# Management and outcome of mesh infection after abdominal wall reconstruction in a tertiary care center

Victor Franchi, Claire Triffault-Fillit, Sophie Jarraud, Jean-Yves Mabrut, Clément Javaux, Olivier Monneuse, Anne Conrad, Tristan Ferry, Maud Robert, Florence Ader, et al.

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## To cite this version:

Victor Franchi, Claire Triffault-Fillit, Sophie Jarraud, Jean-Yves Mabrut, Clément Javaux, et al. Management and outcome of mesh infection after abdominal wall reconstruction in a tertiary care center. Hernia, 2025, 29 (1), pp.76. 10.1007/s10029-025-03265-3. inserm-05344916

HAL Id: inserm-05344916

https://inserm.hal.science/inserm-05344916v1

Submitted on 3 Nov 2025

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# Management and outcome of mesh infection after abdominal wall reconstruction in a tertiary care center

Victor Franchi¹ · Claire Triffault-Fillit¹ · Sophie Jarraud²,³ · Jean-Yves Mabrut⁴,⁵ · Clément Javaux¹ · Olivier Monneuse⁶ · Anne Conrad¹,³ · Tristan Ferry¹,⁷ · Maud Robert⁸,⁹ · Florence Ader¹,³ · Guillaume Passot¹⁰,¹¹ · Florent Valour¹,³

Received: 23 September 2024 / Accepted: 5 January 2025
© The Author(s) 2025

## Abstract

**Purpose** Abdominal wall reconstruction is a common surgical procedure, with a post-operative risk of mesh-associated infection of which management is poorly known. This study aims to comprehensively analyze clinical and microbiological aspects of mesh infection, treatment modalities, and associated outcomes.

**Methods** Patients with abdominal mesh infection were included in a retrospective observational cohort (2010-2023). Patients characteristics and management were described, and determinants for failure were assessed by logistic regression and treatment failure-free survival curve analysis (Kaplan-Meier).

**Results** Two hundred and nine patients (median age, 62 [IQR, 55-71] years) presented a mesh infection occurring within 15 (IQR, 7-31) days after surgery, mainly as an abdominal wall or deep abscess (n=189, 90.4%). Infection was polymicrobial in 89/166 (79.4%) cases, *S. aureus* (n=60, 36.1%), *Enterobacteriaceae* (n=60, 36.1%) and anaerobes (n=40, 24.1%) being the most prevalent pathogens. Surgery was performed in 130 (62.2%) patients, associated with a 13.5 (IQR, 8-21) day course of antimicrobial therapy in 172/207 (83.1%) cases. Sixty-three (30.1%) treatment failures occurred, associated with previous multiple abdominal surgeries (OR, 3.305; 95%CI, 1.297-8.425), complete mesh removal (OR, 0.145; 95%CI, 0.063-0.335) and antimicrobial therapy (OR, 0.328; 95%CI, 0.136-0.787). The higher failure rate of conservative strategies was associated with symptom duration >1 month (OR, 3.378; 95%CI, 1.089-4.005) and retromuscular mesh position (OR, 0.444; 95%CI, 0.199-0.992).

**Conclusion** Mesh infection is associated with high treatment failure rates. Complete mesh removal coupled with targeted antibiotic therapy is associated with better outcomes. Conservative treatment strategies must rely on careful patient selection based on symptom duration and mesh placement.

**Keywords** Abdominal wall repair · Hernia mesh infection · Microbiology · Treatment outcomes · Conservative treatment

## Introduction

Reconstruction of abdominal wall defect can be challenging, especially in comorbid patients and/or with complex hernias, following multiple surgeries or abdominal trauma. The final strategy must be safe and effective, and the use of mesh is now one of the most widely-performed surgical procedures [1, 2]. Post-operative infection represents a notable complication, with reported incidences ranging from 0.3% in clean inguinal hernia repairs to as high as

19.6% in complicated hernia cases [3, 4]. Such infections can lead to severe consequences, including sepsis, need for subsequent surgeries, development of chronic fistulas, persistent pain, or hernia recurrence [5]. Determinants of post-operative mesh infection have been extensively documented in existing literature [3, 6, 7]. They include mainly patient- and surgery-related parameters, such as age, body mass index (BMI), smoking status, length of surgery, open surgery compared with laparoscopic procedures, and hernia localization.

<footnote>Extended author information available on the last page of the article</footnote>
Various management strategies have been described [8–10], involving the following interventions, alone or in combination: systemic antibiotic therapy, percutaneous drainage, complete or partial mesh removal, and negative pressure therapy [11]. However, these strategies have been poorly investigated, and criteria guiding clinicians in the selection of the most appropriate therapeutic approach are not available [12].

The objective of this study is to provide a comprehensive account of the clinical and microbiologic aspects of mesh infection observed in our tertiary care hospital, while describing treatment modalities employed and associated outcomes.

# Patients and methods

## Ethical statement

The study received the approval of the Scientific and Ethical Committees of Hospices Civils de Lyon, France (reference number 23-5457). In accordance with French legislation regarding retrospective observational studies, all patients received written information about the study and their possibility to decline to participate, but the need for written informed consent was waived.

## Study design and data collection

Patients diagnosed with abdominal mesh infection in the four digestive surgery wards of our tertiary care center were identified from records from 2010 to 2023 and included in a retrospective observational cohort study. Patients were identified through electronic medical records by cross-referencing medical documents with keywords related to mesh infection, and using diagnosis data associated with each hospital stay, including a combination of International Classification of Diseases (ICD) codes, and hospital pharmacy registries regarding mesh placement and removal. In patients having experienced several episodes of mesh-related infections, only the first episode was considered.

For each patient, data were collected from medical records into an anonymous standardized case report form. Co-morbidities were summarized using the modified Charlson comorbidity index [13], and the American Society of Anesthesiologists (ASA) score.

## Definitions

The diagnosis of mesh infection was based on clinical evaluation by the treating surgeon. Infections involving skin and subcutaneous tissue only were categorized as superficial.

All other infections were considered as deep. Assessment of the depth of infection was performed by collecting clinical and surgical data, and imaging reports when available. Patients with the superficial wounds who did not undergo subsequent imaging nor surgery were classified as superficial infection on the basis of clinical findings, only. The time to infection was calculated as the number of days between mesh placement or the last surgery at the site and the onset of symptoms. Antimicrobial therapy was deemed appropriate when all pathogens identified in gold-standard sample cultures were targeted by at least one antimicrobial agent. Treatment was considered conservative in every case where the initial management strategy did not involve complete removal of the mesh. Treatment failure was defined as infection persistence or relapse after treatment on a clinical basis (i.e., wound abnormalities suspected of infection, abscess and/or fistula) and/or the need for additional surgery motivated by septic reasons and not planned in the initial treatment scheme.

Microbiology etiology was described according to the results of cultures from normally sterile site samples, excluding superficial swab. Common contaminants, such as Coagulase-Negative Staphylococci (CNS), Corynebacterium spp. or Cutibacterium spp., were considered only when found in at least two samples.

The mesh material was described according to the manufacturer's notice, describing both the material used (synthetic, semi-synthetic, biologic) and its resorption characteristics once implanted (absorbable, semi-absorbable, non-absorbable).

## Statistical analysis

Variables were presented as percentages for dichotomous variables and as medians with interquartile ranges (IQR) for continuous variables. In percentage calculations, missing values were excluded from the denominator. Groups were compared using non-parametric tests (Chi-square, Fisher exact, and Mann-Whitney U tests), as appropriate. Kaplan-Meier curves were used to compare treatment-failure free survival rates between groups, with statistical significance assessed by the log-rank (Mantel-Cox) test. The same analysis process was applied to the subgroup of patients who did not undergo complete mesh removal (conservative treatment group). After analysis of the whole cohort, and in order to consider a potential recruitment bias, patients primarily managed in our reference center (HCL group), i.e. who were not referred due to a previous mesh infection management failure, were independently analyzed.

Determinants of treatment failure were examined using stepwise binary logistic regression and expressed as odds ratios (ORs) along with their corresponding 95% confidence
<table><caption>Table 1 Description of the included population, comparison of patients without or with treatment failure, and determinants of treatment failure (univariate analysis)</caption><thead><tr><th rowspan="2"></th><th rowspan="2">All patients</th><th colspan="2">Descriptive analysis</th><th colspan="2">Univariate analysis</th></tr><tr><th>Failure</th><th>Success</th><th>p-value</th><th>OR (95%CI)</th><th>p-value</th></tr></thead><tbody><tr><td><strong>n</strong></td><td>209</td><td>63</td><td>146</td><td></td><td></td><td></td></tr><tr><td><strong>Demographics and comorbidities</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Gender (male)</td><td>119/209 (56.9%)</td><td>38/63 (60.3%)</td><td>81/146 (55.5%)</td><td>0.517</td><td>1.220 (0.669-2.225)</td><td>0.517</td></tr><tr><td>Age (years)</td><td>62 (55-71)</td><td>61 (55-69.5)</td><td>63 (55-72)</td><td>0.432</td><td>0.992 (0.969-1.016)</td><td>0.528</td></tr><tr><td>BMI (kg/m²)</td><td>29.7 (26.4-33.2)</td><td>29.9 (27.3-32.9)</td><td>29.7 (26.1-33.3)</td><td>0.606</td><td>1.012 (0.963-1.063)</td><td>0.634</td></tr><tr><td>ASA score</td><td>2 (2-3)</td><td>2 (2-2.3)</td><td>2 (2-3)</td><td></td><td>0.793 (0.490-1.281)</td><td>0.342</td></tr><tr><td>Modified Charlson's comorbidity index</td><td>3 (2-5)</td><td>3 (1.5-4)</td><td>3 (2-5)</td><td></td><td>0.972 (0.857-1.103)</td><td>0.663</td></tr><tr><td>Active smoking</td><td>42/209 (20.1%)</td><td>14/63 (22.2%)</td><td>28/146 (19.2%)</td><td>0.614</td><td>1.204 (0.584-2.481)</td><td>0.615</td></tr><tr><td>Previous abdominal surgery</td><td>199/209 (95.2%)</td><td>59/63 (93.7%)</td><td>140/146 (95.9%)</td><td>0.486</td><td>0.632 (0.172-2.322)</td><td>0.490</td></tr><tr><td>&gt; 1 previous abdominal surgeries</td><td>166/209 (79.4%)</td><td>56/63 (88.9%)</td><td>110/146 (75.3%)</td><td>0.026</td><td>2.618 (1.096-6.257)</td><td>0.030</td></tr><tr><td><strong>Index surgery</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Operative indication</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Primary hernia</td><td>42/202 (20.8%)</td><td>14/62 (22.6%)</td><td>28/140 (20.0%)</td><td>0.677</td><td>1.167 (0.565-2.409)</td><td>0.677</td></tr><tr><td>Incisional hernia</td><td>154/202 (76.2%)</td><td>45/62 (72.6%)</td><td>109/140 (77.9%)</td><td>0.416</td><td>0.753 (0.379-1.495)</td><td>0.417</td></tr><tr><td>Acute complication</td><td>11/202 (5.4%)</td><td>4/62 (6.5%)</td><td>7/140 (5.0%)</td><td>0.740</td><td>1.310 (0.369-4.650)</td><td>0.676</td></tr><tr><td>Post-surgical parietal closure</td><td>6/202 (3.0%)</td><td>3/62 (4.8%)</td><td>3/140 (2.1%)</td><td>0.374</td><td>2.322 (0.455-11.841)</td><td>0.311</td></tr><tr><td>Mesh characteristics</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Size (cm²)</td><td>400 (225-775.5)</td><td>500 (300-900)</td><td>360 (225-667.5)</td><td>0.106</td><td>1.001 (1.000-1.002)</td><td>0.058</td></tr><tr><td>Synthetic</td><td>131/175 (74.9%)</td><td>41/58 (70.7%)</td><td>90/117 (76.9%)</td><td>0.371</td><td>0.724 (0.356-1.472)</td><td>0.372</td></tr><tr><td>Biosynthetic</td><td>43/175 (24.6%)</td><td>17/58 (29.3%)</td><td>26/117 (22.2%)</td><td>0.305</td><td>1.451 (0.711-2.963)</td><td>0.307</td></tr><tr><td>Biological</td><td>1/175 (0.6%)</td><td>0/58 (0%)</td><td>1/117 (0.9%)</td><td>1.000</td><td>0.991 (0.975-1.008)</td><td></td></tr><tr><td>Absorbable</td><td>34/173 (19.7%)</td><td>15/57 (26.3%)</td><td>19/116 (16.4%)</td><td>0.122</td><td>1.823 (0.846-3.929)</td><td>0.125</td></tr><tr><td>Semi-absorbable</td><td>51/173 (29.5%)</td><td>13/57 (22.8%)</td><td>38/116 (32.8%)</td><td>0.177</td><td>0.606 (0.292-1.259)</td><td>0.179</td></tr><tr><td>Non-absorbable</td><td>88/173 (50.9%)</td><td>29/57 (50.9%)</td><td>59/116 (50.9%)</td><td>0.999</td><td>1.001 (0.531-1.887)</td><td>0.999</td></tr><tr><td>Mesh location</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Subcutaneous</td><td>37/190 (19.5%)</td><td>11/60 (18.3%)</td><td>26/130 (20.0%)</td><td>0.787</td><td>0.898 (0.411-1.964)</td><td>0.787</td></tr><tr><td>Retromuscular</td><td>76/190 (40.0%)</td><td>23/60 (38.3%)</td><td>53/130 (40.8%)</td><td>0.750</td><td>0.903 (0.482-1.691)</td><td>0.750</td></tr><tr><td>Preperitoneal</td><td>24/190 (12.6%)</td><td>6/60 (10.0%)</td><td>18/130 (13.8%)</td><td>0.458</td><td>0.691 (0.260-1.841)</td><td>0.460</td></tr><tr><td>Intaperitoneal</td><td>56/190 (29.5%)</td><td>22/60 (36.7%)</td><td>34/130 (26.2%)</td><td>0.140</td><td>1.635 (0.849-3.146)</td><td>0.141</td></tr><tr><td>Altemeier class 1</td><td>165/190 (86.8%)</td><td>51/60 (85%)</td><td>114/130 (87.7%)</td><td>0.610</td><td>0.795 (0.330-1.919)</td><td>0.610</td></tr><tr><td><strong>Infection presentation</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Time from surgery to onset of symptoms (days)</td><td>15 (7-31)</td><td>15 (7.3-31)</td><td>17 (7-31)</td><td>0.662</td><td>0.999 (0.999-1.000)</td><td>0.110</td></tr><tr><td>Highest CRP level (mg/L)</td><td>124 (50-200)</td><td>130 (60-250)</td><td>114 (40.8-183.5)</td><td>0.238</td><td>1.002 (0.999-1.005)</td><td>0.179</td></tr><tr><td>Infection type</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Inflammatory wound dehiscence</td><td>9/209 (4.3%)</td><td>0/63 (0%)</td><td>9/146 (6.2%)</td><td>0.060</td><td>-</td><td></td></tr><tr><td>Abcess</td><td>189/209 (90.4%)</td><td>61/63 (96.8%)</td><td>128/146 (87.7%)</td><td>0.042</td><td>4.289 (0.964-19.076)</td><td>0.056</td></tr><tr><td>Abdominal wall abscess</td><td>177/209 (84.7%)</td><td>56/63 (88.9%)</td><td>121/146 (82.9%)</td><td>0.268</td><td>1.653 (0.675-4.049)</td><td>0.272</td></tr><tr><td>Deep abscess</td><td>25/209 (12.0%)</td><td>8/63 (12.7%)</td><td>17/146 (11.6%)</td><td>0.829</td><td>1.104 (0.450-2.708)</td><td>0.829</td></tr><tr><td>Sinus tract</td><td>127/209 (60.8%)</td><td>42/63 (66.7%)</td><td>85/146 (58.2%)</td><td>0.251</td><td>1.435 (0.773-2.664)</td><td>0.252</td></tr></tbody></table>

<figure><img src="image_3.png" /></figure>
<table><caption>Table 1 (continued)</caption><thead><tr><th rowspan="2"></th><th rowspan="2">All patients</th><th colspan="2">Descriptive analysis</th><th colspan="2">Univariate analysis</th></tr><tr><th>Failure</th><th>Success</th><th>p-value</th><th>OR (95%CI)</th><th>p-value</th></tr></thead><tbody><tr><td>Enterocutaneous sinus tract</td><td>20/209 (9.6%)</td><td>4/63 (6.3%)</td><td>16/146 (11.0%)</td><td>0.443</td><td>0.551 (0.177-1.719)</td><td>0.304</td></tr><tr><td>Early post-operative peritonitis</td><td>4/209 (1.9%)</td><td>1/63 (1.6%)</td><td>3/146 (2.1%)</td><td>1.000</td><td>0.769 (0.078-7.537)</td><td>0.821</td></tr><tr><td><strong>Microbiology results</strong></td><td>166/209 (79.4%)</td><td>51/63 (81.0%)</td><td>115/146 (78.8%)</td><td>0.720</td><td>1.146 (0.545-2.410)</td><td>0.720</td></tr><tr><td>Sterile</td><td>10/166 (6.0%)</td><td>4/51 (7.8%)</td><td>6/115 (5.2%)</td><td>0.498</td><td>1.546 (0.417-5.733)</td><td>0.515</td></tr><tr><td>Polymicrobial</td><td>89/166 (53.6%)</td><td>28/51 (54.9%)</td><td>61/115 (53.0%)</td><td>0.825</td><td>1.078 (0.556-2.089)</td><td>0.825</td></tr><tr><td><em>S. aureus</em></td><td>60/166 (36.1%)</td><td>17/51 (33.3%)</td><td>43/115 (37.4%)</td><td>0.616</td><td>0.837 (0.418-1.676)</td><td>0.616</td></tr><tr><td>CoNS</td><td>11/166 (6.6%)</td><td>4/51 (7.8%)</td><td>7/115 (6.1%)</td><td>0.738</td><td>1.313 (0.367-4.701)</td><td>0.676</td></tr><tr><td><em>Streptococcus</em> spp.</td><td>21/166 (12.7%)</td><td>4/51 (7.8%)</td><td>17/115 (14.8%)</td><td>0.312</td><td>0.491 (0.156-1.539)</td><td>0.222</td></tr><tr><td><em>Enterococcus</em> spp.</td><td>33/166 (19.9%)</td><td>7/51 (13.7%)</td><td>26/115 (22.6%)</td><td>0.186</td><td>0.545 (0.219-1.352)</td><td>0.190</td></tr><tr><td><em>Corynebacterium</em> spp.</td><td>3/166 (1.8%)</td><td>2/51 (3.9%)</td><td>1/115 (0.9%)</td><td>0.224</td><td>4.653 (0.412-52.521)</td><td>0.214</td></tr><tr><td><em>Cutibacterium</em> spp.</td><td>5/166 (3.0%)</td><td>3/51 (5.9%)</td><td>2/115 (1.7%)</td><td>0.170</td><td>3.531 (0.572-21.811)</td><td>0.174</td></tr><tr><td>Enterobacteriaceae</td><td>60/166 (36.1%)</td><td>19/51 (37.3%)</td><td>41/115 (35.7%)</td><td>0.843</td><td>1.072 (0.541-2.124)</td><td>0.843</td></tr><tr><td><em>Pseudomonas</em> spp.</td><td>10/166 (6.0%)</td><td>3/51 (5.9%)</td><td>7/115 (6.1%)</td><td>1.000</td><td>0.964 (0.239-3.889)</td><td>0.959</td></tr><tr><td>Anaerobes</td><td>40/166 (24.1%)</td><td>11/51 (21.6%)</td><td>29/115 (25.2%)</td><td>0.612</td><td>0.816 (0.371-1.795)</td><td>0.612</td></tr><tr><td><em>Actinomyces</em> spp.</td><td>9/166 (5.4%)</td><td>2/51 (3.9%)</td><td>7/115 (6.1%)</td><td>0.723</td><td>0.630 (0.126-3.142)</td><td>0.573</td></tr><tr><td>Fungi</td><td>12/166 (7.2%)</td><td>4/51 (7.8%)</td><td>8/115 (7.0%)</td><td>0.533</td><td>1.138 (0.327-3.966)</td><td>0.839</td></tr><tr><td><strong>Infection management</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Local treatment only</td><td>46/209 (22.0%)</td><td>22/63 (34.9%)</td><td>24/146 (16.4%)</td><td>0.003</td><td>2.728 (1.384-5.374)</td><td>0.004</td></tr><tr><td>Radiological drainage</td><td>19/209 (9.1%)</td><td>6/63 (9.5%)</td><td>13/146 (8.9%)</td><td>1.000</td><td>1.077 (0.390-2.974)</td><td>0.886</td></tr><tr><td>Surgery</td><td>130/209 (62.2%)</td><td>29/63 (46%)</td><td>101/146 (69.2%)</td><td>0.002</td><td>0.380 (0.207-0.698)</td><td>0.002</td></tr><tr><td>Complete mesh removal</td><td>78/209 (37.3%)</td><td>9/63 (14.3%)</td><td>69/146 (47.3%)</td><td>&lt;10<sup>-3</sup></td><td>0.186 (0.86-0.404)</td><td>&lt;10<sup>-3</sup></td></tr><tr><td>Partial mesh removal</td><td>11/209 (5.3%)</td><td>3/63 (4.8%)</td><td>8/146 (5.5%)</td><td>1.000</td><td>0.863 (0.221-3.364)</td><td>0.831</td></tr><tr><td>Single-stage abdominal wall reconstruction</td><td>16/129 (12.4%)</td><td>3/29 (10.3%)</td><td>13/100 (13.0%)</td><td>1.000</td><td>0.772 (0.204-2.919)</td><td>0.703</td></tr><tr><td>Post-operative negative pressure therapy</td><td>38/209 (18.2%)</td><td>10/63 (15.9%)</td><td>28/146 (19.2%)</td><td>0.570</td><td>0.795 (0 (0.360-1.755)</td><td>0.570</td></tr><tr><td><strong>Antibiotic treatment</strong></td><td>172/207 (83.1%)</td><td>47/62 (75.8%)</td><td>125/145 (86.2%)</td><td>0.067</td><td>0.501 (0.237-1.060)</td><td>0.071</td></tr><tr><td>Appropriate empiric antibiotic therapy</td><td>99/131 (75.6%)</td><td>25/33 (75.8%)</td><td>74/98 (75.5%)</td><td>0.977</td><td>1.014 (0.404-2.542)</td><td>0.977</td></tr><tr><td>Secondary adaptation</td><td>79/123 (64.2%)</td><td>15/29 (51.7%)</td><td>64/94 (68.1%)</td><td>0.108</td><td>0.502 (0.215-1.172)</td><td>0.111</td></tr><tr><td>Treatment duration (days)</td><td>13.5 (8-21)</td><td>10 (7-19)</td><td>14 (9-21)</td><td>0.239</td><td>0.998 (0.975-1.021)</td><td>0.835</td></tr><tr><td><strong>Outcomes</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Failure</td><td>63/209 (30.1%)</td><td>63/63 (100%)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Time to failure (days)</td><td>38 (16-183)</td><td>38 (16-183)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Hernia recurrence</td><td>67/209 (32.1%)</td><td>20/63 (31.7%)</td><td>47/146 (32.2%)</td><td>0.949</td><td>0.980 (0.520-1.847)</td><td>0.949</td></tr><tr><td>Subsequent surgery for infectious purpose</td><td>48/209 (23.0%)</td><td>48/63 (76.2%)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Follow-up time (weeks)</td><td>73 (26.4-191.1)</td><td>74.9 (32.7-211.8)</td><td>72 (24.5-189.8)</td><td>0.316</td><td>1.001 (0.999-1.004)</td><td>0.199</td></tr></tbody></table>

95%CI, 95% confidence interval; ASA, American Society of Anesthesiologists, BMI, Body mass index; CoNS, Coagulase negative staphylococci; CRP, C-reactive protein; NA, Not applicable; OR, Odd ratio

<figure><img src="image_4.png" /></figure>
intervals (95%CI). Variables included in the final multi-
variate model were selected from non-interacting variables
with clinical significance and *p*-values obtained in univari-
ate analysis less than 0.15. A *p*-value of less than 0.05 was
considered statistically significant. All statistical analyses
were performed using SPSS version 19.0 (SPSS, Chicago,
IL, USA) and GraphPad Prism version 5.03 (GraphPad, San
Diego, CA, USA) softwares.

Results

Included population and index surgery

A total of 209 patients were included, comprising 119 (56.9%) males with a median age of 62 (IQR, 55–71) years. The median modified Charlson's comorbidity Index was 3 (IQR, 2–3), main comorbidities being obesity (median body mass index [BMI], 29.7 [IQR, 26.4–33.2]; >30 in 96 [46.8%] patients), diabetes mellitus (n=60, 28.7%) and solid tumor or hemopathy (n=55, 26.3%). Patient and infection characteristics are summarized in Table 1. The majority (n=199, 95.2%) of patients had undergone previous abdominal surgery, with multiple procedures in 166 (79.4%) cases. Abdominal wall repair was planned for incisional hernias in 154 (76.2%) patients, mostly using synthetic (n=131/175, 74.9%) and non-absorbable (n=83/173, 50.9%) meshes. The most frequent mesh locations were retromuscular (76/190, 40.0%) and intraperitoneal (56/190, 29.5%). Antibiotics were administered as prophylaxis during surgery to 109/122 (89.3%) patients, with cefazolin being the most frequently used drug.

Forty patients (19.1%) were referred to our center after
initial management elsewhere. Of note, baseline character-
istics of this subset of patients were not statistically differ-
ent from patients primarily managed in our center (data not
shown).

Infection presentation

Median time between index surgery and symptoms was 15 (IQR, 7–31) days. Fever was present in 88 (42.1%) patients, only. A CT-scan was performed in 167 (76.9%) patients. Abdominal wall and deep abscesses were observed in 177 (84.7%) and 25 (12.0%) patients, respectively. Sinus tracts were identified in 127 (60.8%) patients. Less common presentations included enterocutaneous fistula (n=20, 9.6%) and isolated inflammatory wound dehiscence (n=9, 4.3%).

Microbiology findings

Reliable samples for microbiological examination were obtained from 166 (79.4%) patients. Ten (6%) samples were culture-sterile. Cultures revealed polymicrobial infections in 86 (53.6%) cases. *Staphylococcus aureus* (n=60, 36.1%) and *Enterobacteriaceae* (n=60, 36.1%) were the most frequently isolated organisms. Multidrug-resistant (MDR) bacteria were uncommon, with 3/60 (5%) methicillin-resistant *S. aureus*, and 9/60 (15%) *Enterobacteriaceae* resistant to 3rd generation cephalosporins. Surgeries involving progressive preoperative pneumoperitoneum were associated with higher occurrence of MDR bacterial infection (3/13 *versus* 9/196, OR, 6.964 [1.509–32.142]; *p*=0.013).

Microbiology data highlights significant differences
toward clinical presentations (Fig. 1).

<figure><img src="image_5.png" /><figcaption>Fig. 1 Microbial distribution according to infection site</figcaption></figure>
## Infection management

Surgical intervention was undertaken in 130 (62.2%) cases, with total or partial mesh removal in 78 (37.3%) and 11 (5.3%) cases, respectively. Single stage abdominal wall reconstruction with a new mesh was performed in 16/129 (12.4%) patients, predominantly using absorbable meshes. Post-operative negative pressure therapy was utilized in 38 (18.2%) patients, while radiological drainage was performed in 19 (9.1%) patients. Antibiotic treatment was prescribed to 172/207 (83.1%) patients for a median duration of 13.5 (IQR, 8–21) days, with therapy deemed appropriate in 99/131 (75.6%) cases.

## Outcomes

After a median follow-up of 73 (IQR, 26.4-191.1) weeks, treatment failure was observed in 63 (30.1%) patients, with a median time to failure of 38 (IQR, 16–183) days after the end of initial infection care. Most patients experiencing failure (n=48/63, 76.2%) underwent subsequent surgery for infectious purposes. Baseline characteristics of patients with treatment failure and success were similar (Table 1). In univariate analysis, the only comorbidity associated with failure was multiple previous abdominal surgeries (OR, 2.618; 95%CI, 1.096–6.257; *p*=0.030). Index surgery parameters, clinical presentation and implicated pathogens were not significantly related with outcomes. Surgical treatment (OR, 0.380; 95%CI, 0.207–0.698; *p*=0.002), and especially total mesh removal (OR, 0.186; 95%CI, 0.860–0.404; *p*<10⁻³), were protective for treatment failure (Fig. 2). Of note, the evaluation of outcome predictors of the subset of patients primarily managed in our center did not allow to highlight specific risk factors compared to the whole population (data not shown).

In multivariate analysis, multiple previous abdominal surgeries (OR, 3.305; 95%CI, 1.297–8.425; *p*=0.012), complete mesh removal (OR, 0.145; 95%CI, 0.063–0.335; *p*<10⁻³) and antibiotic therapy (OR, 0.328; 95%CI, 0.136–0.787; *p*=0.013) were independent predictors of treatment outcome. Of note, outcome of patients referred to our center after a previous failure of infection management was similar.

## Conservative treatment group

The 131 patients who underwent conservative strategy are presented in Table 2. After a median follow-up of 76 (IQR, 25.9-201.1) weeks, treatment failure was observed in 54 (41.2%) patients, with a median time to failure of 36.5 (IQR, 16–183) days after the end of initial infection care. In this subgroup, factors associated with treatment failure were

multiple previous abdominal surgeries (OR, 3.846; 95%CI, 1.452–10.182; *p*=0.006), intraperitoneal mesh placement (OR, 2.723; 95%CI, 1.216–6.096; *p*=0.014), symptoms duration superior to one month (OR, 3.051; 95%CI, 1.175–7.919; *p*=0.021), and presence of a fistula (OR, 2.162; 95%CI, 0.965–6.556; *p*=0.036). Retromuscular mesh placement (OR, 0.428; 95%CI, 0.207–0.886; *p*=0.022) and antibiotic treatment (OR, 0.381; 95%CI, 0.137–1.060; *p*=0.064) emerged as protective factors against treatment failure (Fig. 3).

In multivariate analysis, multiple previous abdominal surgeries (OR, 4.335; 95%CI, 1.534–12.252; *p*=0.006), symptoms duration superior to one month (OR, 3.378; 95%CI, 1.089–10.476; *p*=0.035), and retromuscular mesh placement (OR, 0.444; 95%CI, 0.199–0.992; *p*=0.048) remained independent predictors for failure.

## Discussion

Our study represents one of the largest series examining characteristics, management strategies and outcome determinants of abdominal wall mesh infection [6, 8, 14]. However, some limitations must be acknowledged. First, the retrospective monocentric design of our study introduces inherent biases. Our tertiary care center tends to handle more complex cases with greater comorbidity and surgical complexity, potentially influencing treatment outcomes. Nevertheless, the diversity of practices across the four different visceral surgery wards within our center provides a comprehensive perspective. Notably, results from the subgroup analysis of patients not referred to our center (HCL group) were consistent with those of the total population, mitigating concerns regarding referral bias. A key limitation stems from the retrospective nature of patient recruitment, relying on keyword searches within medical records. This method may have overlooked minor wound events deemed insignificant by surgeons, resulting in underreporting of less severe infections such as inflammatory wound dehiscence. Consequently, our conclusions may not be generalized to cases presenting solely as wound dehiscence. Also, because of the retrospective design and the clinical definition of infection, it is difficult to state whether patients experiencing a complex healing course of the surgical wounds and who did not undergo subsequent surgical procedures had actually an infection involving the mesh. This doubt is in line with the observation that 24/146 (16.4%) patients were cured without local treatment only (i.e., wound care), arguing that they might have experienced a superficial surgical site infection or a wound hazard, but no deep infection. However, we decided to keep them in our analysis because they were considered as suspect of mesh infection by the
<figure><img src="image_6.png" /><figcaption>**Fig. 2** Kaplan-Meier survival curve for probability of survival without treatment failure in all patients with mesh infection after abdominal wall reconstruction, according to the main determinants of outcome</figcaption></figure>

treating team. Future works using a prospective design and standardized approach of wound management after abdominal wall repair could address this question. Nonetheless, our study offers valuable insights into the management and predictive factors for treatment success in more challenging presentations, such as abscesses and fistulas.

Microbiological analysis provided precise data, mostly consistent with the literature although the rate of *S. aureus* infections (36.1%) appeared lower than usually described (46–66%) [8, 14–16], but higher than in a recent French

cohort from another tertiary care center (23%) [17]. Our findings regarding microbial distribution according to infection depth revealed a gradient in bacterial types, reflecting distinct pathophysiological mechanisms between deep infections where gut commensal bacteria are prevailing, and superficial infections where skin commensal bacteria are predominant. Regarding empiric antibiotic treatment, combinations of amoxicillin plus clavulanate, or cefotaxime plus metronidazole, represent good options as they offer coverage regarding most strains of *S. aureus*, *Enterobacteriaceae*,
<table><caption>**Table 2** Description of the conservative treatment subgroup, comparison of patients without or with treatment failure, and determinants of treatment failure (univariate analysis)</caption><thead><tr><th rowspan="2"></th><th rowspan="2">Conservative treatment</th><th colspan="3">Descriptive analysis</th><th colspan="2">Univariate analysis</th></tr><tr><th>Failure</th><th>Success</th><th>p-value</th><th>OR (95% CI)</th><th>p-value</th></tr></thead><tbody><tr><td><strong>n</strong></td><td>131</td><td>54</td><td>77</td><td></td><td></td><td></td></tr><tr><td><strong>Demographics and comorbidities</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Gender (male)</td><td>74/131 (56.5%)</td><td>32/54 (59.3%)</td><td>42/77 (54.5%)</td><td>0.592</td><td>1.212 (0.599-2.451)</td><td>0.592</td></tr><tr><td>Age (years)</td><td>62 (55-69)</td><td>61.5 (55.3-69.8)</td><td>62 (54.5-69)</td><td>0.924</td><td>1.006 (0.976-1.036)</td><td>0.681</td></tr><tr><td>BMI (kg/m²)</td><td>29.7 (26.9-33.2)</td><td>29.1 (26.8-32.6)</td><td>30.1 (26-33.6)</td><td>0.680</td><td>0.993 (0.937-1.052)</td><td>0.825</td></tr><tr><td>ASA score</td><td>2 (2-3)</td><td>2 (2-3)</td><td>2 (2-3)</td><td>0.825</td><td>0.965 (0.547-1.704)</td><td>0.904</td></tr><tr><td>Modified Charlson's Comorbidity index</td><td>3 (2-4.5)</td><td>3 (2-4)</td><td>3 (2-5)</td><td>0.945</td><td>1.003 (0.868-1.157)</td><td>0.966</td></tr><tr><td>Active smoking</td><td>25/131 (19.1%)</td><td>11/54 (20.4%)</td><td>14/77 (18.2%)</td><td>0.754</td><td>1.151 (0.477-2.774)</td><td>0.753</td></tr><tr><td>Previous abdominal surgery</td><td>126/131 (96.2%)</td><td>51/54 (94.4%)</td><td>75/77 (97.4%)</td><td>0.403</td><td>0.453 (0.073-2.809)</td><td>0.395</td></tr><tr><td>&gt;1 previous abdominal surgeries</td><td>100/131 (76.3%)</td><td>48/54 (88.9%)</td><td>52/77 (67.5%)</td><td>0.005</td><td>3.846 (1.452-10.182)</td><td>0.006</td></tr><tr><td><strong>Index surgery</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Operative indication</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Primary hernia</td><td>23/129 (17.8%)</td><td>11/53 (20.8%)</td><td>12/76 (15.8%)</td><td>0.469</td><td>1.396 (0.564-3.456)</td><td>0.469</td></tr><tr><td>Incisional hernia</td><td>102/129 (79.1%)</td><td>39/53 (73.6%)</td><td>63/76 (82.9%)</td><td>0.201</td><td>0.574 (0.244-1.350)</td><td>0.203</td></tr><tr><td>Acute complication</td><td>6/129 (4.7%)</td><td>3/53 (5.7%)</td><td>3/76 (3.9%)</td><td>0.689</td><td>1.459 (0.283-7.528)</td><td>0.651</td></tr><tr><td>Post-surgical parietal closure</td><td>4/129 (3.1%)</td><td>3/53 (5.7%)</td><td>1/76 (1.3%)</td><td>0.305</td><td>4.499 (0.455-44.494)</td><td>0.198</td></tr><tr><td>Mesh characteristics</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Size (cm²)</td><td>500 (288-900)</td><td>500 (300-900)</td><td>450 (0-900)</td><td>0.301</td><td>1.000 (0.999-1.001)</td><td>0.178</td></tr><tr><td>Synthetic</td><td>82/115 (71.3%)</td><td>32/49 (65.3%)</td><td>50/66 (75.8%)</td><td>0.220</td><td>0.602 (0.266-1.359)</td><td>0.222</td></tr><tr><td>Biosynthetic</td><td>32/115 (27.8%)</td><td>17/49 (34.7%)</td><td>15/66 (22.7%)</td><td>0.157</td><td>1.806 (0.793-4.113)</td><td>0.159</td></tr><tr><td>Biological</td><td>1/115 (0.9%)</td><td>0/49 (0%)</td><td>1/66 (1.5%)</td><td>1.000</td><td></td><td></td></tr><tr><td>Absorbable</td><td>29/116 (25%)</td><td>14/49 (28.6%)</td><td>15/67 (22.4%)</td><td>0.447</td><td>1.386 (0.595-3.228)</td><td>0.448</td></tr><tr><td>Semi-absorbable</td><td>35/116 (30.2%)</td><td>11/49 (22.4%)</td><td>24/67 (35.8%)</td><td>0.121</td><td>0.518 (0.224-1.197)</td><td>0.123</td></tr><tr><td>Non-absorbable</td><td>52/116 (44.8%)</td><td>24/49 (49.0%)</td><td>28/67 (41.8%)</td><td>0.442</td><td>1.337 (0.637-2.805)</td><td>0.442</td></tr><tr><td>Mesh location</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Subcutaneous</td><td>25/127 (19.7%)</td><td>11/52 (21.2%)</td><td>14/75 (18.7%)</td><td>0.729</td><td>1.168 (0.483-2.827)</td><td>0.729</td></tr><tr><td>Retromuscular</td><td>62/127 (48.8%)</td><td>19/52 (36.5%)</td><td>43/75 (57.3%)</td><td>0.021</td><td>0.428 (0.207-0.886)</td><td>0.022</td></tr><tr><td>Preperitoneal</td><td>8/127 (6.3%)</td><td>4/52 (7.7%)</td><td>4/75 (5.3%)</td><td>0.715</td><td>1.479 (0.352-6.202)</td><td>0.592</td></tr><tr><td>Intraperitoneal</td><td>34/127 (26.8%)</td><td>20/52 (38.5%)</td><td>14/75 (18.7%)</td><td>0.013</td><td>2.723 (1.216-6.096)</td><td>0.014</td></tr><tr><td>Altemeier class 1</td><td>110/128 (85.9%)</td><td>44/52 (84.6%)</td><td>66/76 (86.8%)</td><td>0.722</td><td>0.833 (0.305-2.276)</td><td>0.722</td></tr><tr><td><strong>Infection presentation</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Time from surgery to onset of symptoms (days)</td><td>14 (8-26)</td><td>13 (7-50)</td><td>14 (8-23.3)</td><td>0.801</td><td>1.000 (0.999-1.000)</td><td>0.533</td></tr><tr><td>Highest CRP level (mg/L)</td><td>130 (60-205)</td><td>142 (60-250)</td><td>124.5 (0-180.8)</td><td>0.234</td><td>1.002 (0.998-1.005)</td><td>0.213</td></tr><tr><td>Infection type</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Inflammatory wound dehiscence</td><td>9/131 (6.9%)</td><td>0/54 (0%)</td><td>9/77 (11.7%)</td><td>0.009</td><td>NC</td><td>NC</td></tr><tr><td>Abscess</td><td>120/131 (91.6%)</td><td>53/54 (98.1%)</td><td>67/77 (87.0%)</td><td>0.026</td><td>7.910 (0.981-63.761)</td><td>0.052</td></tr><tr><td>Abdominal wall abscess</td><td>114/131 (87.0%)</td><td>49/54 (90.7%)</td><td>65/77 (84.4%)</td><td>0.289</td><td>1.809 (0.597-5.474)</td><td>0.293</td></tr><tr><td>Deep abscess</td><td>13/131 (9.9%)</td><td>7/54 (13.0%)</td><td>6/77 (7.8%)</td><td>0.330</td><td>1.762 (0.557-5.571)</td><td>0.334</td></tr><tr><td>Sinus tract</td><td>73/131 (55.7%)</td><td>36/54 (66.7%)</td><td>37/77 (48.1%)</td><td>0.035</td><td>2.162 (1.051-4.446)</td><td>0.036</td></tr><tr><td>Enterocutaneous sinus tract</td><td>6/131 (4.6%)</td><td>4/54 (7.4%)</td><td>2/77 (2.6%)</td><td>0.229</td><td>2.999 (0.529-17.001)</td><td>0.214</td></tr><tr><td>Early post-operative peritonitis</td><td>0/131 (0%)</td><td>0/54 (0%)</td><td>0/77 (0%)</td><td>NC</td><td>NC</td><td>NC</td></tr><tr><td><strong>Microbiology results</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Sterile</td><td>94/131 (71.8%)</td><td>43/54 (79.6%)</td><td>51/77 (66.2%)</td><td>0.094</td><td>1.992 (0.883-4.495)</td><td>0.096</td></tr><tr><td>Polymicrobial</td><td>6/94 (6.4%)</td><td>3/43 (7.0%)</td><td>3/51 (5.9%)</td><td>1.000</td><td>1.199 (0.229-6.275)</td><td>0.828</td></tr><tr><td><em>S. aureus</em></td><td>47/94 (50.0%)</td><td>24/43 (55.8%)</td><td>23/51 (45.1%)</td><td>0.301</td><td>1.537 (0.679-3.478)</td><td>0.301</td></tr><tr><td>CoNS</td><td>36/94 (38.3%)</td><td>14/43 (32.6%)</td><td>22/51 (43.1%)</td><td>0.293</td><td>0.636 (0.273-1.481)</td><td>0.294</td></tr><tr><td></td><td>6/94 (6.4%)</td><td>3/43 (7.0%)</td><td>3/51 (5.9%)</td><td>1.000</td><td>1.199 (0.229-6.275)</td><td>0.828</td></tr></tbody></table>
<table><caption>**Table 2 (continued)**</caption><thead><tr><th rowspan="2"></th><th rowspan="2">Conservative treatment</th><th colspan="3">Descriptive analysis</th><th colspan="2">Univariate analysis</th></tr><tr><th>Failure</th><th>Success</th><th>p-value</th><th>OR (95% CI)</th><th>p-value</th></tr></thead><tbody><tr><td><em>Streptococcus</em> spp.</td><td>8/94 (8.5%)</td><td>4/43 (9.3%)</td><td>4/51 (7.8%)</td><td>1.000</td><td>1.205 (0.282–5.134)</td><td>0.800</td></tr><tr><td><em>Enterococcus</em> spp.</td><td>16/94 (17.0%)</td><td>6/43 (14.0%)</td><td>10/51 (19.6%)</td><td>0.467</td><td>0.664 (0.220–2.008)</td><td>0.469</td></tr><tr><td><em>Corynebacterium</em> spp.</td><td>3/94 (3.2%)</td><td>2/43 (4.7%)</td><td>1/51 (2.0%)</td><td>0.591</td><td>2.439 (0.213–27.863)</td><td>0.473</td></tr><tr><td><em>Cutibacterium</em> spp.</td><td>2/94 (2.1%)</td><td>2/43 (4.7%)</td><td>0/51 (0%)</td><td>0.207</td><td>NC</td><td>NC</td></tr><tr><td>Enterobacteriaceae</td><td>29/94 (30.9%)</td><td>14/43 (32.6%)</td><td>15/51 (29.4%)</td><td>0.742</td><td>1.158 (0.481–2.785)</td><td>0.742</td></tr><tr><td><em>Pseudomonas</em> spp.</td><td>5/94 (5.3%)</td><td>2/43 (4.7%)</td><td>3/51 (5.9%)</td><td>1.000</td><td>0.780 (0.124–4.900)</td><td>0.791</td></tr><tr><td>Anaerobes</td><td>22/94 (23.4%)</td><td>11/43 (25.6%)</td><td>11/51 (21.6%)</td><td>0.647</td><td>1.249 (0.480–3.252)</td><td>0.647</td></tr><tr><td><em>Actinomyces</em> spp.</td><td>4/94 (4.3%)</td><td>2/43 (4.7%)</td><td>2/51 (3.9%)</td><td>1.000</td><td>1.195 (0.161–8.860)</td><td>0.861</td></tr><tr><td>Fungi</td><td>3/94 (3.2%)</td><td>3/43 (7.0%)</td><td>0/51 (0%)</td><td>0.092</td><td>NC</td><td>NC</td></tr><tr><td><strong>Infection management</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Local treatment only</td><td>45/131 (34.4%)</td><td>22/54 (40.7%)</td><td>23/77 (29.9%)</td><td>0.197</td><td>1.614 (0.777–3.349)</td><td>0.198</td></tr><tr><td>Radiological drainage</td><td>18/131 (13.7%)</td><td>6/54 (11.1%)</td><td>12/77 (15.6%)</td><td>0.608</td><td>0.677 (0.237–1.932)</td><td>0.466</td></tr><tr><td>Surgery</td><td>41/131 (31.3%)</td><td>17/54 (31.5%)</td><td>24/77 (31.2%)</td><td>0.970</td><td>1.014 (0.479–2.147)</td><td>0.969</td></tr><tr><td>Partial mesh removal</td><td>11/131 (8.4%)</td><td>3/54 (5.6%)</td><td>8/77 (10.4%)</td><td>0.524</td><td>0.507 (0.128–2.007)</td><td>0.333</td></tr><tr><td>Single-stage<br>abdominal wall<br>reconstruction</td><td>0/51 (0%)</td><td>0/20 (0%)</td><td>0/31 (0%)</td><td>NC</td><td>NC</td><td>NC</td></tr><tr><td>Negative pressure therapy alone</td><td>4/131 (3.1%)</td><td>1/54 (1.9%)</td><td>3/77 (3.9%)</td><td>0.643</td><td>0.465 (0.047–4.598)</td><td>0.512</td></tr><tr><td>Post-operative negative pressure<br>therapy</td><td>29/131 (22.1%)</td><td>8/54 (14.8%)</td><td>21/77 (27.3%)</td><td>0.134</td><td>0.463 (0.188–1.143)</td><td>0.095</td></tr><tr><td><strong>Antibiotic treatment</strong></td><td>112/130 (86.2%)</td><td>42/53 (79.2%)</td><td>70/77 (90.9%)</td><td>0.058</td><td>0.381 (0.137–1.060)</td><td>0.064</td></tr><tr><td>Adapted empiric antibiotic<br>therapy</td><td>58/75 (77.3%)</td><td>22/29 (75.9%)</td><td>36/46 (78.3%)</td><td>0.809</td><td>0.873 (0.290–2.627)</td><td>0.809</td></tr><tr><td>Secondary adaptation</td><td>41/68 (60.3%)</td><td>13/25 (52.0%)</td><td>28/43 (65.1%)</td><td>0.286</td><td>0.580 (0.212–1.584)</td><td>0.288</td></tr><tr><td>Treatment duration (days)</td><td>14 (9–21)</td><td>11 (7–19)</td><td>14 (0–21)</td><td>0.086</td><td>0.996 (0.972–1.021)</td><td>0.782</td></tr><tr><td><strong>Outcomes</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Failure</td><td>54/131 (41.2%)</td><td>54/54 (100%)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Time to failure (days)</td><td>36.5 (16–183)</td><td>36.5 (16–183)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Hernia recurrence</td><td>32/131 (24.4%)</td><td>16/54 (29.6%)</td><td>16/77 (20.8%)</td><td>0.246</td><td>1.605 (0.719–3.582)</td><td>0.247</td></tr><tr><td>Subsequent surgery for infec-<br>tious purpose</td><td>42/131 (32.1%)</td><td>42/54 (77.8%)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Follow-up time (weeks)</td><td>76 (25.9–201.1)</td><td>73.2 (32.3–180.3)</td><td>77.9 (26–203.3)</td><td>0.861</td><td>1.000 (0.997–1.002)</td><td>0.846</td></tr></tbody></table>

95%CI, 95% confidence interval; ASA, American Society of Anesthesiologists, BMI, Body mass index; CoNS, Coagulase negative staphylococci; CRP, C-reactive protein; NA, Not applicable; NC, Not calculable; OR, Odd ratio

and streptococci. Empiric use of broad-spectrum antimicrobials is not warranted in our setting. While differences in bacterial distribution were observed, it seems appropriate to use the same antibiotics for these different infection locations and types. Finally, pre-surgical pneumoperitoneum was associated with higher occurrence of MDR bacterial infection. As this technic is usually proposed for the most complicated abdominal wall repairs, pre-surgical invasive procedure and prolonged hospital stay in more comorbid patients might facilitate surgical site colonization and infection by nosocomial flora.

Management of hernia mesh infection is not codified and remains challenging, as evidenced by the 30.1% treatment failure rate in our study. This rate is congruent with 32.5% (39/120) patients presenting an infection after treatment in the cohort of Zou et al. [8]. Our study confirms the crucial impact of complete mesh removal for infection resolution,

while partial mesh removal showed no significant impact on outcomes. Antibiotic therapy appears to be the second cornerstone of hernia mesh infection management.

In cases where complete surgical removal poses significant risks or challenges, conservative treatment may be considered. However, success rate appears to be lower, particularly in patients with chronic infection (symptom duration > 1 month), non-retromuscular mesh placement, and a history of multiple surgeries. These factors exerted a cumulative effect on treatment success, underscoring the importance of careful patient selection and stratification before adopting a conservative strategy.

While previous studies have highlighted certain predictors of treatment outcomes in conservative strategies, such as the early onset of infection [18], this finding regarding symptom duration as a prognostic factor is original. The association between symptom duration and treatment failure aligns with
<figure><img src="image_7.png" /><figcaption>**Fig. 3** Kaplan-Meier survival curve for probability of survival without treatment failure after conservative management of patients with mesh infection after abdominal wall reconstruction, according to the main determinants of outcome</figcaption></figure>

biofilm-related complications observed in orthopedic prosthetic material infections and the existing proof regarding biofilm development on hernia mesh [19, 20].

In conclusion, hernia mesh infection management remains challenging with high risk of treatment failure. The strategy of combining complete mesh removal with antibiotic therapy is the most promising approach for achieving successful outcomes. When conservative treatment is being considered, the physician must evaluate symptom duration and mesh placement, as the association of symptom duration > 1 month with

non retromuscular located mesh in a multi operated abdomen is associated with > 75% failure risk.

**Authors' contribution** All authors participated in patients’ management and inclusion, and in writing and editing the manuscript, and have read and approved the final version of the manuscript. VF collected data. VF, CTF and FV performed the statistical analysis. FV conceived and supervised the study.

**Funding** Open access funding provided by Hospices Civils de Lyon. The study was performed as part of our routine work and did not receive any financial support.
## Declarations

**Ethical approval** This study received the approval of the Scientific and Ethical Committee of Hospices Civils de Lyon (reference n°23-457). All patients received written information about the study. No written informed consent was required for inclusion.

**Competing interest** The authors have no competing interests to declare.

**Open Access** This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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## Authors and Affiliations

Victor Franchi¹ · Claire Triffault-Fillit¹ · Sophie Jarraud²,³ · Jean-Yves Mabrut⁴,⁵ · Clément Javaux¹ ·

Olivier Monneuse⁶ · Anne Conrad¹,³ · Tristan Ferry¹,⁷ · Maud Robert⁸,⁹ · Florence Ader¹,³ · Guillaume Passot¹⁰,¹¹ ·

Florent Valour¹,³

<figure><img src="image_8.png" /></figure>

Claire Triffault-Fillit
claire.triffault-fillit@chu-lyon.fr

Victor Franchi
victor.franchi@chu-lyon.fr

¹ Department of Infectious Diseases, Hospices Civils de Lyon, Service des Maladies Infectieuses et Tropicales, 103 Grande Rue de la Croix-Rousse, Lyon 69004, France

² Laboratory of Bacteriology, Institut des Agents Infectieux, Hospices Civils de Lyon, Lyon, France

³ International Center for Research in Infectiology (CIRI), Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France

⁴ Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France

⁵ Institute of Hepatology Lyon (IHL), INSERM U1052, Lyon, France

⁶ Emergency and General Surgery Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France

⁷ UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Univ Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France

⁸ Department of Digestive and Bariatric Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France

⁹ CarMeN Laboratory, INSERM U1060, Lyon 1 University, Lyon, France

¹⁰ Department of General Surgery and Surgical Oncology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre-Bénite, France

¹¹ CICLY, Lyon 1 University, Lyon, France