Abstract
Background. 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. We undertook
a multinational study to determine whether a detailed infection prevention protocol using a specific pre-,
intra- and postoperative strategy including topical application of antibiotics (Group B; infection prevention
protocol) would further reduce the incidence of sternal infections compared to established standard
treatment (Group A; standard group).
Patients and methods. 8168 consecutive patients undergoing cardiac surgery from February 2006 to June
2015 at four institutions in three countries were included: 4615 patients in the infection prevention protocol
Group B (prospectively included) and 3553 patients in the standard Group A (retrospectively
studied). Patients were matched using propensity score adjusted analysis. In both groups, a second-generation
cephalosporin was given prior to surgery and repeated if 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 sternal 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 χ2 analyses were used to test statistical significance.
Additionally, logistic regression analyses were applied separated into Group A and B in order to examine
the potential impact of established risk factors for sternal wound infections.
Results. Preoperative patient characteristics and risk factors such as diabetes, gender or age did not differ
between groups while others significantly differed though with merely very small or small differences.
There was a significant difference of major outcome parameters in favour of the infection prevention protocol
(Group B) versus the standard treatment (Group A): incidence of superficial wound infection:
0.4% vs. 2.9% (p<0.001); deep sternal wound infection: 0.6% vs. 2.2% (p<0.001); number of infection
related reoperations: 81 vs. 241 (p<0.001) and number of muscle flap plasty in patients with sternal
destruction: 0.2% vs. 1.1% (p<0.001). There was a significant increase of duration of stay on ICU related
to Group B patients in one center but not in the total sample. Most important, the use of the infection
prevention protocol was associated with a significant reduction in the incidence of sternal wound
infections (odds ratio = 7.004) in all countries and revealed that mammary artery harvesting and body
mass index were not significant risk factors anymore. Furthermore, the use of vancomycin was not associated
with an increased incidence of postoperative renal insufficiency. No patient developed vancomycin
resistant infection. The occurrence of multi-resistant bacteria was not observed. For one country, significant
cost reduction was proven.
Conclusion. The presented infection prevention protocol markedly reduces postoperative sternal wound
infections, reduces infection-related reoperations, muscle flap plasty surgeries, limits the use of postoperative
antibiotics and is thus potentially life-saving. This protocol is highly cost-effective without any
disadvantages such as occurrence of multi-resistant nosocomial infections. Overall this strategy for prevention
of postoperative wound infections has a major impact on the safety of patients undergoing cardiac
surgery via median sternotomy.
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About the authors
- Paul Robert Vogt, Prof., Dr. med., Dr. h.c., Professor of Cardiovascular Surgery, Honorary Doctor of St. Petersburg Pavlov State Medical University (Russia);
-
Alexander Darrall, Statistician;
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Pascal André Berdat, PD Dr. med., Cardiovascular Surgeon;
-
Giuseppe Santoro, Consultant in Hygiene;
-
Daniel Schmidlin, Anesthesiologist, Head of the Department of Anesthesiology and Intensive Care;
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Gennadiy G. Khubulava, Doctor Med. Sc., Academician of Russain Academy of Sciences,
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Head of the Department of Cardiac Surgery; orcid.org/0000-0002-9242-9941;
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Sergey P. Marchenko, Doctor Med. Sc., Professor, Cardiac Surgeon; orcid.org/0000-0003-4512-6101;
-
Martin Andreas, PhD, Assistant Professor for Cardiac Surgery Chair;
-
Günther Laufer, Professor, Cardiac Surgeon;
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Ernst Tabori, Dr. med., Consultant in Hospital Epidemiology and Infection Control, Consultant in Gynecology and Obstetrics, Infectiologist;
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Sebastian Schulz-Stübner, PD Dr. med., Consultant in Hospital Epidemiology and Infection Control, Consultant in Anesthesiology Critical Care, Emergency and Pain Medicine, Psychotherapy Quality Management;
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Aleksey B. Naumov, Cand. Med. Sc., Assistant Professor, Anesthesiologist; orcid.org/0000-0003-0323-0162;
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Vitaliy V. Suvorov, Cand. Med. Sc., Cardiac Surgeon
