Invited Commentary

Abstract

The burden of postoperative infection is felt broadly both in patient outcomes and in resource utilization. Over the past decade, the Nationwide Inpatient Sample and the National Surgical Quality Improvement Program have highlighted the full impact of these adverse events [1Rowell K.S. Turrentine F.E. Hutter M.M. Khuri S.F. Henderson W.G. Use of national surgical quality improvement program data as a catalyst for quality improvement.J Am Coll Surg. 2007; 204: 1293-1300Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 2de Lissovoy G. Fraeman K. Hutchins V. Murphy D. Song D. Vaughn B.B. Surgical site infection: incidence and impact on hospital utilization and treatment costs.Am J Infect Control. 2009; 37: 387-397Abstract Full Text Full Text PDF PubMed Scopus (796) Google Scholar]. Although researchers are increasingly turning to national administrative databases to acquire patient samples, these sources are frequently marred by inconsistent or incomplete clinical data. In this issue of The Annals, Robich and colleagues [3Robich M.P. Sabik J.F. Houghtaling P.L. et al.Prolonged effect of postoperative infectious complications on survival after cardiac surgery.Ann Thorac Surg. 2015; 99: 1591-1600Google Scholar] harness their impressive single-institution operative volume to shed light on the long-term clinical impact of postoperative infections after cardiac operations. Performing propensity-matched analysis on a clinically focused dataset, the authors show that patients who experience postoperative infections and are successfully treated retain an increased risk of death after discharge that gradually decreases over time. In particular, the risk-adjusted survival for patients with septicemia, pneumonia, or harvest site infection is inferior to that in propensity-matched, noninfected control patients. Although the authors report a negative survival impact for as long as 1 year after discharge, a large portion of this excess risk is observed within the first 3 months. Notably, noninfected control patients in the matched group also had relatively poor 1-year survival, suggesting that patients who experience infectious adverse events tend to be sicker at baseline. The authors then identified numerous risk factors associated with postoperative infections, including age, immunosuppression, operative duration, diabetes, prolonged ventilation, and others. These results reinforce intuitive associations with valuable, objective evidence. The authors rightly acknowledged that, as with nearly all propensity-matching studies, there may be unaccounted confounders and imperfect matching. Nevertheless, this study and others carry important implications for both perioperative management and follow-up after discharge. The identification of a high-risk patient may suggest roles for antibiotic prophylaxis prolongation up to 48 hours [4Lador A. Nasir H. Mansur N. et al.Antibiotic prophylaxis in cardiac surgery: systematic review and meta-analysis.J Antimicrob Chemother. 2012; 67: 541-550Crossref PubMed Scopus (83) Google Scholar], fast-track extubation, early mobilization and urinary catheter removal, or surgical techniques aimed at preserving sternal blood supply [5Deo S.V. Shah I.K. Dunlay S.M. et al.Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients.Ann Thorac Surg. 2013; 95: 862-869Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar]. After discharge, these patients should receive aggressive follow-up with a low threshold for readmission. Finally, this study’s results advocate for certain surgical quality indicators to extend beyond the short-term perioperative period, because it is becoming increasingly clear that adverse outcomes months or even years after an operation may nevertheless be associated with adverse events directly related to the operation. Prolonged Effect of Postoperative Infectious Complications on Survival After Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 99Issue 5PreviewWhether patients having infections after cardiac surgery are at a survival disadvantage after hospital discharge is unclear. Our objectives were (1) to identify characteristics of such patients and (2) to determine whether this complication is associated with increased mortality beyond hospital discharge. Full-Text PDF