Godbole Gauri, Pai Vasudev, Kolvekar Shyam, Wilson Andrew P R
Department of Microbiology, University College London Hospitals NHS Foundation Trust, London, UK.
Interact Cardiovasc Thorac Surg. 2012 Apr;14(4):390-4. doi: 10.1093/icvts/ivr129. Epub 2012 Jan 16.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Are antibiotic implants like gentamicin-collagen implants useful in preventing sternal wound infections (SWIs)? Altogether, more than 484 papers were found using the reported search; of these, 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that most randomized controlled trials (RCTs) have been performed with gentamicin-collagen sponges for sternal closure. Two out of four RCTs showed a significant benefit of the implant in a reduction in superficial and deep SWIs in routine and emergency cardiac surgery. One RCT showed a significant reduction in superficial infections in 2005, a follow-up trial by the same group in 2009 showed a reduction in deep infections as well. Another group has shown a reduction in deep and superficial SWI with gentamicin implant, in an RCT on 800 patients, however have not published details of the complete trial. The third trial on 542 patients showed no benefit of the implant, but was not adequately powered. However, the most recent multicentre RCT conducted on 1052 patients showed no benefit of gentamicin-collagen sponges in elective surgery (coronary artery bypass grafting and/or valve surgery) in high-risk patients with diabetes, obesity or both. Concerns were raised that gentamicin sponges dipped in saline 1-2 s prior to application may have lost the gentamicin into the saline, thereby reducing their efficacy and that some surgeons may have been unfamiliar with wound closure with sponges. However, these were robustly refuted by the authors. One RCT showed that gentamicin sponges may cause increased sternal rebleeding if used in double layers. Coagulase-negative staphylococci were predominantly isolated from infected wounds in all the trials except the one from USA, where infections were polymicrobial. Gentamicin resistance among common pathogens causing SWIs can vary from 15 to 80%. Gentamicin-collagen is unlikely to reduce SWIs in high-risk patients and polymicrobial infections.
一篇心脏外科的最佳证据主题文章是根据结构化方案撰写的。所探讨的问题是：庆大霉素 - 胶原蛋白植入物等抗生素植入物在预防胸骨伤口感染（SWIs）方面是否有用？通过报告的检索方式，共找到484多篇论文；其中7篇代表了回答该临床问题的最佳证据。这些论文的作者、期刊、出版日期和国家、研究的患者群体、研究类型、相关结果和结论被制成表格。我们得出的结论是，大多数随机对照试验（RCTs）使用庆大霉素 - 胶原蛋白海绵进行胸骨闭合。四项RCTs中有两项显示，在常规和急诊心脏手术中，植入物在减少浅表和深部SWIs方面有显著益处。一项RCT在2005年显示浅表感染显著减少，同一组在2009年的随访试验显示深部感染也有所减少。另一组在一项针对800名患者的RCT中显示，庆大霉素植入物可减少深部和浅表SWI，但尚未发表完整试验的详细信息。第三项针对542名患者的试验显示植入物无益处，但样本量不足。然而，最近一项针对1052名患者进行的多中心RCT显示，在患有糖尿病、肥胖症或两者兼有的高危患者的择期手术（冠状动脉搭桥术和/或瓣膜手术）中，庆大霉素 - 胶原蛋白海绵无益处。有人担心，在应用前将庆大霉素海绵在盐水中浸泡1 - 2秒可能会使庆大霉素流失到盐水中，从而降低其疗效，而且一些外科医生可能不熟悉用海绵进行伤口闭合。然而，作者有力地反驳了这些观点。一项RCT显示，如果双层使用庆大霉素海绵，可能会导致胸骨再次出血增加。除了来自美国的那项试验感染为多种微生物感染外，在所有试验中，凝固酶阴性葡萄球菌主要从感染伤口中分离出来。导致SWIs的常见病原体中的庆大霉素耐药率在15%至80%之间。庆大霉素 - 胶原蛋白不太可能降低高危患者的SWIs和多种微生物感染。
