Nuss Bar Infection: Incidence, Prevention, Treatment, and Outcomes
 

While it is uncommon, the incidence of Nuss bar infections (i.e., cellulitis, superficial, and deep), including cases beyond the perioperative timeframe, is reported to range anywhere from 1.3% to 6.9% in the literature.  This is a broad definition and extends beyond the usual boundaries of a quality defined surgical site infection. However, these cases remain clinically pertinent particularly for MIRPE which involves placement of an intrathoracic surgical implant.
 

Measures described to prevent infection include preoperative chlorhexidine skin baths, chlorhexidine or Betadine with isopropyl alcohol skin preps, secured surgical drapes, double gloving, sterile technique, avoiding catheter placement near incisions, preoperative antibiotic dosing within 60 minutes of incision, preferential use of a first generation cephalosporin over clindamycin when possible, and discontinuation of antibiotics within 24 hours.
 

Treatment for cellulitis and superficial infections is characteristically successfully treated with oral antibiotics and local wound care.  Treatment for deeper infections is more complex and may require a combination of complex wound management including drainage of purulence with cultures, wound debridement, repeat wound washouts, removal of nonabsorbable braided suture material (Figure 1), wet-to-dry dressing changes and/or wound VAC, and finally delayed wound closure (Figure 2) potentially over a drain.  The number of operations can range anywhere from 1 to 6 in most cases.  Deep bar infection also benefit from a period of IV antibiotics until the wound is closed followed by longer term oral antibiotics which may be adjusted per culture results.  If the culture results are not helpful it is reasonable to start with a combination of oral clindamycin for excellent bone penetration and rifampin for bacterial biofilm penetration. The duration of oral antibiotics is based on clinical response and can be simplified to single agent therapy.  Fortunately, with aggressive management bar preservation is possible in almost all cases.