Prevention Of Sternal Wound Infections Research Articles

Negative Pressure Wound Therapy: Comparison of Outpatient and Inpatient Approaches.

The results of recent studies regarding the efficacy of Negative Pressure Wound Therapy (NPWT) for the prevention of sternal wound infection (SWI) after adult cardiac surgery are not conclusive. Data were collected from patients who were operated upon at the GVM Care & Research group in Italy from 2013 to 2021; all patients who required treatment for sternotomy wound infection with Negative Pressure Wound Therapy (NPWT) through WaterLily™ system (Eurosets, Medolla, MO, Italy) were selected. We compared the preoperative risk characteristics, and particularly those that were most strongly associated with possible dehiscence of the wound. A statistical analysis was performed for comparison of the groups. Out of the total 40,267 patients who underwent cardiac surgery with extracorporeal circulation within this time frame, 1,483 (3.68%) required NPWT, including 690 (46.52%) in the HOME group and 793 (53.47%) in the HOSPITAL group (p =0.76). Thirty-nine (5.65%) patients in the HOME group and 37 (4.66%) in the HOSPITAL group required re-treatment for re-dehiscence after secondary closure (p =0.79). The use of a WaterLily™ system (Eurosets, Medolla, MO, Italy) was safe and effective for the treatment of sternotomy wounds with superficial and deep infections and was associated with a low rate of dehiscence, even when used with discharged and managed outpatient patients.

Negative-Pressure Wound Therapy for Prevention of Sternal Wound Infection after Adult Cardiac Surgery: Systematic Review and Meta-Analysis.

The results of current studies are not conclusive on the efficacy of incisional negative-pressure wound therapy (NPWT) for the prevention of sternal wound infection (SWI) after adult cardiac surgery. A systematic review of the literature was performed through PubMed, Scopus and Google to identify studies which investigated the efficacy of NPWT to prevent SWI after adult cardiac surgery. Available data were pooled using RevMan and Meta-analyst with random effect models. Out of 191 studies retrieved from the literature, ten fulfilled the inclusion criteria and were included in this analysis. The quality of these studies was judged fair for three of them and poor for seven studies. Only one study was powered to address the efficacy of NPWT for the prevention of postoperative SWI. Pooled analysis of these studies showed that NPWT was associated with lower risk of any SWI (4.5% vs. 9.0%, RR 0.54, 95% CI 0.34–0.84, I2 48%), superficial SWI (3.8% vs. 4.4%, RR 0.63, 95% CI 0.29–1.36, I2 65%), and deep SWI (1.8% vs. 4.7%, RR 0.46, 95% CI 0.26–0.74, I2 0%), but such a difference was not statistically significant for superficial SWI. When only randomized and alternating allocated studies were included, NPWT was associated with a significantly lower risk of any SWI (3.3% vs. 16.5%, RR 0.22, 95% CI 0.08–0.62, I2 0%), superficial SWI (2.6% vs. 12.4%, RR 0.21, 95% CI 0.06–0.69, I2 0%), and deep SWI (1.2% vs. 4.8%, RR 0.17, 95% CI 0.03–0.95, I2 0%). This pooled analysis showed that NPWT may prevent postoperative SWI after adult cardiac surgery. NPWT is expected to be particularly useful in patients at risk for surgical site infection and may significantly reduce the burden of resources needed to treat such a complication. However, the methodology of the available studies was judged as poor for most of them. Further studies are needed to obtain conclusive results on the potential benefits of this preventative strategy.

Current Management of Sternal Wounds.

After studying this article, the participant should be able to: 1. Describe the pathogenesis, classification, and risk factors of sternal wound infection. 2. Discuss options for sternal stabilization for the prevention of sternal wound infection, including wiring and plating techniques. 3. Discuss primary surgical reconstructive options for deep sternal wound infection and the use of adjunctive methods, such as negative-pressure wound therapy. Poststernotomy sternal wound infection remains a life-threatening complication of open cardiac surgery. Successful treatment relies on timely diagnosis and initiation of multidisciplinary, multimodal therapy.

Prevention of Sternal Wound Infections in Women Using an External Sternum Fixation Corset.

Purpose: Deep sternal wound infection (DSWI) and mediastinitis are devastating complications after median sternotomy. Previous studies demonstrated an effective prevention of sternal wound infection (SWI) using an external sternal corset in high-risk cardiac surgery patients. The aim of this study is to assess the preventive effect of the Stern-E-Fix corset in high-risk poststernotomy female patients.Methods: A total of 145 high-risk female patients undergoing cardiac surgery through median sternotomy were retrospectively analyzed. Patients were divided into group A (n = 71), who received the Stern-E-Fix corset (Fendel & Keuchen GmbH, Aachen, Germany), and group B (n = 74), who received the elastic thorax bandage (SanThorax) postoperatively for 6 weeks. The mean follow-up period was 12 weeks.Results: Incidence of SWI was 7% in group A vs. 17.6% in group B (p = 0.025). One patient presented with DSWI in group A vs. seven patients in group B (p = 0.063). No patient developed mediastinitis in group A vs. four patients in group B (p = 0.121). In all, 4.2% of group A patients required operative wound therapy vs. 16.2% of group B patients (p = 0.026). The length of hospital stay was significantly longer in group B (p = 0.006).Conclusion: Using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence, DSWI, and mediastinitis in high-risk poststernotomy female patients.

A review of the AATS guidelines for the prevention and management of sternal wound infections.

To summarize the AATS guidelines for the prevention and treatment of sternal wound infections. The current AATS guidelines for the prevention of sternal wound infections during the preoperative, intraoperative, and postoperative periods, and the most effective methods and techniques to treat sternal wound infections were reviewed. The guidelines identified multiple interventions that can be instituted during the preoperative, intraoperative, and postoperative periods to reduce sternal wound infections during cardiac surgery. These include the use of perioperative antibiotics, glycemic control to maintain serum glucose < 180mg/dl, avoidance of bone wax and the use of vancomycin paste to the sternal edges, and figure of eight suture techniques to re-approximate the sternum. Wound Vac therapy should be instituted whenever possible to treat and enhance recovery from mediastinitis. The prevention of sternal wound infections and mediastinitis can be achieved by adherence to the AATS guidelines. The institution of these interventions requires a multi-disciplinary team effort among surgeons, anesthesiologists, referring physicians, nurses, and OR and ICU personnel.

Intraoperative local administration of antibiotics for prevention of sternal wound infection in cardiac surgery

Aim. The article compares the effects of local and systemic use of antibiotics on the incidence of sternal wound infection in patients undergoing cardiac surgery.Methods. 485 patients undergoing adult cardiac surgery for the incidence of sternal wound infection were retrospectively evaluated. The patients were divided into two groups who received systemic (cefazolin) and topical (vancomycin, gentamicin) administration of antibiotics for the prevention of sternal wound infection in the postoperative period. The incidence of sternal wound infection depending on the method of application of antibiotics was also assessed.Results. According to the results of the statistical analysis, intraoperative topical application of antibiotics (vancomycin and gentamicin) significantly reduced the cases of sternal wound infection from 7.9 to 0.45% (odds ratio of 1871.9; 95% confidence interval 1.67-2.1×106; p = 0.036). Thus, to improve the efficiency of impact on the pathogenic flora in the wound and to reduce the risk of sternal infection, topical application of antibacterial drugs: vancomycin for the cancellous bone of the sternum, gentamicin for irrigation of tissue during suturing the wound is one of the methods. Conclusion. As a result of the comparative analysis, prevention of sternal wound infection in cardiac patients with intraoperative topical antibiotics is more effective than systemic antibiotic prophylaxis. To reduce the risk of sternal wound infection, topical application of vancomycin as a putty for the cancellous bone of the sternum and gentamicin for irrigation of the soft tissue in the process of wound suturing is recommended.Received 16 August 2016. Accepted 22 November 2016.Conflict of interest: The authors declare no conflict of interest.Financing: The study had no sponsor’s support.

A meta-analysis of platelet gel for prevention of sternal wound infections following cardiac surgery.

Deep sternal wound infection and bleeding are devastating complications following cardiac surgery, which may be reduced by topical application of autologous platelet gel. Systematic review identified seven comparative studies involving 4,692 patients. Meta-analysis showed significant reductions in all sternal wound infections (odds ratio 3.48 [1.08-11.23], p=0.04) and mediastinitis (odds ratio 2.69 [1.20-6.06], p=0.02) but not bleeding. No adverse events relating to the use of topical platelet-rich plasma were reported. The use of autologous platelet gel in cardiac surgery appears to provide significant reductions in serious sternal wound infections, and its use is unlikely to be associated with significant risk.

Topical spraying of cefazolin and gentamicin reduces deep sternal wound infections after heart surgery: a multicenter, large volume, retrospective study.

The use of topical antimicrobials applied to the sternum during cardiac procedures in combination with intravenous agents to prevent mediastinitis has been reported to yield good results. The objective of this study is to provide optimal method of topical antimicrobials for the prevention of sternal wound infection after cardiac surgery. We retrospectively evaluated the patients undergoing adult cardiac surgery at five institutions between January 1994 and August 2013 for the incidence of deep sternal wound infection (DSWI). The patients were sprayed with a solution of cefazolin and gentamicin into the surgical site several times during surgery. The incidence of DSWI was evaluated. Four major risk factors [diabetes mellitus (DM), emergency operation, dialysis and prolonged operation] were also evaluated for their implications in the outcome with the antimicrobial spraying. Totally, 6960 patients were analyzed. The incidence of DSWI was 0.46% in the spraying group versus 1.7% in control group (p < 0.0001). There is no significant difference of the incidence of DSWI between DM and non-DM groups (p = 1.00), emergency and elective operation groups (p = 0.25) under usage of antimicrobial spraying. However, there is significant difference of the incidence of DSWI between dialysis and non-dialysis groups (p = 0.0222), longer than six-hour duration and lesser than six-hour duration operation groups (p = 0.0269). Topical spraying of cefazolin and gentamicin reduces deep sternal wound infections after cardiac surgery. DM and emergency operation were not the risk factors of DSWI when antimicrobial spraying is administered. Considering the benefits, antimicrobial spraying could be used intermittently during such procedures.

Prevention of Sternal Wound Infections by use of a Surgical Incision Management System: First Reported Australian Case Series

Sternal wound infections are considered a costly and potentially devastating consequence of the median sternotomy in cardiothoracic surgery. Surgical incision management employs the technique of applying a closed, negative pressure vacuum dressing to a closed wound. Several studies have demonstrated a reduction in sternal wound infections using this system. A retrospective audit of cases receiving surgical incision management demonstrated a statistically significant reduction in sternal wound infections against a predicted rate. Of the 62 patients identified, only one was complicated by a sternal wound infection with the greatest reduction seen in the high-risk infection group. Although smaller in size, the results compared well to trials conducted in larger European and US centres. Although not advocating surgical incision management for routine use, it should be considered on patients considered high-risk for sternal wound infection, such as diabetics, the elderly and the obese.

Role of topical application of gentamicin containing collagen implants in cardiac surgery.

Sternal wound infections (SWI) continue to be a major cause of concern after cardiac surgery. It leads to prolonged hospital stay and increased morbidity, mortality and increased hospital costs. Prophylactic systemic antibiotics have been used to prevent surgical site infection (SSI). However, prolonged postoperative use of systemic antibiotics can lead to emergence of resistant organisms. Gentamycin Containing Collagen Implants (GCCI) when used during sternotomy closure produces high local antibiotic concentrations in the wound with a low serum concentration. There is evidence that the concentration of gentamicin in the mediastinal fluid reaches levels high enough to be effective against bacteria that are considered resistant to gentamycin and other antibiotics.However, questions have been raised about the safety and efficacy of GCCI. There were concerns whether GCCI can lead to systemic absorption with renal impairment and whether use of topical antibiotics can lead to emergence of antimicrobial resistance.We, hereby, review the literature on GCCI (Collatamp) and take the opportunity to appraise the scientific community about their role in cardiac surgery. Several recent studies have supported their clinical effectiveness. They should be used in dry condition and should not be soaked in saline even for a short period prior to use. However, for GCCI to become part of routine practice in cardiac surgery further large randomised studies are required. As the incidence of sternal wound infection is low in the specialty of cardiac surgery, for any study to be sufficiently powered to address this issue, multicenter studies might be the way forward.Based on the evidence presented in this manuscript it is recommended GCCI (Collatamp) can be a cost effective adjunct for prevention of sternal wound infection. They can also be used for treatment of Deep Sternal Wound Infection.

EComment. Prevention of sternal wound infection

We read with great interest the article by Sakic et al. [1] assessing the efficacy of surgical modifications on the incidence of postoperative sternal complications after bilateral internal thoracic arteries (BITA) harvesting. In this single-center retrospective study, the authors demonstrated that using a skeletonized approach in patients receiving bilateral internal thoracic arteries with augmented sternal wires is effective in preventing sternal wound complications. As described by others, this series supports the claim that the risk of sternal infection can be reduced by performing internal thoracic artery harvested in a skeletonized manner. Deo et al. [2] conducted the first systematic review and meta-analysis to address the essential clinical question of whether BITA increases the risk of deep sternal wound infection in patients with diabetes; they concluded that the risk may be minimized using a skeletonized approach. The left internal thoracic artery to left anterior descending artery graft has long been established as the cornerstone of improved early and late outcomes in surgically-treated patients. An overwhelming wealth of evidence, mainly retrospective studies, demonstrated that the use of BITA as bypass grafts provided superior early survival and better event-free survival after coronary artery bypass grafting. The Arterial Revascularization Trial [3] is the only randomized study comparing the outcomes of single internal mammary artery (SITA) vs BITA, with a primary outcome of survival at 10 years, and results should be available in five years. The risk of sternal wound complications may need to be weighed against the long-term benefit of BITA grafts. It is, needless to say, that anterior mediastinitis is a rare but ominous complication after BITA harvesting, carrying a high risk of in-hospital mortality. Many factors have been suggested as responsible for postcardiotomy sternal wound infection, and investigations to prevent this dreaded complication are still considered as a greatly researched topic in cardiac surgery. Recently, Grauhan et al. [4] investigated the efficacy of a new commercially available negative pressure wound therapy system (Prevena Incision Management System; KCI, San Antonio, USA) as a dressing treatment to prevent sternal wound infection in obese patients undergoing cardiac surgery. They showed in a prospective study that the application of a special foam as a wound dressing immediately after skin closure and negative pressure of -125 mmHg for the first 6 to 7 days postoperatively significantly reduces the incidence of sternal infection in this high-risk patient population. The technique of skeletonization during BITA harvest preserves sternal microacirculation [5]; the immediate application of a negative-pressure wound dressing after suturing prevents the breakdown of skin sutures and seepage of bacteria into the deeper layers. These two different methods showed to be effective in reducing the likelihood of sternal wound infection, and should be considered in high-risk patients of sternal complications. Conflict of interest: none declared.

Collagen Gentamicin for Prevention of Sternal Wound Infection: Effective or Not?

Prophylactic local application of collagen-gentamicin sponges for prevention of sternal wound infections (SWI) after cardiac surgery has been used routinely in risk patients for several years at our center. However, a recent US study failed to show a significant reduction in SWI with the prophylaxis. Therefore, a systematic reevaluation of the effect of local collagen gentamicin was conducted. A complete follow-up of all cardiac surgery patients 2 months postoperatively was achieved. All SWIs were recorded. The effect of the prophylaxis was analyzed, and differences in risk factors were compensated for using multiple logistic regression analyses and Coarsened Exact Matching (CEM). A total of 950 patients were included. Established risk factors for SWI were confirmed. The use of collagen-gentamicin prophylaxis was independently associated with a highly significant reduction in SWI (odds ratio [OR] = 0.30, 95% confidence interval = 0.16 to 0.57; p < 0.001). Applying the more advanced statistical method, CEM indicated that the effect of the prophylaxis may be even greater. The use of local collagen-gentamicin prophylaxis was associated with an approximately 70% reduction in the rate of SWI compared with standard intravenous antibiotic prophylaxis alone.

Prevention of Sternal Wound Infection in Pediatric Cardiac Surgery

Sternal wound infections (SWIs) are a costly complication for children after cardiac surgery, increasing morbidity, mortality, and financial cost. There are no pediatric guidelines to reduce the incidence of SWI in this vulnerable population. A quality improvement, multidisciplinary team was formed, and a protocol to prevent SWI was developed. A prospective review of patients who underwent pediatric cardiac surgery was conducted over a two-year period to follow adherence to the protocol and incidence of SWI. The Centers for Disease Control definitions for surgical site infections were used to determine the depth and presence of infection. Three hundred and eight children <18 years of age had sternotomies during the study period. There was a reduction in all SWI between the first and second years of the study (odds ratio [OR] = 0.35; confidence interval [CI] 95% 0.12-1.01; P = .059). Delayed sternal closure (DSC) was associated with increased risk of SWI (OR = 5.4; CI 95% 2.13-14.9; P ≤ .001). Institution of a protocol in patients with DSC was associated with decreased infections during the second year (first year: n = 7 (14%), second year: n = 2 (4%), P = .14). Institution of a protocol was associated with a decreased number of infections in children. A multicenter study of a bundled protocol approach to SWI prevention is needed. Children with DSC had a significantly higher risk of developing a wound infection. Initiating strategies to reduce SWI with a focus on children with DSC may result in improved overall infection rates.

Gentamicin collagen sponges for the prevention of sternal wound infection: A meta-analysis of randomized controlled trials

The study objective was to determine whether the application of gentamicin collagen sponges reduces sternal wound infections in patients undergoing cardiac surgery. A meta-analysis of randomized controlled trials was performed. Four randomized controlled trials were eligible for inclusion. By pooling data from 4 randomized controlled trials (4672 per-protocol patients), gentamicin collagen sponges reduced deep sternal wound infections (risk ratio, 0.62; 95% confidence interval, 0.39-0.97) and any sternal wound infections (risk ratio, 0.61; confidence interval, 0.39-0.98). In contrast, no benefit was demonstrated regarding superficial sternal wound infections (4 randomized controlled trials [4672 patients]; risk ratio, 0.65; 95% confidence interval, 0.34-1.25) and all-cause mortality (3 randomized controlled trials [3994 patients]; risk ratio, 0.90; 95% confidence interval, 0.57-1.42). On the basis of data from 2 randomized controlled trials (3410 patients), gentamicin collagen sponges also seemed to reduce surgically treated sternal wound infections (risk ratio, 0.59; 95% confidence interval, 0.41-0.86). The most commonly isolated pathogens were coagulase-negative Staphylococcus spp (43%) and Staphylococcus aureus (28%). Gentamicin collagen sponges seem to reduce the sternal wound infection rate in patients undergoing cardiac surgery. The statistical heterogeneity among the existing trials underlines the need for additional large, high-quality randomized controlled trials.

Sternal Wound Infections in Pediatric Congenital Cardiac Surgery: A Survey of Incidence and Preventative Practice

Guidelines exist for prevention of sternal wound infections (SWI) in adults. There are no guidelines for pediatric patients and limited reports on SWI incidence. The purpose of this study was to determine the incidence of, and preventative practice regarding pediatric SWIs with a long-term aim to develop best practice guidelines. Eighty-nine congenital heart programs were sent a 31 question on-line survey regarding pediatric SWI. Thirty eight (43%) of the 89 programs responded. They reported 8,774 pediatric congenital procedures with a mean SWI rate of 1.53% (range, 0 to 9.09). Mean yearly volume was 237 operations (range, 50 to 720). Neither program size nor delayed sternal closure was associated with increased incidence of SWI. Variations in preoperative measures, antibiotic regimens, and wound care did not statistically impact incidence of SWI. Programs with protocols to monitor and control blood glucose levels postoperatively had statistically lower infection rates (1.04 vs 2.35, p = 0.03), and those that sent mediastinal cultures at time of delayed sternal closure reported lower infection rates (1.34 vs 1.74, p = 0.051). This report provides a multiinstitutional SWI incidence from pediatric programs of 1.53%. Despite variations in clinical practice between programs, this survey revealed two strategies resulting in reduced SWIs; protocol-based management of glucose levels and mediastinal wound cultures sent at time of closure. Pediatric programs do not consistently follow adult preventative guidelines. Multicenter randomized research is needed to formulate preventative guidelines to reduce the incidence of pediatric SWI.

Is skin closure with cyanoacrylate glue effective for the prevention of sternal wound infections?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed whether cyanoacrylate glue was effective at preventing wound infection following sternotomy incision. Altogether more than 108 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that applying cyanoacrylate glue to a sternal wound has superior outcomes in terms of infection rates, both if applied preoperatively (decreasing from 10.8% to 2.7% or 7.8% to 1.1%, according to two studies) and postoperatively (4.9%-2.1%). This trend is true of both deep surgical site infections (0.6%-0%) and superficial site infections (4.3%-2.1%). Furthermore, in patients who had developed mediastinitis following cardiac surgery rates of recurrent sternal detachment and osteomyelitis were significantly reduced in cases where sealant was applied compared to controls (35.3% vs. 0%). In all studies examining hospital stay, duration was reduced in cases where cyanoacrylate glue was used, both in patients treated for recurrent mediastinitis (24.06 vs. 14.16 days) and those with uncomplicated recovery following cardiac surgery (13 vs. 9 days). In addition, two studies examining the use of cyanoacrylate glue to secure the sternum in complicated cases of recurrent detachment report success rates of 86% and 100%.

Prevention of Sternal Wound Infections After Coronary Artery Bypass Graft Surgery With Use of Insulin Drug Therapy

Diabetes is a disease that can increase the risks of developing cardiac problems, which can include coronary artery bypass graft surgery. These patients are at an increased risk of developing serious complications after this surgery, including deep sternal wound infections. In addition, nondiabetic patients may also develop this complication. Therefore, it is essential to monitor and maintain glucose levels after open heart surgery. This literature review discusses some of the studies in this area.

Collagen-gentamicin implant for prevention of sternal wound infection; long-term follow-up of effectiveness

In a previous randomized controlled trial (LOGIP trial) the addition of local collagen-gentamicin reduced the incidence of postoperative sternal wound infections (SWI) compared with intravenous prophylaxis only. Consequently, the technique with local gentamicin was introduced in clinical routine at the two participating centers. The aim of the present study was to re-evaluate the technique regarding the prophylactic effect against SWI and to detect potential shifts in causative microbiological agents over time. All patients in this prospective two-center study received prophylaxis with application of two collagen-gentamicin sponges between the sternal halves in addition to routine intravenous antibiotics. All patients were followed for 60 days postoperatively. From January 2007 to May 2008, 1359 patients were included. The 60-day incidences of any SWI was 3.7% and of deep SWI 1.5% (1.0% mediastinitis). Both superficial and deep SWI were significantly reduced compared with the previous control group (OR=0.34 for deep SWI, P<0.001). There was no increase in the absolute incidence of aminoglycoside resistant agents. The majority of SWI were caused by coagulase-negative staphylococci (CoNS). The incidence of deep SWI caused by Staphylococcus aureus was 0.07%. The results indicate a maintained effect of the prophylaxis over time without absolute increase in aminoglycoside resistance. (ClinicalTrials.gov NCT00484055).

Local collagen‐gentamicin for prevention of sternal wound infections: the LOGIP trial

In cardiac surgery, sternal wound infection (SWI) continues to be one of the most serious postoperative complications. Coagulase-negative staphylococci (CoNS) have become the most common causative agents of SWI. However, many CoNS species are resistant to routine intravenous antibiotic prophylaxis. 2000 cardiac surgery patients were randomised to routine prophylaxis with intravenous isoxazolyl penicillin alone (control group) or to this prophylaxis combined with application of collagen-gentamicin (260 mg gentamicin) sponges within the sternotomy before wound closure. The primary end-point was any sternal wound infection within 2 months postoperatively. The incidence of any sternal wound infection was 4.3% in the treatment group and 9.0% in the control group (relative risk=0.47; 95% confidence interval 0.33 to 0.68; P<0.001). Local gentamicin reduced the incidence of SWI caused by all major clinically important microbiological agents, including CoNS. Routine use of the described prophylaxis in all adult cardiac surgery patients could be recommended.

Prevention of sternal wound infections with locally administered gentamicin

Despite modern surgical techniques and our knowledge of the pathogenesis of surgical site infections (SSIs) and the use of perioperative antibiotic prophylaxis, the incidence of SSIs has not decreased, but has remained at the same level. More effective preventive methods are thus needed and will likely become even more important in the future due to older and sicker patients, the population becoming increasingly obese, type II diabetes becoming more common, and the emergence of resistant bacteria. The use of local antimicrobial prophylaxis was studied. The study population comprised 557 patients who underwent elective CABG. The patients were randomized and patients in the study group received a 10 cm x 10 cm gentamicin-collagen implant. Postoperative SSI occurred in 11 of 272 patients (4.0%) in the study group and in 16 of 270 patients (5.9%) in the control group. This difference was not statistically significant (P=0.20). There were three cases of mediastinitis (1.1%) in the study group and five (1.9%) in the control group (P=0.47).