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Izquierdo-Blasco J, Campins-Martí M, Soler-Palacín P, Balcells J, Abella R, Gran F, Castillo F, Nuño R, Sanchez-de-Toledo J. Impact of the implementation of an interdisciplinary infection control program to prevent surgical wound infection in pediatric heart surgery. Eur J Pediatr 2015; 174:957-63. [PMID: 25652766 DOI: 10.1007/s00431-015-2493-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 01/11/2015] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
Abstract
UNLABELLED Surgical site infection (SSI) remains a major source of morbidity, mortality, and increased health care costs in children undergoing heart surgery. The aim of this study was to assess the effectiveness of an intervention program designed to reduce the high incidence of SSI observed at our center in pediatric patients. An interdisciplinary infection control program including pre-, intra-, and postoperative measures was introduced for children undergoing heart surgery with cardiopulmonary bypass. We conducted a quasi-experimental interventional study comparing a pre-intervention cohort (June 2009 to March 2010) and a post-intervention cohort (July 2011 to July 2012). A significant drop in SSI incidence from 10.9 % (95 % CI 4.7-18.8) to 1.92 % (95 % CI 0.4-5.52) was observed. Variables significantly associated with infection risk were median age (14 days in infected vs 2.3 years in non-infected patients; p<0.01), hospitalization unit (10.3 % SSI cumulative incidence in the neonatal intensive care unit vs 0 cases in the pediatric intensive care unit; p<0.01), and median preoperative hospital stay (14 days in infected vs 1 day in non-infected patients; p=0.03). CONCLUSIONS The implementation of a new intervention program was associated with an 82 % (95 % CI 34-94) reduction in SSI incidence in children undergoing heart surgery at our center. WHAT IS KNOWN • Surgical site infection (SSI) is associated with significant morbidity and mortality following pediatric cardiac surgery. • Younger patients and longer cardiopulmonary bypass times are associated with higher SSI rates. What is New: • Comprehensive infection control program including preoperative, intraoperative and postoperative nonpharmacologic measures is a key factor for the prevention of SSI. • A significant reduction in SSI rates can be achieve despite a narrower-spectrum antibiotic usage.
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Affiliation(s)
- Jaume Izquierdo-Blasco
- Department of Pediatric Intensive Care Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Olsson DP, Holzmann MJ, Sartipy U. Antibiotic Prophylaxis by Teicoplanin and Risk of Acute Kidney Injury in Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:626-31. [DOI: 10.1053/j.jvca.2014.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Indexed: 11/11/2022]
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103
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A novel protocol for antibiotic prophylaxis based on preoperative kidney function in patients undergoing open heart surgery under cardiopulmonary bypass. Gen Thorac Cardiovasc Surg 2015; 63:446-52. [DOI: 10.1007/s11748-015-0552-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 04/16/2015] [Indexed: 11/26/2022]
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104
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Zhang QS, Han B, Xu JH, Gao P, Shen YC. Antimicrobial prophylaxis in patients with colorectal lesions undergoing endoscopic resection. World J Gastroenterol 2015; 21:4715-4721. [PMID: 25914483 PMCID: PMC4402321 DOI: 10.3748/wjg.v21.i15.4715] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 11/25/2014] [Accepted: 01/21/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of prophylaxis with antibiotics on clinical adverse events in patients who underwent endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) for colorectal lesions.
METHODS: From June 2011 to December 2013, a total of 428 patients were enrolled into the study, of which 214 patients admitted to hospital underwent EMR or ESD procedures. These patients were randomized to an antibiotic group, in which patients were given cefuroxime 1.5 g iv half an hour before and 6 h after surgery respectively, and a control group, in which patients were not given any antibiotic. A further 214 outpatients with small polyps treated by polypectomy were compared with controls that were matched by age and gender, and operations were performed as outpatient surgery. Recorded patient parameters were demographics, characteristics of lesions and treatment modality, and the size of the wound area. The primary outcome measures were clinical adverse events, including abdominal pain, diarrhea, hemotachezia, and fever. Secondary outcome measures were white blood cell count, C-reactive protein and blood culture. Additionlly, the relationship between the size of the wound area and clinical adverse events was analyzed.
RESULTS: A total of 409 patients were enrolled in this study, with 107 patients in the control group, 107 patients in the antibiotic group, and another 195 cases in the follow-up outpatient group. The patients’ demographic characteristics, including age, gender, characteristics of lesions, treatment modality, and the size of the wound area were similar between the 2 groups. The rates of adverse events in the antibiotic group were significantly lower than in the control group: abdominal pain (2.8% vs 14.9%, P < 0.01), diarrhea (2.0% vs 9.3%, P < 0.05), and fever (0.9% vs 8.4%, P < 0.05) respectively. The levels of inflammatory markers also decreased significantly in the antibiotic group compared with the control group: leukocytosis (2.0% vs 11.2%, P < 0.01), and C-reactive protein (2.0% vs 10.7%, P < 0.05). Additionally, clinical adverse events were related to the size of the surgical wound area. When the surgical wound area was larger than 10 mm × 10 mm, there were more clinical adverse events.
CONCLUSION: Clinical adverse events are not uncommon after EMR or ESD procedures. Prophylactic antibiotics can reduce the incidence of clinical adverse events. This should be further explored.
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105
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Trent Magruder J, Grimm JC, Dungan SP, Shah AS, Crow JR, Shoulders BR, Lester L, Barodka V. Continuous Intraoperative Cefazolin Infusion May Reduce Surgical Site Infections During Cardiac Surgical Procedures: A Propensity-Matched Analysis. J Cardiothorac Vasc Anesth 2015; 29:1582-7. [PMID: 26275516 DOI: 10.1053/j.jvca.2015.03.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The authors sought to determine whether an institutional transition from intermittent to continuous dosing of intraoperative antibiotics in cardiac surgery affected surgical site infection (SSI) outcomes. DESIGN A retrospective chart review utilizing propensity matching. SETTING A single academic, tertiary care hospital. PARTICIPANTS One thousand one hundred seventy-nine patients undergoing coronary artery bypass grafting (CABG) and/or cardiac valvular surgery between April 2013 and November 2014 who received perioperative cefazolin. INTERVENTIONS By method of cefazolin administration, patients were divided into an "intermittent-dosing" (ID) group and a "continuous-infusion" (CI) group. MEASUREMENTS AND MAIN RESULTS Of the 1,179 patients who underwent cardiac surgery during the study period, 1:1 propensity score matching yielded 399 patients in each group. Rates of diabetes (33.6% ID v 33.8% CI, p = 0.94), coronary artery bypass (62.3% v 61.4%, p = 0.66), and bilateral internal mammary artery harvesting (6.0% v 8.3%, p = 0.22) were similar between groups. SSIs occurred in more ID patients than CI patients (2.3% v 0.5%, p = 0.03). This difference was driven by decreases in extremity and conduit harvest site SSIs (1.8% v 0.3%, p = 0.03), as there were no episodes of mediastinitis, and superficial sternal SSI rates did not differ (0.5% v 0.3%, p = 0.56). There also were significantly fewer episodes of pneumonia in the CI group (6.0% v 2.3%, p = 0.008). Intensive care unit and total lengths of stay did not differ. Thirty-day mortality was 2.8% in both groups (p = 1.00). CONCLUSIONS As compared to ID regimens, CI cefazolin infusion may reduce post-cardiac surgery infectious complications. Further study in larger patient populations is needed.
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Affiliation(s)
| | | | | | | | | | - Bethany R Shoulders
- Cardiac Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laeben Lester
- Cardiac Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Viachaslau Barodka
- Cardiac Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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106
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Targeting cefuroxime plasma concentrations during coronary artery bypass graft surgery with cardiopulmonary bypass. Int J Clin Pharm 2015; 37:592-8. [DOI: 10.1007/s11096-015-0101-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
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107
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Lazar HL. Topical antibiotics help to reduce sternal infections. J Thorac Cardiovasc Surg 2015; 149:1641-2. [PMID: 25746031 DOI: 10.1016/j.jtcvs.2015.01.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 01/30/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, Boston Medical Center, Boston, Mass.
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108
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Hamouda K, Oezkur M, Sinha B, Hain J, Menkel H, Leistner M, Leyh R, Schimmer C. Different duration strategies of perioperative antibiotic prophylaxis in adult patients undergoing cardiac surgery: an observational study. J Cardiothorac Surg 2015; 10:25. [PMID: 25880032 PMCID: PMC4345000 DOI: 10.1186/s13019-015-0225-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 02/10/2015] [Indexed: 11/25/2022] Open
Abstract
Background All international guidelines recommend perioperative antibiotic prophylaxis (PAB) should be routinely administered to patients undergoing cardiac surgery. However, the duration of PAB is heterogeneous and controversial. Methods Between 01.01.2011 and 31.12.2011, 1096 consecutive cardiac surgery patients were assigned to one of two groups receiving PAB with a second-generation cephalosporin for either 56 h (group I) or 32 h (group II). Patients’ characteristics, intraoperative data, and the in-hospital follow-up were analysed. Primary endpoint was the incidence of surgical site infection (deep and superficial sternal wound-, and vein harvesting site infection; DSWI/SSWI/VHSI). Secondary endpoints were the incidence of respiratory-, and urinary tract infection, as well as the mortality rate. Results 615/1096 patients (56,1%) were enrolled (group I: n = 283 versus group II: n = 332). There were no significant differences with regard to patient characteristics, comorbidities, and procedure-related variables. No statistically significant differences were demonstrated concerning primary and secondary endpoints. The incidence of DSWI/SSWI/VHSI were 4/283 (1,4%), 5/283 (1,7%), and 1/283 (0,3%) in group I versus 6/332 (1,8%), 9/332 (2,7%), and 3/332 (0,9%) in group II (p = 0,76/0,59/0,63). In univariate analyses female gender, age, peripheral arterial obstructive disease, operating-time, ICU-duration, transfusion, and respiratory insufficiency were determinants for nosocomial infections (all ≤ 0,05). Subgroup analyses of these high-risk patients did not show any differences between the two regimes (all ≥ 0,05). Conclusions Reducing the duration of PAB from 56 h to 32 h in adult cardiac surgery patients was not associated with an increase of nosocomial infection rate, but contributes to reduce antibiotic resistance and health care costs.
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Affiliation(s)
- Khaled Hamouda
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Mehmet Oezkur
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Bhanu Sinha
- Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands.
| | - Johannes Hain
- University of Würzburg, Institute of Mathematics and Informatics, Chair of Mathematics VIII (Statistics), Würzburg, Germany.
| | - Hannah Menkel
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Marcus Leistner
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Rainer Leyh
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Christoph Schimmer
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
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Eyler RF, Butler SO, Walker PC, DePestel DD, Spoor MT, Pagani FD, Malani PN. Vancomycin Use During Left Ventricular Assist Device Support. Infect Control Hosp Epidemiol 2015; 30:484-6. [DOI: 10.1086/597231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We reviewed the frequency and duration of vancomycin use during 93 left ventricular assist device placements. Vancomycin prophylaxis was administered for a mean duration (± standard deviation) of 10.5 ± 11 days. Empirical vancomycin use was frequent, with a mean duration (± standard deviation) of therapy of 9.8 ± 9 days (median, 8 days) given during 81 (87%) of the implantations. The most common indications for empirical vancomycin treatment were isolated leukocytosis or driveline drainage. Strategies to improve vancomycin use during left ventricular assist device support should be considered.
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110
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Glycopeptides Versus β-Lactams for the Prevention of Surgical Site Infections in Cardiovascular and Orthopedic Surgery. Ann Surg 2015; 261:72-80. [DOI: 10.1097/sla.0000000000000704] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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111
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Andreas M, Zeitlinger M, Wisser W, Jaeger W, Maier-Salamon A, Thalhammer F, Kocher A, Hiesmayr JM, Laufer G, Hutschala D. Cefazolin and linezolid penetration into sternal cancellous bone during coronary artery bypass grafting. Eur J Cardiothorac Surg 2014; 48:758-64. [PMID: 25527166 DOI: 10.1093/ejcts/ezu491] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 11/25/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Deep sternal wound infection is a severe complication after cardiac surgery. Insufficient antibiotic target site concentrations may account for variable success of perioperative prophylaxis. Therefore, we measured perioperative penetration of cefazolin and of linezolid into sternal cancellous bone after sternotomy in coronary artery bypass grafting (CABG) patients by in vivo microdialysis. METHODS Nine patients underwent CABG using a skeletonized left internal mammary artery. Standard antibiotic prophylaxis consisted of 4 g cefazolin prior to skin incision and additional 2 g during skin closure. In addition, 600 mg of linezolid were administered prior to skin incision and after 12 h for study purposes. Two microdialysis probes were inserted into the sternal cancellous bone (left and right side) after sternotomy. RESULTS First mean peak cefazolin and linezolid plasma concentrations were 273 ± 92 µg/ml and 22.1 ± 8.9 µg/ml, respectively. Mean peak concentrations of antibiotics in sternal cancellous bone on the left and right sternal side were 112 ± 59 µg/ml and 159 ± 118 µg/ml for cefazolin and 10.9 ± 4.0 µg/ml and 12.6 ± 6.1 µg/ml for linezolid, respectively. Cefazolin exceeded the required tissue concentrations for relevant pathogens by far, but linezolid did not gain effective tissue concentrations in all patients for some relevant pathogens. Mammary artery harvesting had no significant effect on antibiotic tissue penetration. CONCLUSIONS Direct measurement of antibiotic concentration in sternal cancellous bone with in vivo microdialysis is technically demanding but safe and feasible. We could demonstrate sufficient antibiotic coverage with our standard cefazolin-dosing regimen in the sternal cancellous bone during cardiac surgery. Mammary artery harvesting had no clinically relevant effect on tissue penetration. Linezolid concentrations were not sufficient for some relevant pathogens.
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Affiliation(s)
- Martin Andreas
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilfried Wisser
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Jaeger
- Department of Clinical Pharmacy and Diagnostics, University of Vienna, Vienna, Austria
| | | | - Florian Thalhammer
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alfred Kocher
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Joerg-Michael Hiesmayr
- Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Guenther Laufer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Doris Hutschala
- Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
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Turcotte RF, Brozovich A, Corda R, Demmer RT, Biagas KV, Mangino D, Covington L, Ferris A, Thumm B, Bacha E, Smerling A, Saiman L. Health care-associated infections in children after cardiac surgery. Pediatr Cardiol 2014; 35:1448-55. [PMID: 24996642 DOI: 10.1007/s00246-014-0953-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 06/12/2014] [Indexed: 11/25/2022]
Abstract
Few recent studies have assessed the epidemiology of health care-associated infections (HAIs) in the pediatric population after cardiac surgery. A retrospective cohort study was performed to assess the epidemiology of several types of HAIs in children 18 years of age or younger undergoing cardiac surgery from July 2010 to June 2012. Potential pre-, intra-, and postoperative risk factors, including adherence to the perioperative antibiotic prophylaxis regimen at the authors' hospital, were assessed by multivariable analysis using Poisson regression models. Microorganisms associated with HAIs and their susceptibility patterns were described. Overall, 634 surgeries were performed, 38 (6 %) of which were complicated by an HAI occurring within 90 days after surgery. The HAIs included 7 central line-associated bloodstream infections (CLABSIs), 12 non-CLABSI bacteremias, 6 episodes of early postoperative infective endocarditis (IE), 9 surgical-site infections (SSIs), and 4 ventilator-associated pneumonias (VAPs). Mechanical ventilation (rate ratio [RR] 1.07 per day; 95 % confidence interval [CI] 1.03-1.11; p = 0.0002), postoperative transfusion of blood products (RR 3.12; 95 %, CI 1.38-7.06; p = 0.0062), postoperative steroid use (RR 3.32; 95 % CI 1.56-7.02; p = 0.0018), and continuation of antibiotic prophylaxis longer than 48 h after surgery (RR 2.56; 95 % CI 1.31-5.03; p = 0.0062) were associated with HAIs. Overall, 66.7 % of the pathogens associated with SSIs were susceptible to cefazolin, the perioperative antibiotic prophylaxis used by the authors' hospital. In conclusion, HAIs occurred after 6 % of cardiac surgeries. Bacteremia and CLABSI were the most common. This study identified several potentially modifiable risk factors that suggest interventions. Further studies should assess the role of improving adherence to perioperative antibiotic prophylaxis, the age of transfused red blood cells, and evidence-based guidelines for postoperative steroids.
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Affiliation(s)
- Rebecca F Turcotte
- Department of Pediatrics, Columbia University Medical Center, 3959 Broadway, CHN 10-24, New York, NY, 10032, USA,
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Gelijns AC, Moskowitz AJ, Acker MA, Argenziano M, Geller NL, Puskas JD, Perrault LP, Smith PK, Kron IL, Michler RE, Miller MA, Gardner TJ, Ascheim DD, Ailawadi G, Lackner P, Goldsmith LA, Robichaud S, Miller RA, Rose EA, Ferguson TB, Horvath KA, Moquete EG, Parides MK, Bagiella E, O'Gara PT, Blackstone EH. Management practices and major infections after cardiac surgery. J Am Coll Cardiol 2014; 64:372-81. [PMID: 25060372 DOI: 10.1016/j.jacc.2014.04.052] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/24/2014] [Accepted: 04/03/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Infections are the most common noncardiac complication after cardiac surgery, but their incidence across a broad range of operations, as well as the management factors that shape infection risk, remain unknown. OBJECTIVES This study sought to prospectively examine the frequency of post-operative infections and associated mortality, and modifiable management practices predictive of infections within 65 days from cardiac surgery. METHODS This study enrolled 5,158 patients and analyzed independently adjudicated infections using a competing risk model (with death as the competing event). RESULTS Nearly 5% of patients experienced major infections. Baseline characteristics associated with increased infection risk included chronic lung disease (hazard ratio [HR]: 1.66; 95% confidence interval [CI]: 1.21 to 2.26), heart failure (HR: 1.47; 95% CI: 1.11 to 1.95), and longer surgery (HR: 1.31; 95% CI: 1.21 to 1.41). Practices associated with reduced infection risk included prophylaxis with second-generation cephalosporins (HR: 0.70; 95% CI: 0.52 to 0.94), whereas post-operative antibiotic duration >48 h (HR: 1.92; 95% CI: 1.28 to 2.88), stress hyperglycemia (HR: 1.32; 95% CI: 1.01 to 1.73); intubation time of 24 to 48 h (HR: 1.49; 95% CI: 1.04 to 2.14); and ventilation >48 h (HR: 2.45; 95% CI: 1.66 to 3.63) were associated with increased risk. HRs for infection were similar with either <24 h or <48 h of antibiotic prophylaxis. There was a significant but differential effect of transfusion by surgery type (excluding left ventricular assist device procedures/transplant) (HR: 1.13; 95% CI: 1.07 to 1.20). Major infections substantially increased mortality (HR: 10.02; 95% CI: 6.12 to 16.39). CONCLUSIONS Major infections dramatically affect survival and readmissions. Second-generation cephalosporins were strongly associated with reduced major infection risk, but optimal duration of antibiotic prophylaxis requires further study. Given practice variations, considerable opportunities exist for improving outcomes and preventing readmissions. (Management Practices and Risk of Infection Following Cardiac Surgery; NCT01089712).
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Affiliation(s)
- Annetine C Gelijns
- International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York.
| | - Alan J Moskowitz
- International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Michael A Acker
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Michael Argenziano
- Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Nancy L Geller
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - John D Puskas
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Louis P Perrault
- Montréal Heart Institute, University of Montréal, Montréal, Québec, Canada
| | - Peter K Smith
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Irving L Kron
- Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Robert E Michler
- Department of Cardiothoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York
| | - Marissa A Miller
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Timothy J Gardner
- Center for Heart & Vascular Health, Christiana Care Health System, Newark, Delaware
| | - Deborah D Ascheim
- International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Pamela Lackner
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lyn A Goldsmith
- Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Sophie Robichaud
- Montréal Heart Institute, University of Montréal, Montréal, Québec, Canada
| | - Rachel A Miller
- Department of Medicine, Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Eric A Rose
- International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York
| | - T Bruce Ferguson
- Department of Cardiovascular Sciences; East Carolina Heart Institute at East Carolina University, Greenville, North Carolina
| | | | - Ellen G Moquete
- International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Michael K Parides
- International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Emilia Bagiella
- International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Patrick T O'Gara
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Gorski A, Hamouda K, Özkur M, Leistner M, Sommer SP, Leyh R, Schimmer C. Cardiac surgery antibiotic prophylaxis and calculated empiric antibiotic therapy. Asian Cardiovasc Thorac Ann 2014; 23:282-8. [PMID: 25061221 DOI: 10.1177/0218492314546028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ongoing debate exists concerning the optimal choice and duration of antibiotic prophylaxis as well as the reasonable calculated empiric antibiotic therapy for hospital-acquired infections in critically ill cardiac surgery patients. METHODS A nationwide questionnaire was distributed to all German heart surgery centers concerning antibiotic prophylaxis and the calculated empiric antibiotic therapy. RESULTS The response to the questionnaire was 87.3%. All clinics that responded use antibiotic prophylaxis, 79% perform it not longer than 24 h (single-shot: 23%; 2 doses: 29%; 3 doses: 27%; 4 doses: 13%; and >5 doses: 8%). Cephalosporin was used in 89% of clinics (46% second-generation, 43% first-generation cephalosporin). If sepsis is suspected, the following diagnostics are performed routinely: wound inspection 100%; white blood cell count 100%; radiography 99%; C-reactive protein 97%; microbiological testing of urine 91%, blood 81%, and bronchial secretion 81%; procalcitonin 74%; and echocardiography 75%. The calculated empiric antibiotic therapy (depending on the suspected focus) consists of a multidrug combination with broad-spectrum agents. CONCLUSION This survey shows that existing national guidelines and recommendations concerning perioperative antibiotic prophylaxis and calculated empiric antibiotic therapy are well applied in almost all German heart centers.
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Affiliation(s)
- Armin Gorski
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Khaled Hamouda
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Mehmet Özkur
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Markus Leistner
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Sebastian-Patrick Sommer
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Rainer Leyh
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Christoph Schimmer
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
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Murray MT, Corda R, Turcotte R, Bacha E, Saiman L, Krishnamurthy G. Implementing a standardized perioperative antibiotic prophylaxis protocol for neonates undergoing cardiac surgery. Ann Thorac Surg 2014; 98:927-33. [PMID: 25038006 DOI: 10.1016/j.athoracsur.2014.04.090] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 04/11/2014] [Accepted: 04/21/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND A lack of perioperative antibiotic prophylaxis guidelines for neonates undergoing cardiac surgery has resulted in a wide variation in practice. We sought to do the following: (1) Determine the safety of a perioperative antibiotic prophylaxis protocol for neonatal cardiac surgery as measured by surgical site infections (SSIs) rates before and after implementation of the protocol; and (2) evaluate compliance with selected process measures for perioperative antibiotic prophylaxis. METHODS This quasi-experimental study included all cardiac procedures performed on neonates from July 2009 to June 2012 at a single center. An interdisciplinary task force developed a standardized perioperative antibiotic prophylaxis protocol in the fourth quarter of 2010. The SSI rates were compared in the preintervention (July 2009 to December 2010) versus the postintervention periods (January 2011 to June 2012). Compliance with process measures (appropriate drug, dose, timing, and discontinuation of perioperative antibiotic prophylaxis) was compared in the 2 periods. RESULTS During the study period, 283 cardiac procedures were performed. The SSI rates were similar in the preintervention and postintervention periods (6.21 vs 5.80 per 100 procedures, respectively). Compliance with the 4 process measures significantly improved postintervention. CONCLUSIONS Restricting the duration of perioperative antibiotic prophylaxis after neonatal cardiac surgery to 48 hours in neonates with a closed sternum and to 24 hours after sternal closure was safe and did not increase the rate of SSIs. Compliance with selected process measures improved in the postintervention period. Additional multicenter studies are needed to develop national guidelines for perioperative prophylaxis for this population.
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Affiliation(s)
- Meghan T Murray
- School of Nursing, Columbia University Medical Center, New York, New York
| | - Rozelle Corda
- School of Nursing, Columbia University Medical Center, New York, New York; Department of Surgery, Columbia University Medical Center, New York, New York
| | - Rebecca Turcotte
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Emile Bacha
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, New York; Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Medical Center, New York, New York.
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117
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Topical vancomycin in combination with perioperative antibiotics and tight glycemic control helps to eliminate sternal wound infections. J Thorac Cardiovasc Surg 2014; 148:1035-8; 1038-40. [PMID: 25129595 DOI: 10.1016/j.jtcvs.2014.06.045] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/17/2014] [Accepted: 06/27/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study was undertaken to determine whether topical vancomycin would further reduce the incidence of sternal infections in the presence of perioperative antibiotics and tight glycemic control. METHODS A total of 1075 consecutive patients undergoing cardiac surgery from December 2007 to August 2013 receiving topical vancomycin (2.5 g in 2 mL of normal saline) applied as a slurry to the cut edges of the sternum were compared with 2190 patients from December 2003 to November 2007 who did not receive topical vancomycin. All patients received perioperative antibiotics (cefazolin 2 g intravenously every 8 hours and vancomycin 1 g intravenously every 12 hours) on induction of anesthetic and continuing for 48 hours; and intravenous insulin infusions to maintain serum blood glucose level between 120 and 180 mg/dL. RESULTS Patients receiving topical vancomycin had less superficial sternal infections (0% vs 1.6%; P < .0001), deep sternal infections (0% vs 0.7%; P = .005), any type of sternal infection (0% vs 2.2%; P < .0001) and significantly less sternal infections of any type in patients with diabetes mellitus (0% vs 3.3%; P = .0004). CONCLUSIONS Topical vancomycin applied to the sternal edges, in conjunction with perioperative antibiotics and tight glycemic control, helps to eliminate wound infections in cardiac surgical patients.
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118
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Kobayashi J, Kusachi S, Sawa Y, Motomura N, Imoto Y, Makuuchi H, Tanemoto K, Shimahara Y, Sumiyama Y. Socioeconomic effects of surgical site infection after cardiac surgery in Japan. Surg Today 2014; 45:422-8. [DOI: 10.1007/s00595-014-0969-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 02/14/2014] [Indexed: 12/29/2022]
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119
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Senaratne JM, Jayasuriya A, Irwin M, Gulamhusein S, Senaratne MPJ. A 19-year study on pacemaker-related infections: a claim for using postoperative antibiotics. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:947-54. [PMID: 24766534 DOI: 10.1111/pace.12403] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 02/01/2014] [Accepted: 03/02/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although the incidence of pacemaker-related infection (PMINF) is low, it necessitates removal of the pacing system. There is currently no consensus on antibiotics during implantation. METHODS A prospective database on patients undergoing pacemaker surgery from 1991 to 2009 was reviewed to determine factors associated with PMINF. Specifically, three eras of antibiotic use were compared to elucidate the effect of antibiotics on PMINF: no antibiotics, perioperative antibiotics, and peri- plus postoperative antibiotics. RESULTS There were 3,253 procedures with PMINF identified in 46 (1.4%) patients. Over 19 years, PMINF incidence fell from 3.6% (no antibiotics) to 2.9% (perioperative antibiotics), to 0.4% (peri- plus postoperative antibiotics). On univariate analysis, the following were associated with PMINF: nonuse of postoperative antibiotics (3.0% vs 0.4%, P < 0.001), year of implant (P < 0.001), repeat procedures (2.3% vs 1%, P = 0.006), nonuse of perioperative antibiotics (3.6% vs 1.3%, P = 0.027). With postoperative antibiotics, rates were significantly reduced in new implants (1/1,289 = 0.1% vs 22/967 = 2.3%, P < 0.001) and repeat procedures (7/692 = 1.0% vs 16/305 = 5.2%, P < 0.001). On multivariate analysis, the following were significant (standardized coefficients denote relative importance): postoperative antibiotics (0.776), repeat procedures (0.508), year of implant (0.142), perioperative antibiotics (0.088). CONCLUSIONS The PMINF rate is reduced significantly by perioperative antibiotics with a further significant reduction with postoperative antibiotics. However, the reduction in PMINF rate could be a result of changes in practice in the different time eras. This study suggests consideration of perioperative followed by postoperative antibiotics to minimize pacemaker infections.
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Affiliation(s)
- Janek M Senaratne
- Division of Cardiac Sciences, Grey Nuns Hospital, Edmonton, Alberta, Canada
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120
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Miyahara K, Matsuura A, Takemura H, Mizutani S, Saito S, Toyama M. Implementation of bundled interventions greatly decreases deep sternal wound infection following cardiovascular surgery. J Thorac Cardiovasc Surg 2014; 148:2381-8. [PMID: 24820192 DOI: 10.1016/j.jtcvs.2014.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 03/15/2014] [Accepted: 04/04/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Surgical site infection (SSI), particularly deep sternal wound infection (DSWI), is a serious complication after cardiovascular surgery because of its high mortality rate. We evaluated the effectiveness of an SSI bundle to reduce DSWI and identify the risk factors for DSWI. METHODS During the period January 2004 to February 2012, 1374 consecutive patients undergoing cardiovascular surgery via sternotomy were included. The cohort was separated into periods from January 2004 through February 2007 (period I, 682 patients) and March 2007 through February 2012 (period II, 692 patients). During period II, all preventive measures for DSWI were completed as an SSI bundle. We compared the DSWI rate between the 2 periods. Univariate and multivariate analyses were performed for the entire period to identify the risk factors for DSWI. RESULTS DSWI occurred in 13 patients (1.9%) during period I and in 1 patient (0.14%) during period II. The DSWI rate during period II was significantly decreased by 93%, compared with period I (P=.001). Independent risk factors for DSWI included obesity (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.00-11.75; P=.049), the use of 4 sternal wires (OR, 8.2; 95% CI, 1.39-48.14; P=.020), long operative time (OR, 4.4; 95% CI, 1.20-16.23; P=.026), and postoperative renal failure (OR, 9.0; 95% CI, 2.44-33.30; P=.001). CONCLUSIONS Complete implementation of simple multidisciplinary prevention measures as a bundle can greatly decrease the incidence of DSWI.
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Affiliation(s)
- Ken Miyahara
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan.
| | - Akio Matsuura
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan
| | - Haruki Takemura
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan
| | - Shinichi Mizutani
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan
| | - Shunei Saito
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan
| | - Masashi Toyama
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan
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Parada JM, Carreño M, Camacho J, Sandoval NF, Umaña JP. Factores asociados a la aparición de mediastinitis en 2.073 revascularizaciones miocárdicas. REVISTA COLOMBIANA DE CARDIOLOGÍA 2014. [DOI: 10.1016/s0120-5633(14)70264-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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122
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Hansen E, Belden K, Silibovsky R, Vogt M, Arnold WV, Bicanic G, Bini SA, Catani F, Chen J, Ghazavi MT, Godefroy KM, Holham P, Hosseinzadeh H, Kim KII, Kirketerp-Møller K, Lidgren L, Lin JH, Lonner JH, Moore CC, Papagelopoulos P, Poultsides L, Randall RL, Roslund B, Saleh K, Salmon JV, Schwarz EM, Stuyck J, Dahl AW, Yamada K. Perioperative antibiotics. J Arthroplasty 2014; 29:29-48. [PMID: 24355256 DOI: 10.1016/j.arth.2013.09.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Erik Hansen
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Katherine Belden
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Randi Silibovsky
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Markus Vogt
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - William V Arnold
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Goran Bicanic
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Stefano A Bini
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Fabio Catani
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jiying Chen
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mohammad T Ghazavi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karine M Godefroy
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul Holham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Hamid Hosseinzadeh
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kang I I Kim
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Lars Lidgren
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jian Hao Lin
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jess H Lonner
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher C Moore
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Lazaros Poultsides
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - R Lor Randall
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Brian Roslund
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Khalid Saleh
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Julia V Salmon
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Edward M Schwarz
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jose Stuyck
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Annette W Dahl
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Koji Yamada
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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123
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Huang JH, Sunstrom R, Munar MY, Cherala G, Legg A, Olyeai AJ, Langley SM. Are children undergoing cardiac surgery receiving antibiotics at subtherapeutic levels? J Thorac Cardiovasc Surg 2014; 148:1591-6. [PMID: 24521951 DOI: 10.1016/j.jtcvs.2013.12.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 12/04/2013] [Accepted: 12/24/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Perioperative antibiotics have decreased-but not eradicated-postoperative infections. In patients undergoing cardiac surgery with cardiopulmonary bypass, the dilutional effect of the priming and any additional volume given during the procedure may lead to subtherapeutic antibiotic levels. Our aim was to determine if children undergoing cardiac surgery with cardiopulmonary bypass receive perioperative antibiotics at subtherapeutic levels. METHODS Using published pharmacokinetic data on cefuroxime, we developed a computer simulation model to generate a nomogram predicting patients at risk for subtherapeutic cefuroxime levels based on time from initial dosing and additional volume given. RESULTS A computer-generated 1-compartment pharmacokinetic model was created to predict cefuroxime plasma levels over time for patients of all weights and additional volumes given for both a 25- and 50-mg/kg intravenous dose. For example, following a 25-mg/kg dose, a patient receiving an additional volume of 275 mL/kg is predicted to be subtherapeutic (<16 mg/L=4×minimum inhibitory concentration) at 4 hours. Our nomogram predicts all patients will be subtherapeutic at 8 hours, consistent with general pediatrics dosing schemes. Following a 50-mg/kg dose, levels are predicted to be subtherapeutic after an additional volume of 315 mL/kg at 5.5 hours. CONCLUSIONS Our model predicts which patients undergoing cardiac surgery with cardiopulmonary will have subtherapeutic cefuroxime levels. This nomogram enables providers to determine when to administer additional antibiotics in patients receiving large additional volumes during cardiac surgeries. This rational approach to perioperative antibiotic dosing may result in a reduction in postoperative infection in this vulnerable patient population.
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Affiliation(s)
- Jennifer H Huang
- Division of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health Science University, Portland, Ore.
| | - Rachel Sunstrom
- Division of Pediatric Cardiac Surgery, Oregon Health Science University, Doernbecher Children's Hospital, Portland, Ore
| | - Myrna Y Munar
- College of Pharmacy, Oregon State University, Corvallis, Ore
| | - Ganesh Cherala
- College of Pharmacy, Oregon State University, Corvallis, Ore
| | - Arthur Legg
- Division of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health Science University, Portland, Ore
| | - Ali J Olyeai
- College of Pharmacy, Oregon State University, Corvallis, Ore
| | - Stephen M Langley
- Division of Pediatric Cardiac Surgery, Oregon Health Science University, Doernbecher Children's Hospital, Portland, Ore
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Abstract
In the current era of pay-for-performance standards, the incidence of surgical site infections is increasingly becoming an institutional marker of quality assurance. Surgical site infections lead to increased morbidity and mortality in the surgical population and contribute to an already rising healthcare cost. As a result, the surgical community goes to great lengths to prevent this costly and occasionally lethal complication. Many practices are evidence based, however, many are not. In this article, the most commonly used preventive strategies in practice today and the evidence behind each are reviewed. In addition, an overview of the epidemiology, pathophysiology and microbiology of surgical site infections will be provided.
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Affiliation(s)
- Traci L Hedrick
- Department of Surgery, University of Virginia Health System, PO Box 801380, Charlottesville, VA 22908, USA.
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125
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Hansen E, Belden K, Silibovsky R, Vogt M, Arnold W, Bicanic G, Bini S, Catani F, Chen J, Ghazavi M, Godefroy KM, Holham P, Hosseinzadeh H, Kim KII, Kirketerp-Møller K, Lidgren L, Lin JH, Lonner JH, Moore CC, Papagelopoulos P, Poultsides L, Randall RL, Roslund B, Saleh K, Salmon JV, Schwarz E, Stuyck J, Dahl AW, Yamada K. Perioperative antibiotics. J Orthop Res 2014; 32 Suppl 1:S31-59. [PMID: 24464896 DOI: 10.1002/jor.22549] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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126
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Fang Y, Guan Y, Wan C, Fu Z, Jiang J, Wu C, Zhao J, Sun P, Long C. The Dynamic Observation of Plasma Concentration of Antimicrobial Agents During Balanced Ultrafiltration In Vitro. Artif Organs 2013; 38:48-55. [PMID: 23865445 DOI: 10.1111/aor.12113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Yinghui Fang
- Department of Extracorporeal Circulation; State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Yulong Guan
- Department of Extracorporeal Circulation; State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Caihong Wan
- Department of Extracorporeal Circulation; Beijing Anzhen Hospital; Capital Medical University; Beijing China
| | - Zhida Fu
- Department of Extracorporeal Circulation; State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Juanjuan Jiang
- Key laboratory of Clinical Trial Research in Cardiovascular Drugs; Ministry of Health; State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Chunfu Wu
- Department of Orthopedics; General Hospital of Handan Coal Mineral Group; Handan Hebei China
| | - Ju Zhao
- Department of Extracorporeal Circulation; State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Peng Sun
- Department of Extracorporeal Circulation; State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Cun Long
- Department of Extracorporeal Circulation; State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
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127
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White RW, West R, Howard P, Sandoe J. Antimicrobial Regime for Cardiac Surgery
: The Safety and Effectiveness of Short-Course Flucloxacillin (or Teicoplanin) and Gentamicin-Based Prophylaxis. J Card Surg 2013; 28:512-6. [DOI: 10.1111/jocs.12155] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Ralph W. White
- Department of Cardiothoracic Surgery; Leeds Teaching Hospitals NHS Trust; Leeds UK
| | - Robert West
- Department of Biostatistics; University of Leeds; Leeds UK
| | - Philip Howard
- Department of Pharmacy; Leeds Teaching Hospitals NHS Trust; Leeds UK
| | - Jonathan Sandoe
- Department of Microbiology; Leeds Teaching Hospitals NHS Trust; Leeds UK
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128
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Woodward CS, Son M, Taylor R, Husain SA. Prevention of sternal wound infection in pediatric cardiac surgery: a protocolized approach. World J Pediatr Congenit Heart Surg 2013; 3:463-9. [PMID: 23804910 DOI: 10.1177/2150135112454145] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Cathy S Woodward
- Division of Critical Care, Department of Pediatrics, University of Texas Health Science Center, San Antonio, TX, USA
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129
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Blood concentrations of cefuroxime in cardiopulmonary bypass surgery. Int J Clin Pharm 2013; 35:798-804. [DOI: 10.1007/s11096-013-9810-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022]
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130
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Head SJ, Howell NJ, Osnabrugge RLJ, Bridgewater B, Keogh BE, Kinsman R, Walton P, Gummert JF, Pagano D, Kappetein AP. The European Association for Cardio-Thoracic Surgery (EACTS) database: an introduction. Eur J Cardiothorac Surg 2013; 44:e175-80. [PMID: 23786918 DOI: 10.1093/ejcts/ezt303] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Continuous monitoring of surgical outcomes through benchmarking and the identification of best practices has become increasingly important. A structured approach to data collection, coupled with validation, analysis and reporting, is a powerful tool in these endeavours. However, inconsistencies in standards and practices have made comparisons within and between European countries cumbersome. The European Association for Cardio-Thoracic Surgery (EACTS) has established a large international database with the goals of (i) working with other organizations towards universal data collection and creating a European-wide repository of information on the practice of cardio-thoracic surgery, and (ii) disseminating that information in scientific, peer-reviewed articles. We report on the process of data collection, as well as on an overview of the data in the database. METHODS The EACTS Database Committee met for the first time in Monaco, September 2002, to establish the ground rules for the process of setting up the database. Subsequently, data have been collected and merged by Dendrite Clinical Systems Ltd. RESULTS As of December 2008, the database included 1,074,168 patient records from 366 hospitals located in 29 countries. The latest submission from the years 2006-08 included 404,721 records. The largest contributors were the UK (32.0%), Germany (20.9%) and Belgium (7.3%). Isolated coronary bypass surgery was the most frequently performed operation; the proportion of surgical workload that comprised isolated coronary artery bypass grafting varied from country to country: 30% in Spain and almost 70% in Denmark. Isolated valve procedures constituted 12% of all procedures in Norway and 32% in Spain. Baseline demographics showed an increase in the mean age and the percentage of patients that were female over time. Remarkably, the mortality rates for all procedures declined over the period analysed, to 2.2% (95% confidence interval [CI] 2.2-2.3%) for isolated coronary bypass, 3.4% (95% CI 3.3-3.5%) for isolated valve and 6.2% (95% CI 6.0-6.5%) for bypass + valve procedures. CONCLUSION The EACTS database has proven to be an important step forward in providing opportunities for monitoring cardiac surgical care across Europe. As the database continues to expand, it will facilitate research projects, establish benchmarking standards and identify potential areas for quality improvements.
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Affiliation(s)
- Stuart J Head
- Erasmus University Medical Center, Rotterdam, The Netherlands
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Randomized Cluster Crossover Trials for Reliable, Efficient, Comparative Effectiveness Testing: Design of the Prevention of Arrhythmia Device Infection Trial (PADIT). Can J Cardiol 2013; 29:652-8. [DOI: 10.1016/j.cjca.2013.01.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 01/29/2013] [Accepted: 01/29/2013] [Indexed: 11/23/2022] Open
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Cotogni P, Passera R, Barbero C, Gariboldi A, Moscato D, Izzo G, Rinaldi M. Intraoperative vancomycin pharmacokinetics in cardiac surgery with or without cardiopulmonary bypass. Ann Pharmacother 2013; 47:455-63. [PMID: 23512663 DOI: 10.1345/aph.1r669] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Vancomycin is administered as antimicrobial prophylaxis to patients undergoing cardiac surgery, an intervention that usually requires cardiopulmonary bypass (CPB). Previous studies reported that CPB modifies vancomycin pharmacokinetic parameters. OBJECTIVE To investigate intraoperative vancomycin pharmacokinetic changes in a large population of patients undergoing cardiac surgery with CPB (on-pump) and without CPB (off-pump). METHODS In this prospective study, patients undergoing cardiac surgery received a single dose of vancomycin 1000 mg in a 60-minute intravenous infusion, with skin incision performed between 16 and 120 minutes after the end of the infusion. For the on-pump group, arterial samples were drawn before CPB (end of infusion, skin incision), during CPB (5, 30, and 60 minutes, and then every 60 minutes until CPB end), and after CPB (wound closure). For the off-pump group, arterial samples were drawn time-matched to the CPB period of the on-pump group. RESULTS Two hundred thirty-six consecutive patients were enrolled: 215 in the on-pump group and 21 in the off-pump group. A total of 1682 serum vancomycin concentrations (median 7/patient) were measured. Vancomycin maximum concentration ([Cmax] on-pump, 45.6 mg/L; off-pump, 47.3 mg/L); area under the concentration-time curve, zero to 8 hours ([AUC0-8] on-pump, 104.6 mg*h/L; off-pump, 96.1 mg*h/L); volume of distribution ([Vd] on-pump, 31 L; off-pump, 28.2 L); and total body clearance ([Cl] on-pump, 6.23 L/h; off-pump, 7.05 L/h) were similar. Moreover, Cmax and AUC0-∞ (AUC, zero to infinity) showed values comparable to those found in previous studies performed on noncardiac surgery patients. CONCLUSIONS In our study there were no significant differences in vancomycin Cmax, AUC0-8, Vd, and Cl between the on-pump and off-pump groups. CPB does not seem to significantly modify intraoperative vancomycin pharmacokinetics in patients undergoing cardiac surgery. The results of this study may contribute to increased knowledge of vancomycin pharmacokinetics.
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Affiliation(s)
- Paolo Cotogni
- Anesthesiology and Intensive Care, Department of Medicine, S. Giovanni Battista Hospital, University of Turin, Turin, Italy.
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73-156. [PMID: 23461695 DOI: 10.1089/sur.2013.9999] [Citation(s) in RCA: 698] [Impact Index Per Article: 63.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Dale W Bratzler
- College of Public Health, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma 73126-0901, USA.
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134
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Koval CE, Rakita R. Ventricular assist device related infections and solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:348-54. [PMID: 23465027 DOI: 10.1111/ajt.12126] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- C E Koval
- Department of Infectious Disease, Cleveland Clinic Foundation, Cleveland, OH, USA.
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135
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Feldman D, Pamboukian SV, Teuteberg JJ, Birks E, Lietz K, Moore SA, Morgan JA, Arabia F, Bauman ME, Buchholz HW, Deng M, Dickstein ML, El-Banayosy A, Elliot T, Goldstein DJ, Grady KL, Jones K, Hryniewicz K, John R, Kaan A, Kusne S, Loebe M, Massicotte MP, Moazami N, Mohacsi P, Mooney M, Nelson T, Pagani F, Perry W, Potapov EV, Eduardo Rame J, Russell SD, Sorensen EN, Sun B, Strueber M, Mangi AA, Petty MG, Rogers J. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: Executive summary. J Heart Lung Transplant 2013; 32:157-87. [DOI: 10.1016/j.healun.2012.09.013] [Citation(s) in RCA: 850] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 09/14/2012] [Indexed: 02/08/2023] Open
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136
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. [DOI: 10.2146/ajhp120568] [Citation(s) in RCA: 1364] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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137
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Schmitt C, Lacerda RA, Padoveze MC, Turrini RNT. Applying validated quality indicators to surgical antibiotic prophylaxis in a Brazilian hospital: learning what should be learned. Am J Infect Control 2012; 40:960-2. [PMID: 22622512 DOI: 10.1016/j.ajic.2012.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 01/08/2012] [Accepted: 01/09/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Compliance with the best surgical antibiotic prophylaxis practice is usually low despite many published guidelines. OBJECTIVE This study investigated compliance with the Hospital Infection Control Committee guideline for antibiotic prophylaxis in a Brazilian hospital using quality indicators. METHODS A retrospective study was carried out from November 2009 to March 2010. Medical records from adult inpatients undergoing cardiac, neurologic, and orthopedic clean surgeries were included. The full compliance index was considered 100% when the antibiotic prophylaxis showed adequacy in all evaluated attributes. Analyses were conducted with 5% significance. RESULTS Medical records from 101 cardiac, 128 neurologic, and 519 orthopedic surgical patients were evaluated. The compliance index was 4.9%, and the compliance index according to specialty was 5.8%, 3.1%, and 3.0%, respectively, for orthopedic, neurologic, and cardiac surgeries. The attribute route of administration produced the best outcomes, whereas the attribute duration of antibiotic prophylaxis produced the worst. No association was identified between compliance to the attributes and patient characteristics. CONCLUSION This study showed a low level of adherence to Hospital Infection Control Committee guidelines for antibiotic prophylaxis. This suggests that different strategies should be implemented to promote the best possible practice in the field of antibiotic prophylaxis with greater surgeon engagement.
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138
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When the timing is right: Antibiotic timing and infection after cardiac surgery. J Thorac Cardiovasc Surg 2012; 144:931-937.e4. [DOI: 10.1016/j.jtcvs.2012.01.087] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 12/01/2011] [Accepted: 01/25/2012] [Indexed: 11/21/2022]
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139
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DAROUICHE RABIH, MOSIER MICHAEL, VOIGT JEFFREY. Antibiotics and Antiseptics to Prevent Infection in Cardiac Rhythm Management Device Implantation Surgery. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1348-60. [DOI: 10.1111/j.1540-8159.2012.03506.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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140
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Should intravenous immunoglobulin be given to patients with postoperative chylothorax? Pediatr Crit Care Med 2012; 13:599-600. [PMID: 22955461 DOI: 10.1097/pcc.0b013e31824ea2e6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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141
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Cove ME, Spelman DW, MacLaren G. Infectious complications of cardiac surgery: a clinical review. J Cardiothorac Vasc Anesth 2012; 26:1094-100. [PMID: 22765993 DOI: 10.1053/j.jvca.2012.04.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Indexed: 12/28/2022]
Affiliation(s)
- Matthew E Cove
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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142
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Rodrigues JF, Casado A, Palos C, Santos C, Duarte A, Fernandez-Llimos F. A computer-assisted prescription system to improve antibacterial surgical prophylaxis. Infect Control Hosp Epidemiol 2012; 33:435-7. [PMID: 22418648 DOI: 10.1086/664923] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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143
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Álvarez P, Fuentes C, García N, Modesto V. Evaluation of the duration of the antibiotic prophylaxis in paediatric postoperative heart surgery patients. Pediatr Cardiol 2012; 33:735-8. [PMID: 22349725 DOI: 10.1007/s00246-012-0202-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 11/23/2011] [Indexed: 11/28/2022]
Abstract
The ideal duration of postoperative antibiotic prophylaxis in heart surgery is unknown. The most recent guidelines recommend a decrease in prophylaxis time to decrease the emergence of multiresistant germs. However, compliance with these recommendations is scant. Our aim was to determine whether a decrease in prophylaxis time entails an increase in the infection rate. A retrospective study was performed between September 2003 and March 2006, including all patients of ages between 1 day and 14 years who were admitted to the intensive care unit after heart surgery. Patients being treated for an infection at the time of surgery were excluded. The appearance of nosocomial infection, localisation, and the causative agent, if isolated, were included; demographic and clinical analytical variables, duration and type of antibiotic prophylaxis, and duration of other invasive devices were also included. Standard analysis and multivariable logistical regression were performed. 194 patients were included in the study. The median duration of antibiotic prophylaxis was 72 h (range 24 to 176), with the most-used prophylaxis regimen being second-generation cephalosporins plus aminoglycosides. The incidence of nosocomial infection, mainly bacteraemia, was 11.9%. The type of antibiotic therapy used for prophylaxis did not affect the incidence of infection. In the multivariable logistical regression, only prolongation of antibiotic prophylaxis >48 h, central venous access maintenance time, and intubation increased the infection rate. The suspension of antibiotic prophylaxis in the 48 h after surgery in pediatric patients undergoing heart surgery does not increase the incidence of nosocomial infection. According to our results, prolongation of prophylaxis >48 h increases the infection rate.
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Affiliation(s)
- Pablo Álvarez
- Pediatric Intensive Care Unit, Hospital La Fe, Valencia, Spain.
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144
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Ferreira F, Santos S, Nascimento J, Strabelli T, Carmona M. Influence of cardiopulmonary bypass on cefuroxime plasma concentration and pharmacokinetics in patients undergoing coronary surgery. Eur J Cardiothorac Surg 2012; 42:300-5. [DOI: 10.1093/ejcts/ezr319] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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145
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Dohmen PM, Weymann A, Holinski S, Linneweber J, Geyer T, Konertz W. Use of an Antimicrobial Skin Sealant Reduces Surgical Site Infection in Patients Undergoing Routine Cardiac Surgery. Surg Infect (Larchmt) 2011; 12:475-81. [DOI: 10.1089/sur.2011.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Pascal M. Dohmen
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
- Department of Cardiovascular Surgery, Medical University Berlin, Berlin, Germany
| | - Alexander Weymann
- Department of Cardiovascular Surgery, Medical University Berlin, Berlin, Germany
| | - Sebastian Holinski
- Department of Cardiovascular Surgery, Medical University Berlin, Berlin, Germany
| | - Jörg Linneweber
- Department of Cardiovascular Surgery, Medical University Berlin, Berlin, Germany
| | - Torsten Geyer
- Department of Anesthesiology, Charité Hospital, Medical University Berlin, Berlin, Germany
| | - Wolfgang Konertz
- Department of Cardiovascular Surgery, Medical University Berlin, Berlin, Germany
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146
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Acharya MN, Som R, Tsui S. What is the optimum antibiotic prophylaxis in patients undergoing implantation of a left ventricular assist device? Interact Cardiovasc Thorac Surg 2011; 14:209-14. [PMID: 22159247 DOI: 10.1093/icvts/ivr054] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was what the optimum antibiotic prophylaxis in patients undergoing implantation of a left ventricular assist device (LVAD) is. A total of 373 papers were found, of which 11 represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Eight retrospective and two prospective studies, including one randomized controlled trial (RCT), were identified. Although highly variable, the prophylactic antibiotic protocols employed in these studies generally favour the use of vancomycin, a cephalosporin, beta-lactam and quinolone, with the option of additional fluconazole and mupirocin. However, the lack of standardized definitions for infection, and variations in the choice, timing and duration of prophylactic antibiotics complicates the interpretation of reported infection rates. Driveline and pocket infections comprised the majority of infectious complications, and were principally attributed to Gram-positive organisms, such as Staphylococcus, as well as Pseudomonas species. We conclude that a beta-lactam be used for primary prophylaxis, with vancomycin where the risk of MRSA is high. Topical mupirocin and an anti-fungal are also recommended. Prophylaxis should commence prior to device insertion, and be continued into the peri- and post-operative period. Large-scale RCTs are necessary to assess the impact of different antibiotic regimens on infection within LVAD recipients.
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147
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Lador A, Nasir H, Mansur N, Sharoni E, Biderman P, Leibovici L, Paul M. Antibiotic prophylaxis in cardiac surgery: systematic review and meta-analysis. J Antimicrob Chemother 2011; 67:541-50. [PMID: 22083832 DOI: 10.1093/jac/dkr470] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Antibiotic prophylaxis is recommended in cardiac surgery. Current debate concerns the type of antibiotic(s), dosing and the duration of prophylaxis. METHODS Systematic review of randomized controlled trials comparing one antibiotic regimen versus another in cardiac surgery. We searched The Cochrane Library, PubMed, LILACS, conference proceedings and bibliographies. Two reviewers independently extracted the data. The primary outcome was deep sternal wound infections (DSWIs). Meta-analysis was performed using the Mantel-Haenszel fixed-effect method. Risk ratios (RRs) with 95% confidence intervals (95% CIs) are reported. RESULTS Fifty-nine trials were included. There were no significant differences in DSWI or all other categories of surgical site infections (SSIs) for antibiotic prophylaxis with β-lactams comprising a Gram-negative spectrum of coverage versus prophylaxis targeting Gram-positive bacteria, but the former led to a significantly lower rate of post-operative pneumonia (RR 0.68, 95% CI 0.51-0.90) and all-cause mortality (RR 0.66, 95% CI 0.47-0.92). In trials comparing different antibiotic regimens for different durations, prophylaxis duration of ≤24 h post-operation led to higher rates of DSWI (RR 1.83, 95% CI 1.25-2.66), any sternal SSI, surgical interventions for SSI and endocarditis compared with longer duration prophylaxis. There was no advantage of regimens lasting >48 h post-operation. In the comparison of glycopeptides versus β-lactams, an advantage of glycopeptides was observed when comparators were given for similar duration and for β-lactams when given for a longer duration than the glycopeptides. There was no significant advantage of high antibiotic dosing. CONCLUSIONS Evidence supports second- or third-generation cephalosporins for cardiac surgery prophylaxis and points at a possible advantage of prophylaxis prolongation up to 48 h post-operatively.
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Affiliation(s)
- Adi Lador
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 576] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Bennett-Guerrero E, Phillips-Bute B, Waweru PM, Gaca JG, Spann JC, Milano CA. Pilot Study of Sternal Plating for Primary Closure of the Sternum in Cardiac Surgical Patients. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600608] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - Jeffrey G Gaca
- Oklahoma Heart Institute, Hillcrest Medical Center, Tulsa, OK USA
| | - James C. Spann
- Oklahoma Heart Institute, Hillcrest Medical Center, Tulsa, OK USA
| | - Carmelo A. Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC USA
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