Infection In Cardiac Surgery Patients Research Articles

Risk of Potential Invasive Non-Tuberculous Mycobacterial Infection in Major Cardiothoracic Surgeries.

Nontuberculous Mycobacteria (NTM) commonly colonise municipal water supplies and cause healthcare-associated outbreaks. Although the infections are rare, they are associated with high mortality. Aerosolization of NTM from colonised Heater cooler devices causes invasive infections in cardiac surgery patients. These units are widely used in open-chest heart surgery as an essential part of extracorporeal circulation but have been suggested as being a risk for infection. Water disinfection as well as effective engineering-related mitigation strategies should be designed to decrease the burden of NTM in the hospital water supply. Key Words: Nontuberculous Mycobacteria, Heater cooler devices, Endocarditis, Water, Cardiothoracic surgeries.

Risk Factors for Postoperative Infections in Cardiac Surgery Patients: A Retrospective Study.

Background and objective Cardiac surgery is one of the most common surgical proceduresglobally; its incidence has been on the risedue to the faster pace ofpopulation aging thanks to technological and epidemiological advances. Patients who undergo cardiac surgeriesmayface various postoperative complications that might affect their survival, and one of these major complicationsis infection. Nosocomial pneumonia, surgical site infection (SSI), mediastinitis, bacteremia, and sepsis are common infections encountered after surgeries. In this study, we aimed to determine the common risk factors related to postoperative infections at the King Faisal Cardiac Center from January 2014 to September 2020. Materials and methods Records from 364 patients who underwent cardiac surgery and were aged above 18 yearswere assessed for postoperative infections in this retrospective cohort study. Patients who were immunosuppressed or had active systemic infections were excluded. Consent was waived by the Institutional Review Board. All procedures were performed at the King Faisal Cardiac Center, National Guard Hospital, Jeddah. Results Of the total 364 patients,105 were women and 259 were men. The mean age of the cohort was 59 years (SD = 13) and the mean BMI was 29.1 kg/m2 (SD = 5.3). The study population showed a high prevalence of cardiac risk factors and diseases: diabetes (n = 244, 67%), hypertension (n = 230, 63%), dyslipidemia (n = 144, 40%), smoking (n = 80, 22%), heart failure (n = 41, 11%), and chronic obstructive pulmonary disease (n = 6, 1.6%). The overall rate of postoperative infection was 32.7% (n = 120), and 17 (14%) of these infected patients underwent reoperations for infection. Conclusion Based on a thorough analysis of 364 patients undergoing various cardiac surgical procedures, including a multivariate analysis accounting for preoperative factors, there was a significant association between postoperative infections and hypertension, diabetes, increased preoperative activated partial thromboplastin time, and elevated HbA1c.

Topical vancomycin for sternal wound infection prophylaxis. A systematic review and updated meta-analysis of over 40,000 cardiac surgery patients

BackgroundDespite guideline recommendations, routine application of topical antibiotic agents to sternal edges after cardiac surgery is seldom done. Recent randomized controlled trials have also questioned the effectiveness of topical vancomycin in sternal wound infection prophylaxis. MethodsWe screened multiple databases for observational studies and randomized controlled trials assessing the effectiveness of topical vancomycin. Random effects meta-analysis and risk-profile regression were performed, and randomized controlled trials and observational studies were analyzed separately. The primary endpoint was sternal wound infection; other wound complications were also analyzed. Risk ratios served as primary statistics. ResultsTwenty studies (N = 40,871) were included, of which 7 were randomized controlled trials (N = 2,187). The risk of sternal wound infection was significantly reduced by almost 70% in the topical vancomycin group (risk ratios [95% confidence intervals]: 0.31 (0.23–0.43); P < .00001) and was comparable between randomized controlled trials (0.37 [0.21–0.64]; P < .0001) and observational studies (0.30 [0.20–0.45]; P < .00001; Psubgroup = .57). Topical vancomycin significantly reduced the risk of superficial sternal wound infections (0.29 [0.15–0.53]; P < .00001) and deep sternal wound infections (0.29 [0.19–0.44]; P < .00001). A reduction in the risk of mediastinitis and sternal dehiscence risks was also demonstrated. Risk profile meta-regression showed a significant relationship between a higher risk of sternal wound infection and a higher benefit accrued with topical vancomycin (ß-coeff. = −0.00837; P < .0001). The number needed to treat was 58.2. A significant benefit was observed in patients with diabetes mellitus (risk ratios 0.21 [0.11–0.39]; P < .00001). There was no evidence of vancomycin or methicillin resistance; on the contrary, the risk of gram-negative cultures was reduced by over 60% (risk ratios 0.38 [0.22–0.66]; P = .0006). ConclusionTopical vancomycin effectively reduces the risk of sternal wound infection in cardiac surgery patients.

Mycobacterium abscessus Cluster in Cardiac Surgery Patients Potentially Attributable to a Commercial Water Purification System.

Nontuberculous mycobacteria are water-avid pathogens that are associated with nosocomial infections. To describe the analysis and mitigation of a cluster of Mycobacterium abscessus infections in cardiac surgery patients. Descriptive study. Brigham and Women's Hospital, Boston, Massachusetts. Four cardiac surgery patients. Commonalities among cases were sought, potential sources were cultured, patient and environmental specimens were sequenced, and possible sources were abated. Description of the cluster, investigation, and mitigation. Whole-genome sequencing confirmed homology among clinical isolates. Patients were admitted during different periods to different rooms but on the same floor. There were no common operating rooms, ventilators, heater-cooler devices, or dialysis machines. Environmental cultures were notable for heavy mycobacterial growth in ice and water machines on the cluster unit but little or no growth in ice and water machines in the hospital's other 2 inpatient towers or in shower and sink faucet water in any of the hospital's 3 inpatient towers. Whole-genome sequencing confirmed the presence of a genetically identical element in ice and water machine and patient specimens. Investigation of the plumbing system revealed a commercial water purifier with charcoal filters and an ultraviolet irradiation unit leading to the ice and water machines in the cluster tower but not the hospital's other inpatient towers. Chlorine was present at normal levels in municipal source water but was undetectable downstream from the purification unit. There were no further cases after high-risk patients were switched to sterile and distilled water, ice and water machine maintenance was intensified, and the commercial purification system was decommissioned. Transmission pathways were not clearly characterized. Well-intentioned efforts to modify water management systems may inadvertently increase infection risk for vulnerable patients. National Institutes of Health.

Toll-like receptor polymorphisms (TLR2 and TLR4) association with the risk of infectious complications in cardiac surgery patients.

Postoperative infection is a common healthcare-associated problem, and unfortunately, a serious complication in cardiac surgery patients. Toll-like receptors (TLRs) are crucial in activating non-specific immunity mechanisms and integrating elements of the immune system, due to interactions between specific and non-specific responses. In this study, the association of TLR2 or TLR4 with the risk of postoperative infections in cardiac surgery patients undergoing a coronary artery bypass grafting (CABG) procedures was investigated. Our research was carried out on a cohort of 299 consecutive adult patients with ischemic heart disease (IHD) who underwent a planned CABG procedure. These patients were monitored for the presence of a postoperative infection over a 30-day observation period. All patients were investigated for 2 TLR2 gene mutations - R753Q (rs5743708) and T16934A (rs4696482), and 2 polymorphisms of the TLR4 gene - D299G (rs4986790) and T399I (rs4986791). The final stage of the study was an evaluation of the hypothetical association between TLR2 and TLR4 gene variances and postoperative infections in patients undergoing CAGB procedures. The prevalence of infections in the final cohort was 15.3% (46/299). The most common infections were surgical site infections, which were diagnosed in 21 patients (45.6%), bloodstream infections in 15 patients (32.6%) and pneumonia in 10 patients (21.8%). Logistic regression demonstrated that the presence of the AG+GG of D299G (rs4986790) and CT+TT of T399I (rs4986791) variants was related to a higher incidence of infection in patients undergoing CAGB procedures. To our knowledge, this is the first study of its kind to demonstrate that TLR2 and TLR4 mutations affect the risk of post-CABG infections. Being a carrier of the AG+GG of D299G (rs4986790) or CT+TT of T399I (rs4986791), TLR4 variants constitute a postoperative risk factor for infection in patients undergoing CAGB procedures.

Effect of Hospital-associated SARS-CoV-2 Infections in Cardiac Surgery: A Multicenter Study

BackgroundThe effect of hospital-associated SARS-CoV-2 infections in cardiac surgery patients remains poorly investigated, and current data are limited to small case series with conflicting results. MethodsA multicenter European collaboration was organized to analyze the outcomes of patients who tested positive with hospital-associated SARS-CoV-2 infection after cardiac surgery. The study investigators hypothesized that early infection could be associated with worse postoperative outcomes; hence 2 groups were considered: (1) an early hospital-associated SARS-CoV-2 infection group comprising patients who had a positive molecular test result ≤7 days after surgery, with or without symptoms; and (2) a late hospital-associated SARS-CoV-2 infection group comprising patients whose test positivity occurred >7 days after surgery, with or without symptoms. The primary outcome was 30-day mortality. Secondary outcomes included all-cause mortality or morbidity at early follow-up and SARS-CoV-2–related hospital readmission. ResultsA total of 87 patients were included in the study. Of those, 30 were in the early group and 57 in the late group. Overall, 30-day mortality was 8%, and in-hospital mortality was 11.5%. The reintubation rate was 11.4%. Early infection was significantly associated with higher mortality (adjusted OR, 26.6; 95% CI, 2, 352.6; P < .01) when compared with the late group. At 6-month follow-up, survival probability was also significantly higher in the late infection group: 91% (95% CI, 83%, 98%) vs 75% (95% CI, 61%, 93%) in the early infection group (P = .036). Two patients experienced COVID-19–related rehospitalization. ConclusionsIn this multicenter analysis, hospital-associated SARS-CoV-2 infection resulted in higher than expected postoperative mortality after cardiac surgery, especially in the early infection group.

Rate of Detection and Antibiotic Resistance Pathogens of Purulent-Septic Infections in Cardiac Surgery Patients

Relevance . Among cardiac surgery hospital patients, purulent-septic infections (healthcare-associated infection or further HAI) do often occur. Aim of the work is to study the frequency of detection and antibiotic resistance of certain types of microorganisms in the development of HSI in operated patients of a cardiac surgery hospital. Materials and methods . The results of bacteriological examination of 213 operated patients with signs of HAI and 836 patients without signs of HAI were studied in a cardiac surgery hospital. The sensitivity of dominant microorganisms to antibiotics was determined. Results . Among patients operated in a cardiac surgery hospital Staphylcoccus epidermidis was more often extracted from the wound discharge, K. pneumoniae and fungi of the genus Candida were extracted from sputum, S. epidermidis and fungi of the genus Candida were extracted from blood, K. pneumoniae and Escherichia were extracted coli urine. These microorganisms were found among patients with signs of HAI significantly more often than among patients without signs of HAI. Among the dominant pathogens of HAI, a significant proportion of strains with multiple antibiotic resistance was identified, and among K. pneumoniae were found extremely resistant and pan-resistant clones producing extended-spectrum beta-lactamases. Conclusion. K. pneumoniae , S. epidermidis , E. coli and fungi of the genus Candida were the leading pathogens of HAI among patients operated in a cardiac surgery hospital. A significant number of bacterial strains with multiple antibiotic resistance have been identified.

Training in cardiothoracic surgery: Another victim of COVID-19 pandemic.

Training in cardiothoracic surgery: Another victim of COVID-19 pandemic.

Longitudinal-cross-linking method of the sternum osteosynthesis – an additional way for the prophylaxis of deep sternal infection in cardiac surgery patients

The OBJECTIVE of the study was to compare the results of using the longitudinal – cross-linking method of sternum osteosynthesis with other methods (single wire stitches, 8-shaped wire stitches) for cardiosurgery patients.METHODS AND MATERIALS. The study included 3,150 patients, which were operated on in Samara cardiology dispensary named after V. P. Poliakov from 2012 to 2018. Patients were divided into 2 groups. Group 1 (1397 patients, operated on from 2012 to 2014) used single wire stitches or 8-shaped wire stitches for sternum osteosynthesis. Group 2 (1753 patients, operated from 2015 to 2018) used the longitudinal -cross-linking method of sternum osteosynthesis. The incidence of instability of the sternum without infection, superficial postoperative wound infection, deep sternal infection and hospital mortality were evaluated.RESULTS. Groups (1–68 % of men, average age (59.4±9,9) years; 2–68 % of men, average age 62.3±8.5) were significantly different in obesity patients (25.6 &amp; 29.3 %, p=0.02), amount of smokers (50.5 &amp; 64.2 %, p&lt;0.001) and amount of urgent cases (3 &amp; 10 %, p&lt;0.001). The incidence of sternal instability without infection was less in group 2 (0.64 &amp; 0.29 %; OR, 2.29; 95 % CI, 0.76 to 6.8; p=0.1). The amount of deep sternal infection was significant less in group 2 (1.6 &amp; 0.6 %; OR, 2.53; 95 % CI, 1.2 to 5.2; p=0.009). The hospital mortality was 3.9 % in group 1 and 2.96 % in group 2 (OR, 1.34; 95 % CI, 0.9 to 1.9; p=0.1).CONCLUSION. The longitudinal-cross-linking method of sternum osteosynthesis is the available method that can significantly reduce the incidence of deep sternal infection in cardiosurgery.

Association Between Post-Operative Infection and Blood Transfusion in Cardiac Surgery.

BackgroundBlood transfusion is a commonly used therapy in cardiac surgery, whether it is given during the surgery or in the intensive care unit. It is important to evaluate the risks and benefits of exposure to blood transfusion. The use of blood transfusions can influence patient outcome. Previous studies have implicated blood transfusion as a causative factor in post-operative infection.ObjectivesWe aim to determine the effect of blood transfusion on post-operative infection in cardiac surgery patients at the King Faisal Cardiac Center, Jeddah, Saudia Arabia, from January 2017 to January 2019.MethodsThe regular six-week follow-up of cardiac surgery patients allowed us to maintain a six-week infection span. The main variables included patient characteristics, operative characteristics, pre-operative hemoglobin, six-week infection, blood transfusion, and clinical outcomes. A logistic regression model was developed to identify patient and procedure variables that were associated with blood transfusion and infection. The baseline variables were entered into the model. Variables with p-value less than 0.05 were considered significant.ResultsThe incidence of transfusion out of 197 patients was 93.4% (n = 184). The occurrence of infection was 31.82% (n = 63). There was no difference in post-operative infection for patients who received blood transfusions compared with those who did not receive blood transfusions (p = 0.902). In comparing patients receiving 1-2 units of red blood cells (RBCs) (48%) and those receiving >2 units of RBCs (52%), there was no significance (p = 0.549).ConclusionsThere was no association between the incidence of infection and blood transfusion. While there are other reasons for withholding blood, it would not be recommended to do so based on the concern of infection.

Disinfection and cleaning of heater–cooler units: suspension- and biofilm-killing

Non-tuberculous mycobacteria (NTM) infections in cardiac surgery patients, caused by Mycobacterium chimaera or Mycobacterium abscessus, have been traced to NTM-aerosols produced by heater-cooler units of cardiopulmonary bypass equipment. To develop a protocol to disinfect the water reservoir(s) of heater-coolers to reduce NTM numbers and thereby prevent potential NTM aerosolization; and to devise an approach to disrupt surface biofilms of heater-coolers to reduce reinoculation of the heater-cooler reservoir(s) after disinfection. A laboratory-scale Centers for Disease Control and Prevention bioreactor and a heater-cooler were inoculated with M. chimaera or M. abscessus to measure the ability of different disinfection protocols to reduce NTM colony-forming units in water and biofilm samples and to delay the reappearance of NTM after disinfection. The combination of an enzyme detergent cleaning agent and Clorox® were equivalent to Clorox alone in reducing M. chimaera cfu in heater-cooler water reservoir samples. However, reappearance of those bacteria was delayed by 12 weeks by the combination of enzyme detergent cleaning agent and Clorox exposure compared to Clorox disinfection alone. A combination of an enzyme detergent and Clorox was an effective disinfection treatment and significantly delayed the reappearance of M. chimaera in the heater-cooler reservoir.

Characterization of Postoperative Infection Risk in Cardiac Surgery Patients With Delayed Sternal Closure

To compare the incidence of postoperative infection in cardiac surgery patients who had delayed sternal closure (DSC) with those who had primary sternal closure (PSC) and evaluate the effectiveness of antibiotic prophylaxis in DSC patients. Retrospective, observational cohort study with propensity score matching. Single academic medical center. Cardiothoracic surgery patients, excluding transplantation patients, from a single academic medical center who had DSC or PSC between November 2015 and November 2018. None. Of 2,685 patients who had cardiac surgery with cardiopulmonary bypass, 99 had DSC. Fifty-nine DSC patients met study inclusion criteria, and the final propensity score matched cohort included 57 patients with DSC and 57 patients with PSC. Propensity score matching reduced bias but was unable to balance all covariates. The most common indication for DSC was coagulopathy in 32 of the 57 patients. All patients in the PSC group received routine antibiotic prophylaxis for 48 hours after surgery. Patients in the DSC group received prolonged broadened prophylaxis until 48 hours after sternal closure. Despite prolonged broadened antibiotic prophylaxis, the DSC group had a higher rate of postoperative infection (31.6% v 3.5%; p < 0.005), mainly pneumonia (19.3% v 1.8%; p < 0.005), in the first 30 days after surgery. There was no difference in the incidence of sepsis (5.3% v 0%; p = 0.24), superficial skin and soft tissue infection (1.8% v 1.8%; p = 1), or mediastinitis/deep tissue infection (5.3% v 0%; p = 0.24) in patients with DSC. Seventy-seven percent of causative organisms for infection were Gram-negative bacteria in the matched cohort. The incidence of postoperative infection, particularly pneumonia, is high in cardiothoracic surgery patients with DSC, even with prolonged broadened antibiotic prophylaxis, but the rate of mediastinitis/deep tissue infection did not appear to be greater with DSC. Additional research is needed into optimal antibiotic prophylaxis in this high-risk group of patients.

Reduced Incidence of Carbapenem-Resistant Klebsiella pneumoniae Infections in Cardiac Surgery Patients after Implementation of an Antimicrobial Stewardship Project.

Infections due to carbapenem-resistant Klebsiella pneumoniae (CR-Kp) are associated with increased mortality in cardiac surgery patients. In this short communication, we report on the changes in the incidence of CR-Kp colonization and CR-Kp infection in cardiac surgery patients from 2014 to 2018 in a teaching hospital in Italy, after the implementation of an antimicrobial stewardship project in 2014. During the study period, 2261 patients underwent open-heart surgery. Of them, 130 were found to be colonized by CR-Kp (5.7%) and 52 developed a postoperative CR-Kp infection (2.3%). The crude in-hospital mortality in patients with CR-Kp infections was 48% (25/52). The incidences of both CR-Kp colonization (incidence rate ratio (IRR) 0.82, 95% confidence intervals (CI) 0.78–0.86, p < 0.001) and CR-Kp infection (IRR 0.76, 95% CI 0.69–0.83, p < 0.001) considerably decreased over the study period. This encouraging result should prompt further concerted efforts, directed towards retaining the positive impact of stewardship and infection-control interventions on CR-Kp-related morbidity in the long term.

A multi-institutional cohort study confirming the risks of Clostridium difficile infection associated with prolonged antibiotic prophylaxis

ObjectivesThe incidence and severity of Clostridium difficile infection (CDI) have increased rapidly over the past 2 decades, particularly in elderly patients with multiple comorbidities. This study sought to characterize the incidence and risks of these infections in cardiac surgery patients. MethodsA total of 5158 patients at 10 Cardiothoracic Surgical Trials Network sites in the US and Canada participated in a prospective study of major infections after cardiac surgery. Patients were followed for infection, readmission, reoperation, or death up to 65 days after surgery. We compared clinical and demographic characteristics, surgical data, management practices, and outcomes for patients with CDI and without CDI. ResultsC difficile was the third most common infection observed (0.97%) and was more common in patients with preoperative comorbidities and complex operations. Antibiotic prophylaxis for >2 days, intensive care unit stay >2 days, and postoperative hyperglycemia were associated with increased risk of CDI. The median time to onset was 17 days; 48% of infections occurred after discharge. The additional length of stay due to infection was 12 days. The readmission and mortality rates were 3-fold and 5-fold higher, respectively, in patients with CDI compared with uninfected patients. ConclusionsIn this large multicenter prospective study of major infections following cardiac surgery, CDI was encountered in nearly 1% of patients, was frequently diagnosed postdischarge, and was associated with extended length of stay and substantially increased mortality. Patients with comorbidities, longer surgery time, extended antibiotic exposure, and/or hyperglycemic episodes were at increased risk for CDI.

Preoperative Staphylococcus Aureus Screening and Targeted Decolonization in Cardiac Surgery

We assessed the impact of preoperative Staphylococcus aureus screening and targeted decolonization on the incidence of postoperative methicillin-resistant S aureus (MRSA) colonization, intensive care unit MRSA transmission, and surgical site infections in cardiac surgery patients. We reviewed medical records for all adult patients during two periods: preintervention (January 2007 to April 2010) and intervention (January 2011 to December 2014). In the intervention period, we performed nasal screening for methicillin-sensitive S aureus and MRSA using polymerase chain reaction within 30 days of the operation. Colonized patients received intranasal mupirocin twice daily and chlorhexidine baths daily for 5 days; patients colonized with MRSA also received prophylactic vancomycin plus cefazolin with contact isolation precautions. Nasal surveillance for MRSA was performed on intensive care unit admission and weekly thereafter. Multivariable logistic regression models were constructed to determine risk factors for postoperative MRSA colonization, and surgical site infections and the impact of our screening program was assessed in these models. Poisson regression was used to assess MRSA transmission. Comparing 2,826 preintervention and 4,038 intervention patients, cases differed in age, diabetes mellitus, preoperative infection, preoperative length of stay, and bypass time (all p ≤ 0.03). Intervention patients had risk-adjusted reductions in MRSA colonization (odds ratio 0.53, 95% confidence interval [CI]: 0.37 to 0.76, p < 0.001), transmission (incidence rate ratio 0.29, 95% CI: 0.13 to 0.65, p= 0.002), and surgical site infections (odds ratio 0.58, 95% CI: 0.40 to 0.86, p= 0.007). Increased duration of preoperative decolonization therapy was associated with decreased postoperative MRSA colonization (odds ratio 0.73, 95% CI: 0.53 to 1.00, p= 0.05). Preoperative S aureus screening with targeted decolonization was associated with reduced MRSA colonization, transmission, and surgical site infections. Duration of preoperative therapy correlated with decreased frequency of postoperative MRSA colonization.

Violation of prophylactic vancomycin administration timing is a potential risk factor for rate of surgical site infections in cardiac surgery patients: a prospective cohort study

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.

Healthcare-Associated Infections in Cardiac Surgery Patients With Prolonged Intensive Care Unit Stay

Healthcare-associated infections (HAIs) are responsible for many deaths of hospitalized patients each year. Patients with prolonged hospitalization are at high risk for HAIs. Increased efforts have been made to decrease these infections, but a recent report from the Centers for Disease Control suggests that some HAIs may be increasing. We hypothesized that HAIs would remain frequent among cardiac surgery patients with prolonged intensive care unit stay and would be associated with increased mortality. We performed a retrospective cohort study of adult cardiac surgery patients with prolonged intensive care unit stay (more than 7 days) over a 3-year period. Mortality differences were calculated based on whether particular HAIs occurred. Multivariable logistic regression was used to examine risk factors associated with the development of HAI. The relationship between HAI and mortality was estimated using propensity score adjusted logistic regression analysis. Of 2,595 patients, 388 (15.0%) had a prolonged intensive care unit stay. Of these patients, 48.5% had at least one HAI. Unadjusted inhospital mortality for patients with HAI was 28.7%, versus 13.0% for patients without. Red blood cell transfusion was associated with increased HAI risk. After propensity score adjustment, surgical site infection and central line associated bloodstream infection were associated with increased mortality. The HAIs caused by vancomycin-resistant Enterococcus sp, methicillin-resistant Stapholococcus aureus, and multidrug-resistant organisms appeared to be associated with disproportionally high mortality. Healthcare-associated infections remain frequent among cardiac surgery patients with prolonged intensive care unit stay and are associated with increased mortality. Evidence-based strategies are needed to reduce these infections.

Procalcitonin and white blood cells, combined predictors of infection in cardiac surgery patients

BackgroundSepsis is strongly associated with an increased risk of postoperative mortality, longer length of hospital stay, and elevated health care costs. Early clinical symptoms overlap with those of systemic inflammatory response syndrome, a response that commonly occurs after cardiac surgery with cardiopulmonary bypass. Since a combination of biomarkers has been demonstrated to improve the prediction of postoperative infection, the objective of the present study was to test whether the combination of C-reactive protein (CRP), white blood cells (WBC), and procalcitonin (PCT) is able to predict postoperative infection in a large cohort of cardiac surgery patients. Material and methodsCase-control study involving 423 patients who underwent cardiac surgery with cardiopulmonary bypass. Patients were retrospectively classified into two groups based on whether they developed severe sepsis or septic shock during the postoperative period. Blood samples for biological measurements (PCT, CRP, and WBC) were drawn on the first day in the intensive care unit, then once daily in the morning until the 10th postoperative day. ResultsCRP median values were similar in both groups. WBC and PCT median values were significantly higher in patients with infection than without during the first 10 postoperative days. With elevation cutoffs ≤3 times (OR: 4.058; 95% CI: 2.206-7.463; P = 0.001) and ≥4 times (OR: 10.274, 95% CI: 3.690-28.604; P < 0.001), the median value for PCT (1.7 ng/mL) and/or WBC (13,000 cells/mm3) on the second postoperative day was significantly associated with the development of infection. ConclusionsThe goal of this study was to use a large cohort of cardiac surgery patients to ensure that the results were representative of this population. The combination of PCT and WBC levels over the first three postoperative days was able to predict postoperative infection within the 30 d following cardiac surgery.

Calculated Empiric Antibiotic Therapy of Nosocomial Infection in Cardiac Surgery Patients

Objectives: There is a wide variation of hospital-acquired infections in the postoperative period ranging from 2.7% to 26.8%. In case of clinically suspected hospital-acquired infection the diagnosis is sometimes difficult, since clinical and laboratory signs of inflammation may be caused not only by infection, but also by tissue injury and mainly by the systemic inflammatory response syndrome associated with cardiopulmonary bypass. The choice of empirical therapy depends on the suspected site of infection and local microbial-susceptibility patterns. Inappropriate or delayed antibiotic treatment is associated with increased mortality. Thus, intravenous antibiotic therapy should be started as early as possible and should cover all likely pathogens. Structured deescalation concepts and strict limitation of treatment duration should lead to reduced selection pressure.

Evaluation of fever and infections in cardiac surgery patients.

Fever following cardiac surgery is common and may be infectious or noninfectious in etiology. In this article, we review the major causes of postoperative fever while highlighting special considerations in cardiac surgery patients. We also outline a structured approach to evaluation and present an overview of diagnostic and management considerations for mediastinitis, postpericardiotomy syndrome, prosthetic valve endocarditis, aortic vascular graft infections, and ventricular assist device infections.