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Epidural abscesses
- Andrew Jeffreys, Richard Horton, Bronwen Evans (13 April 2006)
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Antibiotics for epidural abscess
- Graeme M Sanders, Thottungal R Athmaja (20 March 2006)
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Andrew Jeffreys, Anaesthetist Western Health Melbourne Australia, Richard Horton, Bronwen Evans
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Editor - We read with interest the review by Grewel and colleagues1 and have followed the epidural abscess story closely over the last few years. We wish to add our experience to the growing collection of case series. We experienced a cluster of three cases of epidural analgesia related epidural abscesses at Western Hospital over a period of nine months in 2001-2002. An investigation was performed looking for risk factors and potential for improved patient care. A search back to 1992 revealed one other epidural catheter related abscess, which occurred in 1996. Epidural catheters were inserted by different anaesthetic teams in all cases. Two of the cases (Case 1, a 24 year old female and Case 2, a 45 year old male) had bowel surgery for inflammatory bowel disease and had been taking prednisolone 20mg daily pre and post operatively. Case 3 occurred in a 57-yr-old female who had a history of chronic pain and several previous admissions for treatment of MRSA injection site abscesses. She requested epidural analgesia for a total knee replacement. Case 4 was a previously well 57-yr-old male who had epidural analgesia for fractured ribs T6-T8 sustained in a fall. No difficulties were noted at the time of insertion of any of the catheters however all were subsequently manipulated and re-dressed to manage unilateral block or catheter kinking. Full sterile technique was the standard of care at the time and aqueous povidine iodine solution was routinely used for skin preparation. Catheters remained in situ for 4 days in all cases except Case 4 whose catheter was removed on day 2 when infection was suspected. Signs of infection (swelling, tenderness and discharge) at the catheter insertion site was the trigger for further investigation and treatment in Cases 1, 2 and 4. These patients developed subcutaneous collections with involvement of the adjacent epidural space at T10, T11 and T7 respectively. Diagnosis was confirmed using gadolinium contrast enhanced MRI in all cases. There was a delay in diagnosis of 9 days in Case 1. This delay had decreased to one day by case 4. None of these patients developed neurological deficits, however Case 1 did complain of lower limb pains that were attributed at the time to peripheral manifestations of inflammatory bowel disease. Cases 1,2 and 4 grew methicillin sensitive S.aureus from their catheter insertion sites. In consultation with our neurosurgical and infectious disease units they were treated conservatively with six weeks of parenteral antibiotics along with close observation, including repeat MRI scans to confirm resolution. All three of these patients were successfully treated in this way. Case 3 re-presented to Casualty on day 10 post operatively after having been discharged on day 7. She complained of back pain, was febrile and tender over T8-T10 and the insertion site L2. Neurological examination was normal. Urgent MRI confirmed an epidural collection at T8 -T10. She underwent laminectomy and drainage followed by several weeks of antibiotics. Cultures collected at operation grew MRSA. She made a complete recovery. During the period 1996 – 2002 approximately 3600 non-obstetric epidurals were inserted in our Health Service. Consequently the incidence of catheter related epidural abscess in this period was 1:900. This is similar to that reported in other recent case series2, 3, 4. The incidence during the period of the cluster was 1:200. Two of our patients were having colectomies for inflammatory bowel disease and were likely to have been immunosuppressed. The incidence of epidural catheter related epidural abscess in this subgroup of patients was 10% in the period 1996 –2002. Our experience was consistent with many of the points made by Grewel and colleagues. The likely mechanism of infection in at least three of our cases was spread from the patient’s skin via the catheter insertion site. Haematogenous spread was possible in Case 3. Three of our cases had catheters in situ for greater than three days. All of the catheters were manipulated and redressed which is likely to have increased bacterial colonisation. Our patients were fortunate that the outcome in all cases was very good. Apart from the potential for neurological damage they were all at significant risk of eventual overwhelming sepsis had the infections remained untreated. Three of our patients were treated with long-term parenteral antibiotics without drainage. This confirms that cases such as these with smaller abscesses without clinical or radiological evidence of compression, discitis or osteomyelitis, can be managed with long term antibiotics alone where a likely causative organism has been identified. We have changed some aspects of our practice in view of our review of these cases. We now routinely use alcoholic skin prep. Personnel inserting epidurals continue to gown and glove and wear masks but all staff in proximity now also wear a mask. Manipulating catheters post insertion is discouraged, and the need for sterile technique when doing so has been reinforced. We use transparent dressings that are now semi- permeable. We have increased the surveillance of epidural catheters. Sites are inspected twice daily and the day following removal. This routinely occurs after the third postoperative day unless there is a strong indication to continue epidural analgesia. In the event that the insertion site becomes inflamed with swelling and/or pus observed, the catheter is removed, cultures obtained and antibiotics (ceftriaxone 2g 12 hourly and vancomycin 1g 12 hourly) commenced. An MRI scan is urgently performed to guide further management. Our experience, along with the results of a recent Australian prospective randomised trial5 that questions some of the benefits of ‘real world’ epidural analgesia, has led to a decline in the use of non- obstetric epidural analgesia in our health service. This, along with the other changes in our practice, may be responsible for us having had no further cases of epidural catheter related abscesses since 2002. Andrew Jeffreys Richard Horton Bronwen Evans Western Health Melbourne Australia References: 1. Grewal S, Hocking G, Wildsmith J. Epidural abscesses. Br J Anaesth 2006; 96: 292-302 2. Phillips J, Stedeford J, Hartsilver E, Roberts C. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2002; 89: 778-82 3. Gosavi C, Bland D, Poddar R, Horst C. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2004; 92: 294 -5 4. Hearn M. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2003; 90: 706-7 5. Rigg JRA, Jamrozick K, Myles PS, et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276-82 Conflict of Interest:None declared |
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Graeme M Sanders, Consultant Anaesthetist Medway NHS Trust, Thottungal R Athmaja
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Editor - We read the excellent review article by Grewal and colleagues on epidural abscess (1). We recently published a case report about Acinetobacter infection of the epidural fat (2). In the article, we suggested that the first line antibiotic therapy for epidural infection in the United Kingdom should be a combination of vancomycin and gentamicin. This is contrary to the advice given by Grewal and colleagues. What we are concerned about are the colonisation rates of methicillin resistant Staphylococcus aureus (MRSA) in our community. For patients never admitted to hospital before, our colonisation rate is about 1%, but for those admitted to hospital it rises to 5%. We believe that it is unacceptable not to treat MRSA empirically in these patients where delay in treatment may have disastrous neurological sequelae. Can we justify getting the antibiotic wrong in 1 in 20 patients? Once culture results are known and MRSA excluded, vancomycin can be stopped. References: (1) Grewal S, Hocking G, Wildsmith JAW. Epidural abscess. BJA 2006; 96: 292-302. (2) Athmaja TR, Sanders GM. An unusual presentation of epidural acinetobacter infection. Reg Anesth Pain Med 2005; 30: 577-9. Conflict of Interest:None declared |
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