postoperative suction drainage device, were enrolled. We compared the group with positive or negative postoperative drainage fluid cultures, respectively, on surgical outcome. We included 246 patients. The drainage fluid culture was positive in 42.3% of the cases. Early surgical reintervention concerned 14.6% of the cases (n = 36), including 61.1% of patients with positive drainage fluid culture (n = 22/36). The risk factors associated with positive drainage fluid cultures were the debridement of the infected site (without orthopaedic device removal), an infection located at the spine, perioperative positive cultures to Staphylococcus aureus. The complete change of the orthopaedic device, and coagulase-negative staphylococci on the preoperative samples, was associated with negative drainage fluid cultures. Positive drainage fluid culture was predictive of early surgical reintervention, and coagulase-negative staphylococci in the preoperative samples and knee infection were predictive of surgical success. Postoperative drainage fluid cultures were predictive of early surgical reintervention. Randomized multicentric studies should be further conducted.

Diagnostic performance of suction drainage fluid culture for acute surgical site infection after aseptic instrumented spine surgery: a retrospective analysis of 363 cases

PURPOSE

Analyze the diagnostic performance of suction drainage fluid culture for acute surgical site infection, which has not been specifically reported in spine surgery patients.

METHOD

This was a retrospective single-center observational study including data from 363 patients who underwent aseptic instrumented spine surgery between 2015 and 2017. A suction drain was inserted in all cases. Data analyzed were patient age, gender, ASA score, indication for surgery (degenerative disease, tumor, trauma), spine level (cervical, thoracic, lumbar), procedure performed and spine level, operative time, body temperature, postoperative C-reactive protein time-curve, clinical aspect of surgical scar, bacteriology results of suction drainage fluid, and in case of revision surgery, lavage fluid. Major criteria for periprosthetic infection proposed by the Musculoskeletal Infection Society (MSIS) were accepted as the gold standard for the diagnosis of acute surgical site infection.

RESULTS

The overall rate of surgical site infection was 6.9% (5.76% for 1- or 2-level fusion, 5.81% for 3- or 4-level fusion, and 15.6% for 5-level fusion and above). The suction drain was withdrawn on the second postoperative day in 44.1% of cases and the third day in 39.1%. The sensitivity of suction drainage fluid culture for the diagnosis of surgical site infection was 20% [95%CI 6.8-40.7%] with a 96.2% [95%CI 93.2-97.9] specificity.

CONCLUSION

The diagnostic performance of suction drainage fluid culture after aseptic instrumented spine surgery for acute surgical site infection is insufficient to warrant its use in routine practice.

Are systematic drain tip or drainage fluid cultures predictive of surgical site infections?

Systematic cultures of drain tips or drainage fluids for the early detection of surgical site infections (SSIs) are controversial. To examine the association between the results of systematic drain tip or drainage fluid cultures and the occurrence of SSIs in clean or clean-contaminated surgery. Searches were performed in the PubMed, and Cat.inist databases for observational studies published before 31st March 2017. Studies reporting results of drain tip or drainage fluid systematic cultures and SSIs after clean or clean-contaminated surgeries were included, and meta-analyses were performed. Seventeen studies, including 4390 patients for drain tip cultures and 1288 for drainage fluid cultures, were selected. The pooled negative predictive values were high (99%, 95% confidence interval (CI) 98-100 for drain tip cultures and 98%, 95% CI 94-100 for drainage fluid cultures). The positive predictive values were low (11%, 95% CI 2-24 for drain tip cultures and 12%, 95% CI 3-24 for drainage fluid cultures). The sensitivities were low (41%, 95% CI 12-73 for drain tip cultures and 37%, 95% CI 16-60 for drainage fluid cultures). The specificities were high (93%, 95% CI 88-96) for drain tip cultures and moderate (77%, 95% CI 54-94) for drainage fluid cultures. Systematic cultures of drain tips or drainage fluids appear not to be relevant, because their positive predictive values were low in the prediction of SSIs.

Prediction of surgical site infection in spine surgery from tests of nasal MRSA colonization and drain tip culture

PURPOSE

MRSA is an organism that is a possible risk factor for postoperative SSI. The purpose of the study was to examine relationships among surgical site infection (SSI) after spinal surgery, nasal methicillin-resistant staphylococcus aureus (MRSA) colonization, and wound drain culture results.

METHODS

The subjects were 132 patients who underwent spinal instrumentation surgery. A preoperative nasal swab was used to check for the presence of MRSA colonization, and a wound drain tip culture was performed for detection of SSI. Data from culture studies using nasal samples and those from the distal tip of the wound drain were used for analysis.

RESULTS

Five patients (3.8%) had nasal MRSA, 17 (13%) had positive drain tip cultures, 15 (11%) had SSIs, and 10 (8%) had SSIs with MRSA. Patients with nasal MRSA had a higher rate of detection of bacteria in the drain tip culture (40 vs. 19%, p = 0.065), and the SSI rate was significantly higher in patients with a positive drain tip culture (33 vs. 10%, p = 0.012). The total SSI rate differed significantly between patients with and without nasal MRSA (40 vs. 10%, p = 0.039); however, the SSI with MRSA rate did not differ significantly between these groups.

CONCLUSION

MRSA carriers were not necessarily associated with MRSA infection, but were related to a positive drain tip culture and SSI, which might be due to endogenous skin bacteria. Therefore, possible SSI should be considered in patients with nasal MRSA colonization or bacteria detected in a drain tip culture.

Is a Drain Tip Culture Required After Spinal Surgery?

STUDY DESIGN

The efficacy of use of a drain tip culture for early detection of surgical-site infection (SSI) was investigated in 329 patients after spinal surgery.

OBJECTIVE

To examine the efficacy of a wound drain tip culture for detection of SSI in spinal surgery.

SUMMARY OF BACKGROUND DATA

A complication of SSI after spinal surgery has high associated morbidity and mortality, and is often difficult to treat.

MATERIALS AND METHODS

The subjects were patients who underwent spinal surgery at our institution between January 2010 and March 2013. All subjects were treated with antimicrobial prophylaxis based on evidence-based guidelines and were followed for at least 6 months after surgery. Data from culture studies using the distal tip of the wound drain were used for analysis.

RESULTS

Drain tip cultures were positive in 34 cases and there were 19 SSIs. Ten of the 34-tip culture-positive wounds developed SSI. Drain tip cultures had a sensitivity of 52%, specificity of 92%, positive predictive value (PPV) of 29%, and negative predictive value of 97% for predicting a wound infection. The association between a positive suction tip culture and wound infection was significant (P<0.05). The PPV for SSI was 60% in cases in which methicillin-resistant bacteria were detected in a drain tip, and the SSI rate in these cases differed significantly compared with those with non-methicillin-resistant bacteria (P=0.01).

CONCLUSIONS

A drain tip culture is useful for early detection of SSI caused by methicillin-resistant bacteria.

Suction Drain Tip Culture after Spine Surgery: Can It Predict a Surgical Site Infection?

Study Design

Retrospective clinical study.

Purpose

To assess the diagnostic value of suction drain tip culture in patients undergoing primary posterior spine surgery.

Overview of Literature

To date, the diagnostic value of suction drain tip culture for predicting surgical site infection (SSI) has not been firmly established in orthopedic or spinal surgery.

Methods

In total, 133 patients who underwent primary posterior spine surgery from January 2013 to April 2015 were included in this retrospective study. Patients diagnosed with infective disease or condition was excluded. The suction drain tip was cut off approximately 5 cm from its far end. The sample was sent to the microbiological laboratory of the hospital for culture analysis. Any signs of infection, such as wound discharge or dehiscence, fever, chills, or chronic pain, were recorded. The culture outcome, identification of bacteria, and postoperative transition of the serum C-reactive protein level were also recorded in all patients. The wounds were followed up for a minimum of 3 months.

Results

A positive drain tip culture was found in 48 patients (36.1%), of whom, 6 developed SSI. The sensitivity of drain tip culture for SSI after primary posterior spine surgery was 60.0%, and the specificity was 65.9%. The association between the incidence of positive suction tip culture and SSI was not statistically significant. Among the 48 positive drain tip cultures, there was no significant association between the occurrence of SSI and virulence of isolated bacteria. There was no significant association between drain tip culture positivity and the duration of drainage, or between the rate of SSI and duration of drainage.

Conclusions

Suction drain tip culture analysis is a poor predictor of SSI after primary posterior spine surgery. Routine use of a drain tip culture is not supported by the results of this study.

Prognostic value of suction drain tip culture in determining joint infection in primary and non-infected revision total hip arthroplasty: a prospective comparative study and review of the literature

INTRODUCTION

Closed suction drainage in joint replacement surgery has been considered to carry an obvious risk of bacteria invasion. Previous studies have shown controversial results regarding the role of suction drain culture in predicting artificial joint infection. Furthermore, the efficacy of the method has not been established in revision total hip or knee arthroplasty.

MATERIALS AND METHODS

Suction drain tips from 110 patients who underwent 73 primary and 37 revision non-infected total hip arthroplasties were prospectively cultured. The drains removed at 48 h postoperatively. The patients had an average age of 64.3 years (range 25-81 years) and followed up for 2-4 years (average 2.8 years).

RESULTS

Positive cultures were identified in two primary (2.74%) and six revision (16.22%) total hip replacements (p = 0.017). The most frequently isolated microorganisms were Staphylococcus aureus (3 cases) and S. epidermidis (2 cases). Resistance to perioperative antibiotics was found in three out of eight isolated pathogens. However, no infection was recorded in any of the eight patients whose cultures found positive.

CONCLUSION

Although suction drains are more often contaminated in revision total hip arthroplasty, the prognostic value of the method in determining joint infection is very limited and its routine use is not supported from the clinical data.

Suction drainage culture as a guide to effectively treat musculoskeletal infection

Following surgery for musculoskeletal infection, a positive suction drainage culture (SDC) is consistent with persistent sepsis. Our objective was to determine the effect of a negative SDC obtained in subsequent operations on the outcome of a musculoskeletal infection. 99 patients were prospectively enrolled, all treated surgically for musculoskeletal infection utilizing suction drainage and appropriate antimicrobial therapy. Surgery consisted of irrigation, debridement, and prosthetic exchange or implant removal. SDC was considered negative if all bottles resulted in negative cultures. Following SDC results, patients were placed into 1 of 2 treatment groups: 1) Negative SDC, and no new operation; or 2) Positive SDC, and new operation(s) until SDC was negative. Antibiotic therapy ranged from 6-12 weeks (osteomyelitis) to 10-21 d (soft tissue). Both groups were similar with regard to baseline characteristics. Cure was obtained in 91.8% of patients (56/61) in group 1 and 91.6% of patients (22/24) in group 2. Similar results were obtained in patients with an infection in the presence of an implant. In conclusion, a negative SDC following surgery for a musculoskeletal infection is a strong indication of eventual outcome.

Conventional drainage versus four hour clamping drainage after total knee arthroplasty in severe osteoarthritis: a prospective, randomised trial

Total knee replacement in severe osteoarthritis usually requires extensive soft tissue releases often associated with considerable bleeding. In a prospective, randomised trial we compared postoperative conventional suction drainage versus four hour clamping drainage in 60 patients undergoing total knee arthroplasty for severe osteoarthritis. We compared blood loss, number of transfusions, postoperative complications and knee function and found significantly less postoperative blood loss through the drains (p < 0.001), and fewer blood transfusions (p = 0.09) were needed in the clamped group. We conclude that clamping drainage after total knee arthroplasty in severe osteoarthritis reduces blood loss through the drains and the need for blood transfusions.

The value of bacterial culture during clean orthopedic surgery: a prospective study of 1,036 patients

OBJECTIVE

To determine whether bacterial cultures of the wounds of patients undergoing clean orthopedic surgery would help predict infection.

METHODS

During 1 year, 1,256 cultures were performed for 1,102 patients who underwent clean orthopedic surgery. Results were analyzed to evaluate their ability to predict postoperative infection.

RESULTS

The sensitivity, specificity, positive predictive value, and negative predictive value of the cultures were 38%, 92%, 7%, and 99%, respectively.

CONCLUSIONS

Cultures performed during clean orthopedic surgery were not useful for predicting postoperative infection.

Suction drain tip culture in orthopaedic surgery: a prospective study of 214 clean operations

We conducted a prospective cohort study in order to determine whether suction drain specimen cultures from orthopaedic surgery predicted an early wound infection. We included 218 consecutive clean orthopaedic operations requiring drains in one unit over a period of 1 year. The suction drain tip, drain fluid and wound discharge specimens were cultured, and the surgical wound was followed up for 3 months. There were six deep and two superficial wound infections. Wound infection was significantly related to positive suction tip culture but not to positive drain fluid culture. Following our methodology for culture, a positive drain tip culture predicts wound infection in 50% and a negative culture virtually excludes the possibility of a deep infection.

Bacteriological investigation of infected pressure ulcers in spinal cord-injured patients and impact on antibiotic therapy

STUDY DESIGN

Retrospective.

OBJECTIVES

To improve the use of bacteriological results for treating spinal cord-injured patients with infected pressure ulcers.

SETTING

Microbiology and Orthopaedics Department, Ambroise Paré University Hospital, Boulogne-Billancourt, France.

METHODS

Tissue specimens, sampled at the end of the surgical intervention from unbridled and cleaned ulcers were analysed. Drainage liquids were cultured at day 1 (D1) and day 5 (D5) postsurgery. For part of the patients, a presurgery superficial sample was analysed and compared with the surgical and postsurgical samples.

RESULTS

In all, 168 surgical samples from 101 patients, 183 D1 and 104 D5 wound drainage liquids were included in this study. Out of the 168 surgical samples 17 (10%) had a negative culture, whereas 151 (90%) had a positive culture. For drainage liquids, the culture was negative in 48% and 56% of the samples at D1 and D5, respectively. The most frequently isolated species were enterobacteria, followed by staphylococci and streptococci.

CONCLUSION

Culturing deep tissue specimens sampled from the surgically cleaned and unbridled ulcers allows for the isolation of the bacterial species that are really involved in the ulcer infection. As the identification of these bacteria and their antibiotic susceptibility are available, when the culture results of the D1 postsurgical drainage liquid is also available, it is easier to choose targeted antibiotic treatment.