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Risk Factors and Treatment of Pectus Bar Infections

Robert J. Obermeyer

Children's Hospital of the King's Daughters, Norfolk, Virginia, USA


Purpose:  Identify variables that may influence the incidence of Pectus bar infections. Introduce an infection prevention and treatment protocol for Pectus bar infections.

Methods:  The literature was reviewed for the incidence of Pectus bar infections and bar preservation rates after deep bar infections. Our database was queried for infections under an IRB-approved retrospective chart review to evaluate clinical, surgical and postoperative variables of patients operated on between 10/1/2005 and 12/30/2015. Those with postoperative infection were evaluated for infection characteristics, management, and outcomes including bar preservation. All statics were performed using univariate analyses.

Results:  The literature review demonstrated infection rates between 3.6 – 6.9%. Over a similar 8-year time period (10/2005-6/2013), 3.5% (30) of 854 patients at our institution developed cellulitis or infection. After introducing an Infection Prevention Bundle over the last 2.5 years (7/2013-12/2015) the infection rate has decreased to 1.3% (3) after performing 237 additional cases (3.5% vs 1.3%, p = .07). Patients given clindamycin preoperatively (6 of 29 patients) had higher infection rates than those who received cefazolin (27 of 1062) (20% vs 2.5%, p<.001).  The duration of postoperative antibiotic therapy for <48 hours compared to >72 hours did not influence the incidence of infections (3.2% vs 2.7%, p=.656). Patients treated with peri-incisional ON-Q catheters (I-Flow, Kimberly-Clark, Irvine, CA) had higher infection rates (8.3% vs 2.1%, p<.001).  Of the 33 patients who developed an infection over the last 10 years, the characteristics are as follows: Cellulitis (24%), Superficial Infection (28%), and Deep Infection (45%). Only the fifteen patients with Deep Infections required surgical intervention. Utilizing our Infection Treatment Bundle our bar preservation rate after a Deep Infection has increased from 75% to 80% which compares favorably to the summed literature which averages 48% (10 of 21) and ranges from 25 – 80%.

Conclusion: Our Infection Prevention Bundle is demonstrating a trend toward lower infection rates and our Infection Treatment Bundle is demonstrating a trend toward higher bar preservation rates after infections. Our data demonstrates that clindamycin may be an inferior antibiotic for the Nuss procedure and peri-incisional ON-Q catheters may be increase the risk of Pectus bar infections.

Keywords: Pectus, excavatum, Nuss, Infection