Deep sternal wound infection after cardiac surgery

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Abstract

Background

Deep sternal wound infection (DSWI) is a serious postoperative complication of cardiac surgery. In this study we investigated the incidence of DSWI and effect of re-exploration for bleeding on DSWI mortality.

Methods

We reviewed 73,700 cases registered in the Japan Adult Cardiovascular Surgery Database (JACVSD) during the period from 2004 to 2009 and divided them into five groups: 26,597 of isolated coronary artery bypass graft (CABG) cases, 23,136 valvular surgery cases, 17,441 thoracic aortic surgery cases, 4,726 valvular surgery plus CABG cases, and 1,800 thoracic aortic surgery plus CABG cases. We calculated the overall incidence of postoperative DSWI, incidence of postoperative DSWI according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI cases according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI according to whether re-exploration for bleeding, and the intervals between the operation and deaths according to whether re-exploration for bleeding were investigated. Operative mortality is defined as in-hospital or 30-day mortality. Risk factors for DSWI were also examined.

Results

The overall incidence of postoperative DSWI was 1.8%. The incidence of postoperative DSWI was 1.8% after isolated CABG, 1.3% after valve surgery, 2.8% after valve surgery plus CABG, 1.9% after thoracic aortic surgery, and 3.4% after thoracic aortic surgery plus CABG. The 30-day and operative mortality in patients with DSWI was higher after more complicated operative procedures. The incidence of re-exploration for bleeding in DSWI cases was 11.1%. The overall 30-day/operative mortality after DSWI with re-exploration for bleeding was 23.0%/48.0%, and it was significantly higher than in the absence of re-exploration for bleeding (8.1%/22.0%). The difference between the intervals between the operation and death according to whether re-exploration for bleeding had been performed was not significant. Age and cardiogenic shock were significant risk factors related to re-exploration for bleeding, and diabetes control was a significant risk factor related to DSWI for all surgical groups. Previous CABG was a significant risk factor related to both re-exploration for bleeding and DSWI for all surgical groups.

Conclusions

The incidence of DSWI after cardiac surgery according to the data entered in the JACVSD registry during the period from 2004 to 2009 was 1.8%, and more complicated procedures were followed by higher incidence and mortality. When re-exploration for bleeding was performed, mortality was significantly higher than when it was not performed. Prevention of DSWI and establishment of an effective appropriate treatment for DSWI may improve the outcome of cardiac surgery.

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Most cited references 14

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Postoperative mediastinitis in cardiac surgery - microbiology and pathogenesis.

B Gårdlund, C Bitkover, J Vaage (2002)

During 1992-2000, postoperative mediastinitis developed after 126 (1.32%) of 9557 consecutive cardiac surgery procedures. The study was done to describe the variation in clinical characteristics and microbiological etiology in mediastinitis. The records of 126 cases of postoperative mediastinitis were reviewed. The median time from operation to the development of mediastinitis was 7 days. Sternal dehiscence was seen in 86 patients (68%). Coagulase negative staphylococci (CNS) were isolated in 46% of the cases with a verified microbiological etiology, Staphylococcus aureus in 26% and gram-negative bacteria in 18%. CNS were more frequently isolated in patients with sternal dehiscence (44/80, 55%) than in patients with stable sternum (10/38, 26%) (P=0.003). However, S. aureus was more frequent in patients with stable sternum (18/38, 47%) than in patients with sternal dehiscence (13/80, 16%) (P<0.001). High body mass index was associated with coagulase negative staphylococci (P<0.001) and with sternal dehiscence (P=0.008). Chronic obstructive pulmonary disease was also associated with sternal dehiscence (P<0.001) and with coagulase negative staphylococci (P=0.04). Patients who had been reoperated before onset of mediastinitis tended to have an increased risk for a gram-negative etiology (32 vs. 15% in patients not reoperated, P=0.06). The overall 90-day all cause mortality in patients with mediastinitis was 19%. High age, need for reoperation before mediastinitis, and a long primary operation time was associated with increased mortality (P=0.02, P=0.007 and P=0.001, respectively). No specific bacterial etiology was associated with increased mortality nor was the presence of bacteriemia. Three different types of postoperative mediastinitis can be distinguished: (1) mediastinitis associated with obesity, chronic obstructive pulmonary disease, and sternal dehiscence, typically caused by coagulase negative staphylococci; (2) mediastinitis following peroperative contamination of the mediastinal space, often caused by S. aureus, and (3) mediastinitis mainly caused by spread from concomitant infections in other sites during the postoperative period, often caused by gram negative rods. The proposed classification of mediastinitis into three groups with different pathogenic mechanisms may be useful in understanding which prophylactic counter measures have the potentials to be effective in a given situation.

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J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care.

F D Loop, B W Lytle, D M Cosgrove … (1990)

Of 6,504 consecutive patients who underwent isolated coronary bypass grafting in 1985 to 1987, 72 (1.1%) patients experienced sternal wound complications. Ten patients (14%) with wound complications died of multi-system failure. Only the patients with negative cultures fared well; of the bacterial culture categories, polymicrobial infection carried the worst prognosis. Effects of recurring infection were seen throughout the first year. Patients, grouped according to conduits received, experienced these wound complication rates: vein grafts only, 11/1,085 (1.0%); one internal thoracic artery, 38/4,073 (0.9%); and bilateral internal thoracic artery grafts, 23/1,346 (1.7%). There were no significant differences in wound complication rates between primary and reoperation patients or among conduit groups. By logistic regression analysis, the relative risk for patients with diabetes and bilateral internal thoracic artery grafting was 5.00 (95% confidence interval, 2.4 to 10.5). Operation time as a continuous variable increased the relative risk of wound complication 1.47 times per hour (1.3 to 1.7); obesity, 2.90 times (1.8 to 4.8); and blood units as continuous variable, 1.05 times per unit (1.01 to 1.10). Bilateral internal thoracic artery grafting in nondiabetic patients carried no greater risk of wound complication than that in patients with vein grafts only or with one internal thoracic artery graft.

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Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival.

D Sexton, Kyle K. Kesler, N Archibald … (1995)

Mediastinitis is a severe complication of coronary artery bypass graft surgery (CABG). The purpose of the present study was to determine preoperative and intraoperative variables that predict mediastinitis and to determine the impact of this complication on long-term survival. Data on 20 preoperative and intraoperative variables were collected prospectively on 6459 consecutive patients who underwent CABG between January 1987 and January 1994. Eighty-three patients (1.3%) developed mediastinitis postoperatively, and a total of 24 patients (29%) died. Multivariate analysis identified 4 of the 20 variables as highly significant independent predictors for the development of mediastinitis: obesity (P = .0002), New York Heart Association congestive heart failure class (P = .002), previous heart surgery (P = .008), and duration of cardiopulmonary bypass (P = .05). A comprehensive review of the literature identified 13 other studies that evaluated 48 factors as predictors of mediastinitis; these data were critically analyzed and compared with the results from this series. In this series, postoperative interval mortality during the first 90 days after surgery for the patients with mediastinitis was 11.8% compared with 5.5% for the patients without mediastinitis. Interval mortality between 1 and 2 years after surgery remained high for the mediastinitis group (8.1%) relative to the nonmediastinitis group (2.3%). These differences were not eliminated by adjusting for important variables that influenced late survival in this population. The present study and a review of the literature suggest that obesity and duration of surgery are the most important predictors of mediastinitis. Furthermore, although the early increase in mortality has been well described, the present study documents for the first time that mediastinitis has a significant negative influence on long-term survival independent of the patient's preoperative condition.

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Author and article information

Journal

Journal ID (nlm-ta): J Cardiothorac Surg

Journal ID (iso-abbrev): J Cardiothorac Surg

Title: Journal of Cardiothoracic Surgery

Publisher: BioMed Central

ISSN (Electronic): 1749-8090

Publication date Collection: 2013

Publication date (Electronic): 20 May 2013

Volume: 8

Page: 132

Affiliations

[1 ]Department of Cardiovascular Surgery, Kyorin University, 6-20-2, Shinkawa, Mitaka, Tokyo, Japan

[2 ]Japan Cardiovascular Surgery Database Organization, 7-3-1, Hongo, Bunkyo, Tokyo, Japan

[3 ]Department of Cardiac Surgery, University of Tokyo, 7-3-1, Hongo, Bunkyo, Tokyo, Japan

[4 ]Department of Plastic Surgery, Kyorin University, 6-20-2, Shinkawa, Mitaka, Tokyo, Japan

[5 ]Department of Plastic Surgery, Teikyo University, 2-11-1, Kaga, Itabashi, Tokyo, Japan

Article

Publisher ID: 1749-8090-8-132

DOI: 10.1186/1749-8090-8-132

PMC ID: 3663691

PubMed ID: 23688324

SO-VID: 7edc1a52-6965-48ce-889d-83f1a249e4dc

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Deep sternal wound infection after cardiac surgery

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Abstract

Background

Methods

Results

Conclusions

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SICOT-J (Orthopedic surgery and traumatology)

Most cited references 14

Postoperative mediastinitis in cardiac surgery - microbiology and pathogenesis.

J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care.

Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival.

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