Abstract
Introduction
Minimally invasive repair of pectus excavatum (MIRPE) involves the implantation of metal hardware for chest wall remodeling. For optimal outcomes, the bars must remain in place for approximately 3 years; however, infection may limit bar retention and necessitate premature removal. From 2005 to 2013, Children’s Hospital of The King’s Daughters (CHKD) noted an increase in the postoperative infection rate following MIRPE. These findings prompted the development of infection-prevention bundle (IPB) and infection-treatment bundles. This study provides long-term follow-up evaluating the impact of these bundles on the incidence and timing of superficial and deep bar infections, as well as bar salvage.
Methods
A single-institution, institution review board (IRB) approved retrospective cohort study (IRB No. 14-03-WC-0034) was conducted among patients undergoing MIRPE from 2005 to 2025. Infection-prevention and infection-treatment pathways were implemented in 2013, and patients were stratified into pre- and post-implementation cohorts. Postoperative infections were classified by timing (early, ≤90 days; late, >90 days) and severity (superficial or deep). Deep infections were further assessed for bar salvage and retention. Data was summarized by descriptive statistics and compared between cohorts using univariable analysis.
Results
During the study period 1,695 patients underwent MIRPE. There were 854 patients in the pre-bundle cohort and 841 patients in the post-bundle cohort. Following infection prevention bundle implementation early (3.0% to 1.5%, p=0.02) and superficial infections (2.1% to 0.8%, p=0.01) decreased significantly while late (0.4% versus 0.7%, p=0.74), deep (1.4% versus 1.4%, p=0.52) and overall infection incidence (3.51% versus 2.26%, p=0.06) did not significantly change between cohorts.
Among patients with deep bar infections there was a significant increase in bar salvage (75% versus 100%, p=0.03), length of preservation (2.2 versus 2.8 years, p=0.05), and median time to infectious presentation (33.0 versus 64.0 days p=0.03). Median time from infection presentation to operative intervention decreased 10.5 to 3.0 days, although this did not reach statistical significance (p=0.06). There was no significant difference in the operative techniques used to treat infection.
Conclusion
Infection after MIRPE is rare. Implementation of an infection prevention bundle was associated with a significant reduction in early and superficial infections. Despite these measures, the incidence of deep bar infection remained unchanged. Deep infections presented significantly later, with some occurring beyond the Centers for Disease Control and Prevention recommended 90-day surveillance period. This supports the need for extended surveillance matching the life of the implant. Although deep bar infections were not prevented with the infection prevention bundle, early antibiotic and surgical therapy allowed successful treatment with preservation of bars.