title: Risk factors and management of Nuss bar infections in 1717 patients over 25 years.
abstract: OBJECTIVE
  An increase in postoperative infections after Nuss procedures led us to seek risks and review management. We report potential risk factors and make inferences for prevention of infections.
  
  
  METHODS
  An IRB-approved retrospective chart review was used to evaluate demographic, clinical, surgical, and postoperative variables of patients operated on between 10/1/2005 and 6/30/2013. Those with postoperative infection were evaluated for infection characteristics, management, and outcomes with univariate analyses.
  
  
  RESULTS
  Over this 8-year period (2005-2013), 3.5% (30) of 854 patients developed cellulitis or infection, significantly more than 1.5% (13) in our previous report of 863 patients, 1987-2005 (p=.007). The most frequent organism cultured was methicillin-sensitive Staphylococcus aureus. Patients who were given clindamycin preoperatively (5 of 26 patients) had higher infection rates than those who received cefazolin (25 of 828) (19% vs 3%, p<.001). Patients treated with a peri-incisional ON-Q (I-Flow, Kimberly-Clark, Irvine, CA) also had higher infection rates (8.3% vs 2.4%, p<.001). Of the 30 patients who developed an infection, eighteen (60%) with cellulitis or superficial infections did not require surgical treatment or early bar removal. The other twelve patients (40%) with deep hardware infections required an average of 2.2 operations (range 1-6), with 3 (25%) requiring removal of their stabilizer and 3 (25%) requiring early bar removal. None of these three patients experienced recurrence of pectus excavatum at 2 to 4 years of follow-up.
  
  
  CONCLUSIONS
  Preoperative antibiotic selection and use of ON-Q's may influence infection rates after Nuss repair. Nuss bars could be preserved in 90% of all patients with an infection and even 75% of those with a deep hardware infection. Attempts to retain the bar when an infection occurs may help prevent pectus excavatum recurrence. Level of Evidence=III.
authors.affiliation: Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA. Electronic address: robert.obermeyer@chkd.org.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Obermeyer
authors.affiliation: Eastern Virginia Medical School, Norfolk, VA, USA.
authors.forename: Erin
authors.initials: E
authors.lastname: Godbout
authors.affiliation: Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Goretsky
authors.affiliation: Old Dominion University, Norfolk, VA, USA.
authors.forename: James F
authors.initials: JF
authors.lastname: Paulson
authors.affiliation: Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
authors.forename: Frazier W
authors.initials: FW
authors.lastname: Frantz
authors.affiliation: Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
authors.forename: M Ann
authors.initials: MA
authors.lastname: Kuhn
authors.affiliation: Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
authors.forename: Michele L
authors.initials: ML
authors.lastname: Lombardo
authors.affiliation: Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
authors.forename: E Stephen
authors.initials: ES
authors.lastname: Buescher
authors.affiliation: Children's Hospital of The King's Daughters, Norfolk, VA, USA.
authors.forename: Ashley
authors.initials: A
authors.lastname: Deyerle
authors.affiliation: Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Kelly
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis; D002481:Cellulitis / Q000382:microbiology / Q000517:prevention & control; D005660:Funnel Chest / Q000601:surgery*; D006801:Humans; D008297:Male; D019736:Prostheses and Implants; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D013203:Staphylococcal Infections / Q000517:prevention & control; D013530:Surgical Wound Infection / Q000382:microbiology / Q000517:prevention & control*; D014945:Wound Healing
chemical_list: D000900:Anti-Bacterial Agents
keywords: Excavatum; Infection; Nuss; Pectus