Surgical Wound Infection

ABC

Original Article

Clinical and Microbiology Predictors for Therapeutic Failure in Sternal Surgical Site Infections – A Retrospective Cohort Study

Jaqueline Fabiano Palazzo et al. Diego Augusto Medeiros Santos Bruno Adler Maccagnan Pinheiro Besen Caio Sambo … Gabriel Fialkovitz da Costa Leite Samuel Terra Gallafrio Danielle Menosi Gualandro Lani Paola Bonilla Cuello Marcus Vinicius Barbosa Santos Tania Mara Varejão Strabelli Pablo Maria Alberto Pomerantzeff Fabio Biscegli Jatene Rinaldo Siciliano

Abstract

Background

Although sternal surgical site infections (SSI) are an important complication after cardiac surgeries, predictors of treatment failure are poorly studied.

Objectives

The aim of this study is to assess the clinical and microbiology predictors of a sternal SSI therapeutic failure.

Methods

Patients who presented a sternal SSI were retrospectively analyzed. Data regarding demographic characteristics, clinical findings, initial laboratory and radiologic findings and treatment of index sternal SSI were evaluated. Primary outcome was treatment failure, comprising infection relapse (clinical sternal SSI after complete treatment) or infection persistence (outpatient antimicrobial treatment failure). The microbiology was assessed at the index infection and in the outcome. P-values < 0.05 were considered statistically significant.

Results

Among 489 included patients, mean age was 58 years, 265 (55%) were female, 185 (38%) had diabetes mellitus. The overall prevalence of therapeutic failure was 14% (67), occurring in a median of 174 days (±41) after index cardiac surgery. Most frequent etiologies were cocci Gram-positive and Klebsiella pneumoniae. None of laboratory or thoracic tomographic findings presented during the index sternal SSI was related to outcome. After multivariate analysis, Staphylococcus aureus, carbapenem-resistant Gram-negative bacilli (GNB), fungi, diabetes mellitus and presence of mediastinitis/osteomyelitis were positive predictors of therapeutic failure.

Conclusions

Emerging carbapenem-resistant GNB, fungi and S. aureus were etiologies associated with higher risk of therapeutic failure in sternal SSI. DM and deep sternal wound infections were also contributing factors. Its clinical implications and the exact role of multi-resistant microorganism itself are subject for more studies.

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ABC

Editorial

Risk Factors for Surgical Site Infection after Pediatric Cardiac Surgery

Rafael Quaresma Garrido et al. Cristiane da Cruz Lamas

Infections after pediatric cardiac surgery are important adverse events that can increase morbidity and mortality in these patients. Most studies describe the incidence of infection as between 0.5 and 8%, but some studies in low- to middle-income countries report rates of up to 48%.^– The main microorganisms involved are Staphylococcus aureus, coagulase-negative staphylococci, and occasionally hospital-acquired Gram negatives. In high-income countries, there is a predominance of skin-colonizing Gram-positives, while in low- to middle-income countries, there is an increase in the frequency of hospital-acquired Gram-negatives. ^–

There are divergences between the risk factors for infection in pediatric cardiac surgery, as there are few studies dedicated to this population. In regard to pre-operative conditions or those inherent to the patient, we have as risk factors being a younger child, especially those under 12 months of age, the presence of immunodeficiencies, prolonged periods of pre-operative hospitalization and previous use of antimicrobials (the latter two conditions because they alter the colonizing microbiota) and malnutrition. Pre and post operative risk factors are the inadequacy of antibiotic prophylaxis, breaches of aseptic technique, prolonged cardiopulmonary bypass time (>105 minutes) and aortic clamping time (>85 minutes), excessive bleeding in the first 24 hours, blood transfusion, early chest reexploration due to operative bleeding, occurrence of nosocomial infections (pneumonia and bloodstream infections mainly) and the presence of invasive devices such as drains and pacemaker wires.^–

[…]

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ABC

Original Article

Risk Factors for Surgical Site Infection in Patients Undergoing Pediatric Cardiac Surgery

Anna Christina de Lima Ribeiro et al. Rinaldo Focaccia Siciliano Antonio Augusto Lopes Tania Mara Varejão Strabelli

Abstract

Background

Surgical site infection is an important complication after pediatric cardiac surgery, associated with increased morbidity and mortality.

Objectives

We sought to identify risk factors for surgical site infection after pediatric cardiac surgeries.

Methods

A case-control study included patients aged between 1 year and 19 years and 11 months of age, submitted to cardiac surgery performed at a tertiary cardiac center from January 1 ^st , 2011, through December 31, 2018. Charts were reviewed for pre-, intra, and postoperative variables. We identified two randomly selected control patients with the same pathophysiological diagnosis and underwent surgery within thirty days of each index case. Univariate and multivariate logistic regression analyses were performed to identify risk factors. Statistical significance was defined as p<0.05.

Results

Sixty-six cases and 123 controls were included. Surgical site infection incidence ranged from 2% to 3.8%. The following risk factors were identified: Infant age (OR 3.19, 95% CI 1.26 to 8.66, p=0.014), presence of genetic syndrome (OR 6.20, CI 95% 1.70 to 21.65, p=0.004), categories 3 and 4 of RACHS-1 (OR 8.40, CI 95% 3.30 to 21.34, p<0.001), 48 h C-reactive protein level range was detected as a protective factor for this infection (OR 0.85, 95% CI 0.73 to 0.98, p=0.023).

Conclusions

The risk factors defined in this study could not be modified. Therefore, additional surveillance and new preventive strategies need to be implemented to reduce the incidence of surgical site infection. The increased CRP in the postoperative period was a protective factor that needs further understanding.

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ABC

Original Article

Surgical Site Infection Prevention Bundle in Cardiac Surgery

Lilian Silva de Andrade et al. Erci Maria Onzi Siliprandi Larissa Lemos Karsburg Francine Possebon Berlesi … Otávio Luiz da Fontoura Carvalho Darlan Sebastião da Rosa Rodrigo Pires dos Santos

Abstract

Background:

Surgical site infections (SSI) are among the most prevalent infections in healthcare institutions, attributing a risk of death which varies from 33% to 77% and a 2- to 11-fold increase in risk of death. Patients submitted to cardiac surgery are more susceptible to SSI, accounting for 3.5% to 21% of SSI. The mortality rate attributable to these causes is as high as 25%. Prevention of SSI in cardiac surgery is based on a bundle of preventive measures, which focus on modifiable risks.

Objective:

The objective of this study was to identify SSI risk factors in clean cardiac surgery.

Methods:

A retrospective cohort study analyzed 1,846 medical records from patients who underwent clean cardiac surgery. Fisher’s exact test was used for bivariate comparison, and Poisson regression was used for independent analysis of SSI risk, considering a significance level of p < 0.05.

Results:

The results of the study comprised a multivariate analysis. The variables that were associated with the diagnosis of SSI were: surgical risk index (OR: 2.575; CI: 1.224-5.416), obesity (OR: 2.068; CI: 1.457-2.936), diabetes mellitus (OR: 1,678; CI: 1.168-2.409), and blood glucose level (OR: 1.004; CI: 1.001-1.007).

Conclusions:

This study evidenced that complete adherence to the bundle was not associated with a reduction in the risk of surgical infections. Diabetes mellitus, obesity, and surgical risk index assessment were, however, identified to increase association and consequently risk of SSI in cardiac surgery.

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IJCS

Original Article

Factors Associated with Post-Sternotomy Mediastinitis. Case-Control Study

Débora Cristine Gomes Pinto et al. Antônio Fernandino de Castro Bahia Neto Flávia Lage Gonçalves Isabel Cristina Gomes … Eduardo Back Sternick Alessandra Maciel Almeida Nulma Souto Jentzsch

Abstract

Background:

Mediastinitis is a severe post-median sternotomy infection with poor prognosis, even with early diagnosis and treatment.

Objectives:

To evaluate the profile of patients submitted to sternotomy, identify the risk factors for the development of mediastinitis and evaluate the bacteriological diagnosis of patients with this infection.

Methods:

Case-control study carried out in a large hospital in Belo Horizonte (MG, Brazil) in patients submitted to median sternotomy, from January 2015 to January 2018. The sample consisted of 65 patients, of which 13 were cases and 52, controls (1:4). For the statistical analysis, Student’s t test, Mann-Whitney test and Fisher exact test were used, in addition to logistic regression, with a level of significance of 5%.

Results:

There was a predominance of males (63.1%), and the mean age was 58.8 ± 10.3 years. Evolution to death occurred in 9.2% of the patients and in 23.1% of those with mediastinitis. Myocardial revascularization was performed in 75.4% of the cases. Predominance of male gender, longer hospitalization time, post-surgical fever and death, and a greater number of risk factors were more frequent characteristics in patients who developed mediastinitis. The most common microorganism found in patients with mediastinal infection was Staphylococcus aureus (30.7%), in addition to a high occurrence of Gram-negative bacteria (46,2%).

Conclusion:

The results are in accordance with the literature. Efforts should be focused on the control of risk factors prior to the procedure, in addition to improving measures that can decrease or eliminate the onset of mediastinitis, aiming at infection prevention and control.

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