Abstract
BackgroundIntensivists and cardiothoracic surgeons are commonly worried about surgical site infections (SSIs) due to increasing length of stay (LOS), costs and mortality. The antimicrobial prophylaxis is one of the most important tools in the prevention of SSIs. The objective of this study was to investigate the relationship between the timing of antimicrobial prophylaxis administration and the rate of SSIs.MethodsA prospective cohort study was carried out over 1-year period in all consecutive adult patients undergoing elective cardiac surgery. The population was stratified in patients whose antimicrobial prophylaxis administration violated or not the vancomycin timing protocol (i.e., when the first skin incision was performed before the end of vancomycin infusion). To compare SSI rates, the cohort was further stratified in patients at low and high risk of developing SSIs.ResultsOver the study period, 1020 consecutive adult patients underwent cardiac surgery and according to study inclusion criteria, 741 patients were prospectively enrolled. A total of 60 SSIs were identified for an overall infection rate of 8.1%. Vancomycin prophylaxis timing protocol was violated in 305 (41%) out of 741 enrolled patients. SSIs were observed in 3% of patients without violation of the antimicrobial prophylaxis protocol (13/436) compared with 15.4% of patients with a violation of the timing protocol (47/305) (P < 0.0001). Patients at low risk with protocol violation had a higher occurrence of SSIs (P = 0.004) and mortality (P = 0.03) versus patients at low risk without protocol violation. Similarly, patients at high risk with protocol violation had a higher occurrence of SSIs (P < 0.001) and mortality (P < 0.001) versus patients at high risk without protocol violation. The logistic regression analysis showed that internal mammary artery use (P = 0.025), surgical time (P < 0.001), intensive care unit (ICU) LOS (P = 0.002), high risk of developing SSIs (P < 0.001) and protocol violation (P < 0.001) were risk factors for SSI occurrence as well as age (P = 0.003), logistic EuroSCORE (P < 0.001), ICU LOS (P < 0.001), mechanical ventilation time (P < 0.001) and protocol violation (P < 0.001) were risk factors for mortality.ConclusionsThis study showed that violation of the timing of prophylactic vancomycin administration significantly increased the probability of SSIs and mortality from infectious cause in cardiac surgery patients.
Highlights
Intensivists and cardiothoracic surgeons are commonly worried about surgical site infections (SSIs) due to increasing length of stay (LOS), costs and mortality
Several operation characteristics can influence the risk of infection in cardiac surgery: skin antisepsis; length of operation; surgical technique; coronary artery bypass graft (CABG) surgery involving the use of a saphenous vein autograft that can carry bacteria from the harvest site deep into the cardiac operative site; use of the internal mammary artery (IMA) that deprives the sternum of blood supply; the use of prosthetic intracardiac or aortic implants; cardiopulmonary bypass or systemic cooling for myocardial protection; and invasive devices remaining after surgery [1, 8, 9]
According to variables considered as risk factors for infectious complications, 402 patients were considered at low risk of developing SSIs and 339 were considered at high risk
Summary
Intensivists and cardiothoracic surgeons are commonly worried about surgical site infections (SSIs) due to increasing length of stay (LOS), costs and mortality. The antimicrobial prophylaxis is one of the most important tools in the prevention of SSIs. The objective of this study was to investigate the relationship between the timing of antimicrobial prophylaxis administration and the rate of SSIs. The incidence of surgical site infections (SSIs) after cardiac surgery ranges differently according to the type of wound infection; superficial wound infection occurs in 2 to 20% of patients and deep sternal wound infection occurs in 0.25 to 5% [1,2,3,4,5,6]. In patients undergoing cardiac surgery, an SSI is associated with increased morbidity, prolonged length of stay and increased costs with an in-hospital mortality rate of 10–20% [1, 6, 11]. The debate over choice, dose, duration and timing of antimicrobial prophylaxis protocol is still all the rage [14]
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