Sacral Neuromodulation Implant Infection: Risk Factors ... - Springer Link

Curr Urol Rep (2017) 18: 16 DOI 10.1007/s11934-017-0663-1

LOWER URINARY TRACT SYMPTOMS & VOIDING DYSFUNCTION (J SANDHU, SECTION EDITOR)

Sacral Neuromodulation Implant Infection: Risk Factors and Prevention Calvin Lee 1 & Javier Pizarro-Berdichevsky 2,3,4 & Marisa M. Clifton 2 & Sandip P. Vasavada 1,2

Published online: 21 February 2017 # Springer Science+Business Media New York 2017

Abstract Device infection is one of the most common complications of sacral nerve stimulator placement and occurs in approximately 3–10% of cases. Infection is a serious complication, as it often requires complete explantation of the device. Not much is known regarding risk factors for and methods of preventing infection in sacral nerve stimulation. Multiple risk factors have been linked to device infection including prolonged percutaneous testing and choice of preoperative antibiotic. Methods of infection prevention have also been studied recently, including antibiotic-impregnated collage and type of skin preparation. This review will discuss the recent literature identifying risk factors and means of preventing infection in sacral nerve stimulation. Finally, we will outline a protocol we have enacted at our institution which has resulted in an incidence of infection of 1.6%. This article is part of the Topical Collection on Lower Urinary Tract Symptoms & Voiding Dysfunction * Sandip P. Vasavada [email protected] Calvin Lee [email protected] Javier Pizarro-Berdichevsky [email protected]; [email protected] Marisa M. Clifton [email protected] 1

Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH 44195, USA

2

Department of Urology, Cleveland Clinic Foundation, Q10-1, 9500 Euclid Avenue, Cleveland, OH 44195, USA

3

Urogynecology Unit, Hospital Dr. Sotero del Rio, Santiago, Chile

4

Division de Obstetricia y Ginecologia, Pontificia Universidad Catolica de Chile, Santiago, Chile

Keywords Sacral neuromodulation . Sacral nerve stimulation . Infection . Device infection . Infection prevention

Introduction Infection is one of the most common and serious complications following placement of a sacral nerve stimulator (SNS) [1], with many infections often requiring explantation of the entire device. The cumulative incidence of infection has been estimated to be between 3 and 10% within 3 years of device implantation [2–4]. Multiple organisms have been identified to be involved in SNS infections including Staphylococcus and Pseudomonas [5, 6]. Despite the known frequency of SNS infection, no clinical criteria exist for its detection and treatment. Infection is often diagnosed through clinical suspicion based on pain, tenderness, and erythema around the device pocket. This typically occurs within the first several weeks following implantation. Treatment of the infection often requires complete device removal, although no studies have demonstrated whether washout can adequately treat infection. In cases in which washout and broad-spectrum antibiotics insufficiently treat device infection, complete device removal should be performed. Given the rate and need for explantation, there is great interest in being able to identify and prevent infection following SNS implantation. This article will review the most recent literature discussing risk factors and prevention of SNS infection and also describe a protocol that has resulted in reduced incidence of infection at our institution.

16 Page 2 of 6

Risk Factors for Infection Length of Stage 1 Testing Candidates for sacral nerve stimulation frequently undergo a two-stage testing procedure to determine whether the device will be effective in treating their symptoms. During the initial testing phase (stage 1), the device leads are exposed from the patient’s skin. The two-stage procedure has been identified as a potential source of infection in patients undergoing SNS, with some studies showing an increased risk of infection with prolonged testing [2, 7], and other studies finding no link between prolonged device testing (>14 days) and increased risk of infection [6, 8]. Lai and Grewal performed a prospective study in which they observed 38 patients who underwent a two-stage InterStim implantation [9••]. Cultures were taken from the device at the beginning of the second stage, and the investigators identified the length of time between the first and second stages as a significant risk factor for subsequently developing a positive culture. Of the patients who had at least 14 days between the first and second stages, 50% developed positive cultures. In contrast, only 14% of the patients who had fewer than 14 days between the first and second stages ultimately developed positive cultures. Furthermore, having a positive culture was associated with subsequently developing an infection. Of the 38 patients, nine (24%) had positive cultures, with three of these patients ultimately developing infection. In contrast, only one patient with a negative culture ultimately developed an infection (3%). However, the study did not comment on the direct relationship between stage 1 duration and ultimately developing device infection. Furthermore, the investigators deviated from the AUA “Best Practice Policy Statement on Antimicrobial Prophylaxis” by using only vancomycin for prophylaxis as opposed to the recommended combination of aminoglycoside and vancomycin/ cephalosporin [10]. The less comprehensive antibiotic regimen used by the investigators may explain the somewhat higher incidence of infection in their study (11%). By comparison, a similar study was performed by Amend et al., in which 21 patients prospectively underwent SNS implantation [11••]. After a mean testing phase of 52 days, 16 patients went on to have permanent implantation while five patients had the device removed due to insufficient improvement of symptoms. Bacterial colonization was present in the devices of 43% of patients. However, despite the prolonged testing phase, none of the patients who progressed to a chronic implant developed infection during a mean follow-up of 33.9 months. However, the lower infection rate could be attributed to a more aggressive antiseptic regimen employed by the authors of this study: a 3-day course of IV antibiotics postoperatively and covering the wounds with povidoneiodine gel every other day. Furthermore, this study may have

Curr Urol Rep (2017) 18: 16

failed to capture any infections due to its small sample size, with only 16 patients included. Given the small sample size and the low incidence of infection in each of the previous studies, it is likely that neither study was sufficiently powered to detect differences in infection risk. Furthermore, the latter study did not have a control group with which to compare rates of infection. Thus, it is still unclear whether the length of stage 1 testing is a risk factor for device infection. A large, randomized trial must be performed before prolonged cutaneous testing can be identified as a risk factor for device infection. Until then, the benefits of prolonged testing (including improved treatment efficacy) must be weighed against the potential risk of device infection requiring explantation. Choice of Preoperative Antibiotic A retrospective study performed by Haraway et al. suggests that using only cefazolin prior to SNS implantation may increase the risk of subsequent infection [12••]. Investigators performed a case-control study on a group of patients who underwent stage 2 implantation of an implantable pulse generator in order to determine infection risk factors. Out of 136 total patients, eight went on to develop device infection (infection rate of 5.9%). The investigators found that choice of preoperative antibiotic was a significant risk factor for subsequent infection. At the authors’ institution, preoperative antibiotic choices included cefazolin only, vancomycin only, or vancomycin with gentamicin. The majority of the infections developed in patients treated with cefazolin only. Cultures of the infected patients’ devices found that 7 out of 8 were infected with cephalosporin-resistant Staphylococcus aureus. The odds ratio for developing subsequent infection in patients treated only with cefazolin was 7.3 (95% confidence interval 1.2–54.8). Non-obstructive Urinary Retention A recent review was performed on all the device implantation procedures that were performed at our institution between 2010 and 2015, a total of 1033 procedures with a 1.6% incidence of infection [13••]. Following this review, the only significant risk factor for infection following an IPG manipulation was a pre-implant indication of non-obstructive urinary retention in which patients often necessitated selfcatheterization for bladder management (p = 0.008).

Infection Prevention Antibiotic-Impregnated Collagen Multiple studies have evaluated the use of antibioticimpregnated materials in surgical patients. In one such study,


investigators prophylactically used gentamicin-impregnated collagen (Collatamp®) in eight patients undergoing SNS implantation for fecal incontinence [14]. In these patients, gentamicin-impregnated collagen was placed over the sacral nerve stimulator prior to closing the wound. At a median follow-up of approximately 3 months, none of the patients had evidence of infection. However, this is a small study with short follow-up and lack of a control group. Furthermore, these findings are contradicted by the results of previous studies in colorectal surgery patients, in which the use of gentamicin-collagen sponges was associated with no benefit [15, 16]. In one study, a total of 161 patients undergoing pilonidal cyst excision were randomized to receive either Collatamp® before wound closure or no treatment [15]. The authors found no significant differences in terms of wound infection, wound healing, or cyst recurrence between the groups. Additionally, this study also had a longer follow-up of 1 year compared to the 3 months in the Simpson study. A second study randomized 602 patients undergoing laparoscopic colorectal surgery to receive either gentamicincollagen sponge placed superficial to the fascia, or no intervention [16]. With a primary endpoint of surgical site infection occurring within 60 days of surgery, the authors found that patients who received the impregnated collagen actually had a significantly increased risk of surgical site infection compared to the control group (30.0 vs. 20.9%, p = 0.01). Given these conflicting results, a controlled, adequately powered study with longer follow-up than the study performed by Simpson et al. will need to be performed to determine whether antibiotic-impregnated collagen in SNS placement is of benefit. Type of Skin Preparation Currently, there is no guidance regarding the optimal type of skin preparation to use prior to device placement. However, multiple studies have been performed in other surgical populations to determine the benefit of different preparation solutions. A recent randomized trial compared chlorhexidinealcohol to iodine-alcohol for skin antisepsis prior to Cesarean section [17••], with the measured outcome being incidence of surgical site infection (superficial or deep) within 30 days of procedure. A total of 1147 patients were enrolled. After completion of the study, the authors found that patients who were cleansed with chlorhexidine-alcohol were less likely to develop surgical site infection than patients who were cleansed with iodine-alcohol (4.0 vs. 7.3%, p = 0.02). Chlorhexidine has the added benefit of remaining on patients’ skin for up to 48 h, which could explain the reduced incidence of infection. Nonetheless, Cesarean section is a cleancontaminated procedure, compared to SNS placement which is a clean procedure, so the results may not be completely applicable to SNS device surgery.

Page 3 of 6 16

Chlorhexidine has also been studied in joint arthroplasty surgery. Kapadia et al. provided 3717 patients with chlorhexidine cloths to be used prior to total knee arthroplasty [18•]. However, due to non-compliance, the authors were able to stratify the group into 991 patients who used the cloths and 2726 controls. After a 1-year surveillance, it was determined that fewer patients in the group who used the chlorhexidine cloths prior to surgery developed surgical site infections than in the control group (0.3 vs. 1.9%, p = 0.002). The same group also looked at the same intervention in patients undergoing total hip arthroplasty and found similar results, with 0.6% of patients using the cloths developing a surgical site infection compared to 1.62% of controls (p = 0.0226) [19]. While the results could be explained by the treatment group being overall more compliant and performing better self-care, the improved incidence of infection may be explained by the fact that chlorhexidine stays on patients’ skin for a prolonged period of time. The benefit of other skin preparations has also been researched. In another study of patients undergoing total joint arthroplasty, 575 patients were randomized to receive either povidone-iodine and alcohol followed by iodine povacrylex and isopropyl alcohol, or povidone-iodine and alcohol alone [20]. The study found a significant reduction in the incidence of superficial surgical site infection with the intervention group (1.8 vs. 6.5%, p = 0.02); however, there was no difference in the incidence of deep infections. Another study also looked at the incidence of infection in patients undergoing cardiac implantable electronic devices using different skin preparations [21••]. In this study, patients received a given skin preparation based on when they presented for device placement: patients who presented between January 2010 and June 2012 received a standard skin preparation while patients who presented between July 2012 and November 2013 not only received the standard skin preparation but also received instructions to cleanse the surgical site with 75% alcohol before the procedure and were cleansed with povidone-iodine 10 min prior to incision. Patients with the more comprehensive skin preparation had a lower incidence of surgical site infection than patients receiving the standard skin preparation (0.7 vs. 4.3%, p = 0.007). This particular study design may be subject to confounding, as the authors may have improved their infection prevention techniques throughout the study period; as a result, it is unclear whether the more rigorous infection prevention regimen can explain the different infection incidences. While these studies involved multiple different surgeries and multiple different skin preparation regimens, they demonstrate that not all skin preparations are equally effective for preventing infection. Chlorhexidine may provide added antimicrobial benefit for multiple hours after its use and reduce the risk of surgical site infection. Additionally, more rigorous skin preparation regimens can also reduce the risk of surgical site

16 Page 4 of 6

infection. Finally, as shown by Kapadia et al. and Chen et al., having patients begin a skin preparation regimen at home prior to their procedure may also reduce the overall risk of infection. Postoperative Antibiotics No data exist regarding the use of postoperative antibiotics following SNS placement. However, the use of postoperative antibiotics for implant-based, reconstructive breast surgery was the subject of a retrospective study performed by Townley et al. [22••]. This study divided 188 patients into two groups based on whether they received a standard prophylaxis regimen (a single dose of preoperative antibiotic, implant site irrigation, and skin cleaning) or the standard regimen in addition to skin re-prepping with poviodine, pocket irrigation with bacitracin, and postoperative cephalexin three times daily until drain removal. Ninety-four patients were included in each group after matching based on BMI. After a mean follow-up of 14.9 months, there was no significant difference in incidence of infection between the treatment groups (12% in controls vs. 10% in treatment group, p = 0.8). On multivariate analysis, only previous chest wall radiotherapy was found to be a significant predictor of infection (p = 0.003). These results contrast directly with those of a similar study performed by Clayton et al. [23]. In the latter study, data from a total of 250 patients who underwent postmastectomy implant were retrospectively analyzed. The patients received a given prophylaxis regimen based on when they underwent surgery, with patients between October 2007 and October 2008 receiving both preoperative and postoperative antibiotics until drains were removed. Data was also included from patients who underwent surgery between January 2009 and January 2010, when only preoperative and intraoperative antibiotics were administered. A statistically significant increase in surgical site infection was noted in the group treated with only preoperative antibiotics (18.1 vs. 34.3%, p = 0.004); furthermore, there was a significant increase in the incidence of infections requiring reoperation (4.3 vs. 16.4%, p = 0.002). The authors also found a significant difference in time to infection, with patients receiving only preoperative antibiotics developing infection at a mean of 90 days following their operation compared to 256 days in the group receiving postoperative antibiotics (p = 0.011). Thus, this study suggests there is a role for postoperative antibiotics in preventing implant site infection. Postoperative antibiotics have also been studied for cardiac pacemakers. Senaratne et al. studied postimplantation infections in 3253 procedures occurring over a period of 19 years [24••]. During this period, the infection prophylaxis regimen changed from no antibiotics (beginning of 1991 to March 1993) to two doses of perioperative cefazolin or clindamycin (March 1993 to July 1999) and finally to postoperative


oral cephalexin or clindamycin for 4 days postoperatively in addition to perioperative antibiotics (July 1999 to 2009). The authors observed a decrease in infection incidence with each successive period, from 3.6% during the no antibiotic period, 2.9% during the perioperative antibiotic only period, and 0.4% during the postoperative antibiotic period. The use of postoperative antibiotics was identified as a significant factor contributing to fewer infections on univariate analysis (3.0 vs. 0.4%, p < 0.001); however, the year the procedure was performed was also identified as a significant factor (p < 0.001) which suggests that the authors’ infection prevention techniques improved over time. Nonetheless, the impact of postoperative antibiotics was preserved on multivariate analysis. Furthermore, the incidence of infection was reduced using postoperative antibiotics for both new implants (2.3 vs. 0.1%, p < 0.001) and repeat procedures (5.2 vs. 1.0%, p < 0.001). Combined, these studies suggest that there may be a benefit to using postoperative antibiotics for procedures involving chronic implants. However, as none of these studies involved patients receiving SNS, further research will be required to investigate the efficacy of postoperative antibiotics in patients undergoing SNS placement.

Our Experience Currently, there is a paucity of data regarding the optimal perioperative and postoperative infection prevention program for SNS implantation. However, utilizing the available literature and integrating the experience of a high-volume SNS surgery center, our institution has enacted a protocol to prevent infection in patients undergoing SNS placement. Antibiotics Prior to stage 1 of a two-stage implantation, we administer IV cefazolin (weight-based dosing) or 600 mg clindamycin IV if the patient is allergic to penicillin. Based on prior observation of high incidence of methicillin-resistant S. aureus infection, the patient is managed postoperatively with trimethoprimsulfamethoxazole twice daily for 5 days or clindamycin 400 mg three times per day if the patient is allergic to trimethoprim-sulfamethoxazole. Then, prior to the second stage (or before a combined stage procedure), the patient is given vancomycin and IV gentamicin (weight-based dosing). Postoperatively, patients are managed with trimethoprimsulfamethoxazole twice daily for 5 days or clindamycin 400 mg three times per day if the patient is allergic to trimethoprim-sulfamethoxazole.


Intraoperative We use ChloraPrep® as our perioperative skin preparation. The implantation site is then covered with 3M™ Ioban 2™ Antimicrobial Incise Drapes prior to incision at the discretion of the surgeon. The use of Ioban prevents surgeon touch of the gluteal skin and allows an additional barrier for reduced contamination risk. Additionally, surgeons employ a “minimal touch” technique at the time of generator placement. Gloves are changed prior to handling the implantable pulse generator (IPG) and the device is opened immediately before placement. The IPG is then directly placed into the premade, copiously irrigated pocket. Finally, a new instrument kit is used to close the incision site after device placement. Duration Between Stages The duration of the initial stage of the two-stage procedure is limited to 1–2 weeks in order to reduce the risk of infection while allowing ample time to trial the device.

Results Using the infection prevention protocol described above, our institution has been able to reduce the rate of postoperative infection as evidenced by a recent review [13••]. Between 2010 and 2015, 1033 SNS procedures were performed and the overall infection rate for patients undergoing any type of SNS procedure was 1.6%. Specifically, 650 patients underwent procedures requiring manipulation of the IPG, and of these patients only 1.8% developed infection postoperatively. This incidence of infection is lower than the 3–10% that has been previously reported. As stated above, a preoperative diagnosis of non-obstructive urinary retention was the only significant risk factor for IPG infection. A multivariable infection risk factor analysis was not possible due to the very low incidence of infection.

Conclusion This review has highlighted a number of potential risk factors that may predict subsequent device infection following SNS implantation, including insufficient preoperative antibiotic coverage and diagnosis of non-obstructive urinary retention. While a patient’s preoperative diagnosis cannot be changed, clinicians should take care to optimize the modifiable risk factors in order to reduce a patient’s risk of developing an infection; for example, broader spectrum antibiotics can be used preoperatively to decrease infectious risk. Great variation exists in the type of skin preparation that can be used prior to SNS surgery; however, evidence from other surgical fields

Page 5 of 6 16

may suggest that more rigorous skin preparations, with some even beginning the night prior to surgery, may reduce the overall risk of surgical site infection. Additionally, it is still unclear whether certain interventions such as shorter stage 1 testing, use of antibiotic-impregnated collagen, or postoperative antibiotics affect the risk of developing infection. Wellpowered randomized controlled trials specifically designed to address infection prevention are needed in the future to determine the effect of these interventions, although the number of patients required to show differences will likely be large. Finally, we have outlined in this review the infection prophylaxis procedure we use at our institution, which has resulted in a reduced infection incidence of 1.6%. Acknowledgements The journal would like to thank Dr. Howard Goldman and Dr. Gopal Badlani for providing the topic and review of this article. Compliance with Ethical Standards Conflict of Interest Calvin Lee and Marisa M. Clifton each declare no potential conflicts of interest. Javier Pizarro-Berdichevsky reports travel expenses covered by Medtronic for IUGA 2016. Sandip P. Vasavada reports personal fees from Medtronic and Axonics. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.

Carmel ME, Vasavada SP, Goldman HB. Troubleshooting sacral neuromodulation issues. Curr Urol Rep. 2012;13(5):363–9. 2. White WM, Mobley JD, Doggweiler R, Dobmeyer-Dittrich C, Klein FA. Incidence and predictors of complications with sacral neuromodulation. Urology. 2009;73(4):731–5. 3. Wexner SD, Hull T, Edden Y, Coller JA, Devroede G, McCallum R, et al. Infection rates in a large investigational trial of sacral nerve stimulation for fecal incontinence. J Gastrointest Surg. 2010;14(7): 1081–9. 4. Mellgren A, Wexner SD, Coller JA, Devroede G, Lerew DR, Madoff RD, et al. Long-term efficacy and safety of sacral nerve stimulation for fecal incontinence. Dis Colon Rectum. 2011;54(9): 1065–75. 5. Guralnick ML, Benouni S, O’Connor RC, Edmiston C. Characteristics of infections in patients undergoing staged implantation for sacral nerve stimulation. Urology. 2007;69(6):1073–6. 6. Huwyler M, Kiss G, Burkhard FC, Madersbacher H, Kessler TM. Microbiological tined-lead examination: does prolonged sacral neuromodulation testing induce infection? BJU Int. 2009;104(5): 646–50. discussion 650.

16 Page 6 of 6 7.

8.

9.••

10.

11.••

12.••

13.••

14.

15.

16.

17.••

Dudding T, Vaizey C. Bacterial colonization of stimulation electrode wires in patients undergoing temporary sacral nerve stimulation. Colorectal Dis. 2010;12(2):141–3. Kessler TM, Burkhard FC, Madersbacher H, Kofler A, Poewe W, Kiss G. Safety of prolonged sacral neuromodulation tined lead testing. Curr Med Res Opin. 2008;24(2):343–7. Lai HH, Grewal S. Bacterial colonization rate of InterStim and infection outcome with staged testing. Urology. 2013;82(6):1255– 60. This is a prospective study following 38 patients who underwent sacral neuromodulation. This study gives evidence linking prolonged stage 1 testing with bacterial colonization and subsequent device infection. Wolf JS, Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ, et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008;179(4):1379–90. Amend B, Bedke J, Khalil M, Stenzl A, Sievert K-D. Prolonged percutaneous SNM testing does not cause infection-related explanation. BJU Int. 2013;111(3):485–91. This is a prospective study that followed 21 patients who received sacral nerve stimulation for a variety of indications. This study is notable because, after a mean stage 1 testing period of 52 days, none of the patients developed subsequent device infection. Haraway AM, Clemens JQ, He C, Stroup C, Atiemo HO, Cameron AP. Differences in sacral neuromodulation device infection rates based on preoperative antibiotic selection. Int Urogynecol J. 2013;24(12):2081–5. This is a retrospective study looking at outcomes in 136 patients who underwent sacral nerve stimulator placement. Infection rates were compared according to type of preoperative antibiotic that was used. The study demonstrated that choice of preoperative antibiotic could affect the risk of subsequent infection. Clifton M, Quirouet A, Pizarro-Berdichevsky J, Gill B, Dielubanza E, Okafor H, et al. Infection rate after sacral neuromodulation surgery: a review of 1033 InterStim procedures. Neurourol Urodynam. 35(S1):S57. This was a retrospective study that included all 1033 sacral nerve stimulator procedures performed at the Cleveland Clinic between 2010 and 2015. This study is notable for the low rate of infection (1.6%) achieved in part by using the infection prevention protocol outlined in this review. This study also identifies pre-implant indication of non-obstructive urinary retention as a significant risk factor for subsequent infection. Simpson JAD, Peacock J, Maxwell-Armstrong C. Use of a gentamicin-impregnated collagen sheet (Collatamp(®)) following implantation of a sacral nerve stimulator for faecal incontinence. Colorectal Dis. 2012;14(4):e200–2. Andersson RE, Lukas G, Skullman S, Hugander A. Local administration of antibiotics by gentamicin-collagen sponge does not improve wound healing or reduce recurrence rate after pilonidal excision with primary suture: a prospective randomized controlled trial. World J Surg. 2010;34(12):3042–8. Bennett-Guerrero E, Pappas TN, Koltun WA, Fleshman JW, Lin M, Garg J, et al. Gentamicin-collagen sponge for infection prophylaxis in colorectal surgery. N Engl J Med. 2010;363(11):1038–49. Tuuli MG, Liu J, Stout MJ, Martin S, Cahill AG, Odibo AO, et al. A randomized trial comparing skin antiseptic agents at Cesarean delivery. N Engl J Med. 2016;374(7):647–55. This was a


18.•

19.

20.

21.••

22.••

23.

24.••

randomized controlled trial that enrolled 1147 patients to receive either chlorhexidine-alcohol or iodine-alcohol as skin preparation prior to Cesarean section. This study identified different incidences of infection with different skin preparations, suggesting that certain skin preparations may be more effective than others for preventing surgical site infection. Kapadia BH, Zhou PL, Jauregui JJ, Mont MA. Does preadmission cutaneous chlorhexidine preparation reduce surgical site infections after total knee arthroplasty? Clin Orthop Relat Res. 2016. This was a prospective cohort study in which 3717 patients were given chlorhexidine cloths to cleanse the surgical site prior to total knee arthroplasty. This study demonstrates that having patients begin infection prevention at home prior to their procedure may further reduce the incidence of surgical site infection. Kapadia BH, Jauregui JJ, Murray DP, Mont MA. Does preadmission cutaneous chlorhexidine preparation reduce surgical site infections after total hip arthroplasty? Clin Orthop Relat Res. 2016. Morrison TN, Chen AF, Taneja M, Küçükdurmaz F, Rothman RH, Parvizi J. Single vs repeat surgical skin preparations for reducing surgical site infection after total joint arthroplasty: a prospective, randomized, double-blinded study. J Arthroplasty. 2015. Chen H-C, Chen M-C, Chen Y-L, Tsai T-H, Pan K-L, Lin Y-S. Bundled preparation of skin antisepsis decreases the risk of cardiac implantable electronic device-related infection. Europace. 2015. This is a prospective cohort study in which 665 patients undergoing placement of implantable cardiac devices were enrolled to receive either a standard infection prophylaxis regimen or the standard regimen in addition to alcohol wash on the night prior to procedure and povidone-iodine 10 min prior to procedure. This study is notable for looking at a procedure that is analogous to sacral nerve stimulator placement and demonstrating that more rigorous skin preparations beginning the night prior to surgery can reduce the incidence of infection. Townley WA, Baluch N, Bagher S, Maass SWMC, O’Neill A, Zhong T, et al. A single pre-operative antibiotic dose is as effective as continued antibiotic prophylaxis in implant-based breast reconstruction: a matched cohort study. J Plast Reconstr Aesthet Surg. 2015;68(5):673–8. This is a retrospective study comparing infection incidence in patients undergoing implant-based breast reconstruction. This study is notable for finding no difference in infection incidence between patients who were given postoperative antibiotics and patients who were managed with a standard perioperative antibiotic regimen. Clayton JL, Bazakas A, Lee CN, Hultman CS, Halvorson EG. Once is not enough: withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of infection. Plast Reconstr Surg. 2012;130(3):495–502. Senaratne JM, Jayasuriya A, Irwin M, Gulamhusein S, Senaratne MPJ. A 19-year study on pacemaker-related infections: a claim for using postoperative antibiotics. Pacing Clin Electrophysiol. 2014;37(8):947–54. This is a retrospective study that included data from 3253 cardiac pacemaker implantations occurring over a period of 19 years. This study is notable for demonstrating reduced risk of infection with the use of post-operative antibiotics.