Significant reduction of sternal wound infection in cardiac surgical patients
The Bulletin of Bakoulev Center Cardiovascular Diseases
Значительное снижение частоты развития стернальной инфекции у кардиохирургических пациентов
Objective: Sternal wound infections continue to be a major source of morbidity and mortality after cardiac surgery being associated with markedly increased hospital costs. Prophylactic antibiotics and glycaemic control have decreased but not eradicated this life-threatening complication. This multinational study was undertaken to determine whether a detailed infection prevention protocol using specific pre-, intra-and postoperative measures including topical application of antibiotics (Group B;
... tibiotics (Group B; novel closure group) would further reduce the incidence of sternal infections compared to established standard treatment (Group A; standard group). Patients and Methods: 8,168 consecutive patients underwent cardiac surgery from February 2006 to June 2015: 4,615 patients in the novel closure Group B (prospectively included) and 3,553 patients in the standard Group A (retrospectively studied). Patients were matched using propensity score adjusted analysis. In both groups, a prophylactic second-generation cephalosporin was given prior to surgery and repeated once surgery exceeded six hours. Group A, but not Group B patients, received additional three doses of antibiotics after surgery. Patients were followed for one year to include external would infection presenting after discharge from the hospital. Data are presented as the means and standard deviations for continuing variables and as occurrences and percentages for categorical variables. Welch's t-tests and χ 2 analyses were used to test statistical significance. Additionally, logistic regression analyses were applied separated into Group A and B in order to examine potential differential effects of established risk factors for sternal wound infections. Results: The results are summarized in the Tables 1 to 4. Preoperative patient characteristics and risk factors such as diabetes, gender or age did not differ between groups while others significantly differed but with merely very small or small differences. There was a significant difference of major outcome factors in favour of the novel closure protocol (Group B) versus the standard treatment (Group A): incidence of superficial wound infection: 0.4% vs. 2.9%; deep sternal wound infection: 0.6% vs. 2.2%; number of infection related reoperations: 81 vs. 241 and number of muscle flap plasty in patients with sternal destruction: 0.2% vs. 1.1%. Admittedly, there was a significant increase of duration of stay on ICU related to Group B patients in Russia but not in the total sample. More important, use of the novel closure protocol revealed that mammary artery harvesting and body mass index were not significant risk factors anymore. Furthermore, the use of vancomycin was not associated with increased incidence of postoperative renal insufficiency. No patient developed vancomycin resistant infection. Occurrence of multi-resistant bacteria has not been observed. Conclusion: This infection prevention protocol as presented here markedly reduces postoperative sternal wound infections, saves lives, reduces infection-related reoperations, muscle flap plasty surgeries, limits the use of postoperative antibiotics and is highly cost-effective. The use of topical antibiotics did not provoke the occurrence of multi-resistant nosocomial infections. This concept markedly reduces the risk of postoperative wound infections, and, hence, represents a major step with regard to the safety for patients undergoing cardiac surgery through a median sternotomy.