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In Contrast to Prior Study, New Data Shows Bacteria Found at Revision IPP Surgery Differs from Previously Identified Biofilm
Martin S. Gross, MD1, Culley C. Carson, III, MD2, Steven K. Wilson, MD3, John R. Delk, MD4, Craig F. Donatucci, MD5, Gerard D. Henry, MD6.
1Dartmouth-Hitchcock Medical Center/Dartmouth-Hitchcock Keene, Keene, NH, USA, 2UNC School of Medicine Department of Urology, Chapel Hill, NC, USA, 3Institute for Urologic Excellence, Indio, CA, USA, 4University of Arkansas for Medical Sciences, Little Rock, AR, USA, 5Eli Lilly and Company, Indianapolis, IN, USA, 6Regional Urology, Shreveport, LA, USA.

BACKGROUND: In 1995, Licht et al. introduced the idea that organisms found at removal and replacement of an IPP for non-infectious reasons were subsequently responsible for those found at later IPP infection if it occurred. Three of their culture positive patients later became infected and higher colony counts of the same organism were found at time of explantation. None of their IPP patients with a negative culture at reoperation developed a subsequent prosthetic infection. This is the only study to our knowledge that compares cultures at removal and replacement with cultures at later surgery. We reviewed our series of similar surgical IPP patients undergoing removal and replacement to see if this remains true today.
METHODS: We identified 304 patients at our four institutions that had undergone revision of an IPP between June 2001 and December 2012. Eleven later underwent another IPP revision surgery and additional cultures were drawn. Complications leading to revision surgery included mechanical failure (6), autoinflation (1), floppy glans (1), hematoma formation (1), loss of fluid (1), and retained components (1). These patients then later underwent IPP revision surgery for: infection (7), autoinflation (2), bladder laceration (1), and erosion (1). We reviewed patient charts to compile appropriate perioperative and follow-up data.
RESULTS: Eight cultures taken at the time of removal and replacement were negative, and six of these prostheses subsequently became infected. In contrast, three IPPs had positive cultures (two s. epidermidis, one s. lugdunensis) at removal and replacement. Only one became infected, and the causative agent was identified as s. warneri. All IPPs had been in place for an average of 4.4 years (range 1 month to 12 years). Mean patient age was 69 (range 54-81). Four of the eleven patients were diabetics. Time to infection was approximately 6.2 months (range 1 week to 30 months). Ten total organisms were identified in these eleven cases with the following frequency: s. epidermidis (3), e. faecalis (2), candida (1), citrobacter (1), e.coli (1), MRSA (1) and s. warneri (1).
CONCLUSIONS: In contrast to the findings of Licht et al., our series shows that bacteria (or lack thereof) found at revision surgery are not the same bacteria as those found in subsequent revision, explantation, or salvage. These findings may be due to both infection retardant coatings and antimicrobial washout, which has become the standard of care in IPP revisions. This is the first study to our knowledge that directly refutes the conventional wisdom established by Licht et al.


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