algosdoc said:
We usually explant the system at this time, but partially this depends on whether the infection is in the pocket or is a superficial infection above the pocket. If it is above the pocket, we retain the system. In the past, before the document by Folett was published, we would actually salvage the pumps and stims by a thorough soak in bacitracin solution during the time we were irrigating the wound with 3 liters of irrigant. In that way we were able to salvage about 1/2 the pumps and stims that otherwise would have been explanted, and there is a more recent paper that suggests that is possible based on a small series. But the hospital infection control committees believe strongly that the hardware should be entirely explanted even if it means a return to severe intractable pain that in one of my patients lead to a suicide attempt. But the infection control committees have covered their rear ends and feel no culpability for patients that will never get another pump or stim because some of these patients are on Medicaid, that does not pay for these devices in our state.
Recently, I treated a patient for what I thought was infection due to erythema of the skin directly over the pump, and the diabetes was much more difficult to control. I made the decision to operate and culture, with probable explant. There was no purulence and in fact no drainage at all when the wound was opened, gram stain was negative, and subsequently only s. epidermidis was cultured. The cause of the erythema was the patient's massive intraabdominal fat content causing compression of the pump against the skin due to the fact that he had virtually no fat between the external abdominal oblique and the skin. The pump was revised to another pocket, remained without infection, but the internists on the infection control committee went ballistic anyway, claiming the entire system should have been removed for a s. epi culture. Is that your understanding- that skin organism cultures should result in explantation of a pump or stim when there is no drainage, a negative gram stain, no fluid in the pocket, no fever?
Algos,
You pose a very difficult problem, but your decision making process is perfectly logical. Assume your child has a self limited URI and recovers completely. If Strept cultures come back positive a few days later and the pediatrician prescribes Abx...do you give it? Similar dilemma.
I think I would have done something similar, if it were a baclofen pump. ITB withdrawal is life threatening. I would probably breakdown and use a new pump however...I would be nervous about a residual infectious biofilm on the old pump ....Your bacitracin soaking idea is great; it probably kills all the bacteria....but, I am also concerned about not completely disrupting the biofilm scaffolding.
I would probably do something along the lines of...open the posterior midline incision....identify the catheter and cut it proximal to the anchor... and tie it off ....(after induction of GETA, I may program the pump to give a low dose ITB bolus over 20 minutes)...then go to the ant. abdominal wound and release the pump and pull out the proximal catheter. Pack the ab wound with a VAC pack and tegaderm/ioband the midline incision...flip the patient....new equipment/new prep...and get a new IT pump and use a 2 piece catheter system to reconnect....I may get CSF culture from the catheter as well.
If it were a regular IT pump with opioids....I would probably explant the system, but program a bolus equivalent to 25% of the daily dose, prior to removal...if the infection is more subtle, then I would wean the pump drug dose.....then I would come back and replace it a few months later.
In any case, the decision to explant or leave it in is a very tough one...
It would be great to publish your case as a case report...it is very admirable that you did your best to help your patient.
Finally, why did your case go to a hospital committee, if it wasn't Meth Resistant SE? Ordinarily, you just consult the ID specialist and they render an opinion.
Were the committee's decisions protected as confidential peer review, primarily for education purposes, e.g. like an M+M conference...or was there another agenda? For instance, did they solicit the opinions of other surgeons in the hospital, just to give you a hard time--I am asking you to read between the lines, before you answer.
