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Diaddigo SE, LaValley MN, Kuonqui K, Janhofer DE, Ascherman JA. Flap management following orthotopic heart transplantation: A single institution's review of 66 sternal wound complications. J Plast Reconstr Aesthet Surg 2024; 90:266-272. [PMID: 38401198 DOI: 10.1016/j.bjps.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/14/2024] [Accepted: 02/01/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Sternotomy wound complications are more frequent after orthotopic heart transplantation (OHT) compared to other cardiac surgeries, primarily due to additional risk factors, including immunosuppression. Flap closure often becomes necessary for definitive treatment, although there is a scarcity of data on the outcomes of sternal wound reconstruction in this specific population. METHODS A retrospective analysis was conducted on 604 sternal wound reconstructions performed by a single surgeon between 1996 and 2023. Inclusion criteria comprised patients who underwent OHT as their primary cardiac procedure. Surgical interventions involved sternal hardware removal, debridement, and muscle flap closure. RESULTS The study included 66 patients, with culture-positive wound infection being the most common indication for reconstruction (51.5%). The median duration between transplantation and sternal wound reconstruction was 25 days. Bilateral pectoralis major myocutaneous advancement flaps (n = 63), rectus abdominis flaps (n = 2), or pectoralis major turnover flaps (n = 1) were used. Intraoperative wound cultures revealed positivity in 48 patients (72.7%), with Staphylococcus epidermidis being the most frequently cultured organism (25.0%). The overall complication rate was 31.8%, and two patient deaths were related to sternal wounds, resulting from multiorgan failure following septic shock. The majority of the patients reported excellent long-term functional and esthetic outcomes. CONCLUSIONS Sternal wounds following OHT pose a significant morbidity risk. Our strategy focuses on immediate and aggressive antibiotic therapy, thorough debridement, and definitive closure with bilateral pectoralis myocutaneous advancement flaps. This approach has demonstrated complication and mortality rates comparable to the general cardiac surgery population, as well as excellent functional and esthetic results.
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Affiliation(s)
- Sarah E Diaddigo
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Myles N LaValley
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Kevin Kuonqui
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - David E Janhofer
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Jeffrey A Ascherman
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, NY 10032, USA.
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2
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Abstract
IMPORTANCE Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer. OBSERVATIONS Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient's endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient's immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis. CONCLUSIONS AND RELEVANCE Surgical site infections affect approximately 0.5% to 3% of patients undergoing surgery and are associated with longer hospital stays than patients with no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of chlorhexidine gluconate plus alcohol-based skin preparation agents, decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures, controlling for perioperative glucose concentrations, and using negative pressure wound therapy can reduce the rate of surgical site infections.
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Affiliation(s)
- Jessica L Seidelman
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - Christopher R Mantyh
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
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3
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Perezgrovas-Olaria R, Audisio K, Cancelli G, Rahouma M, Ibrahim M, Soletti GJ, Chadow D, Demetres M, Girardi LN, Gaudino M. Deep Sternal Wound Infection and Mortality in Cardiac Surgery: A Meta-analysis. Ann Thorac Surg 2023; 115:272-280. [PMID: 35618048 DOI: 10.1016/j.athoracsur.2022.04.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a rare but severe complication after cardiac surgical procedures and has been associated with increased early morbidity and mortality. Studies reporting long-term outcomes in patients with DSWI have shown contradictory results. We performed a study-level meta-analysis evaluating the impact of DSWI on short- and long-term clinical outcomes. METHODS A systematic literature search was conducted to identify studies comparing short- and long-term outcomes of patients submitted to cardiac surgical procedures who developed DSWI and patients who did not. The primary outcome was overall mortality. Secondary outcomes were in-hospital mortality, follow-up mortality, major adverse cardiovascular events, myocardial infarction, and repeat revascularization. Postoperative outcomes were also investigated. RESULTS Twenty-four studies totaling 407 829 patients were included. Overall, 6437 (1.6%) patients developed DSWI. Mean follow-up was 3.5 years. DSWI was associated with higher overall mortality (incidence rate ratio [IRR], 1.99; 95% CI, 1.66-2.38; P < .001), in-hospital mortality (odds ratio, 3.30; 95% CI, 1.88-5.81; P < .001), follow-up mortality (IRR, 2.02; 95% CI, 1.39-2.94; P = .001), and major adverse cardiovascular events (IRR, 2.04; 95% CI, 1.60-2.59; P < .001). No differences in myocardial infarction and repeat revascularization were found, but limited studies reported those outcomes. DSWI was associated with longer postoperative hospitalization, stroke, myocardial infarction, and respiratory and renal failure. Sensitivity analyses on isolated coronary artery bypass grafting studies and by adjustment method were consistent with the main analysis. CONCLUSIONS Compared with patients who did not develop DSWI, patients with DSWI after cardiac surgical procedures had increased risk of death as well as short- and long-term adverse clinical outcomes.
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Affiliation(s)
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mudathir Ibrahim
- Department of General Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
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4
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Gökler J, Aliabadi-Zuckermann AZ, Kaider A, Ambardekar AV, Antretter H, Artemiou P, Bertolotti AM, Boeken U, Brossa V, Copeland H, Generosa Crespo-Leiro M, Eixeré-Esteve A, Epailly E, Farag M, Hulman M, Khush KK, Masetti M, Patel J, Ross HJ, Rudež I, Silvestry S, Suarez SM, Vest A, Zuckermann AO. Indications, Complications, and Outcomes of Cardiac Surgery After Heart Transplantation: Results From the Cash Study. Front Cardiovasc Med 2022; 10:879612. [PMID: 35756840 PMCID: PMC9218180 DOI: 10.3389/fcvm.2022.879612] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Allograft pathologies, such as valvular, coronary artery, or aortic disease, may occur early and late after cardiac transplantation. Cardiac surgery after heart transplantation (CASH) may be an option to improve quality of life and allograft function and prolong survival. Experience with CASH, however, has been limited to single-center reports. Methods We performed a retrospective, multicenter study of heart transplant recipients with CASH between January 1984 and December 2020. In this study, 60 high-volume cardiac transplant centers were invited to participate. Results Data were available from 19 centers in North America (n = 7), South America (n = 1), and Europe (n = 11), with a total of 110 patients. A median of 3 (IQR 2–8.5) operations was reported by each center; five centers included ≥ 10 patients. Indications for CASH were valvular disease (n = 62), coronary artery disease (CAD) (n = 16), constrictive pericarditis (n = 17), aortic pathology (n = 13), and myxoma (n = 2). The median age at CASH was 57.7 (47.8–63.1) years, with a median time from transplant to CASH of 4.4 (1–9.6) years. Reoperation within the first year after transplantation was performed in 24.5%. In-hospital mortality was 9.1% (n = 10). 1-year survival was 86.2% and median follow-up was 8.2 (3.8–14.6) years. The most frequent perioperative complications were acute kidney injury and bleeding revision in 18 and 9.1%, respectively. Conclusion Cardiac surgery after heart transplantation has low in-hospital mortality and postoperative complications in carefully selected patients. The incidence and type of CASH vary between international centers. Risk factors for the worse outcome are higher European System for Cardiac Operative Risk Evaluation (EuroSCORE II) and postoperative renal failure.
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Affiliation(s)
- Johannes Gökler
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- *Correspondence: Johannes Gökler,
| | | | - Alexandra Kaider
- Center for Medical Statistics, Informatics, and Intelligent Systems (CeMSIIS), Medical University of Vienna, Vienna, Austria
| | - Amrut V. Ambardekar
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Herwig Antretter
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Panagiotis Artemiou
- National Institute of Cardiovascular Diseases, Medical Faculty of the Comenius University, Bratislava, Slovakia
| | - Alejandro M. Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Vicens Brossa
- Heart Transplant Division, Hospital Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - Hannah Copeland
- Division Cardiac Surgery, Lutheran Hospital, Indiana University School of Medicine, Indiana, IA, United States
| | - Maria Generosa Crespo-Leiro
- Complejo Hospitalario Universitario a Coruña (CHUAC), Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), La Coruña, Spain
| | | | - Eric Epailly
- Heart and Heart-Lung Transplant Unit Medical, Department of Cardiovascular Surgery, Les Hôpitaux Universitaires NHC, Strasbourg, France
| | - Mina Farag
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Michal Hulman
- National Institute of Cardiovascular Diseases, Medical Faculty of the Comenius University, Bratislava, Slovakia
| | - Kiran K. Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Marco Masetti
- Heart Failure and Heart Transplant Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico S. Orsola, Bologna, Italy
| | - Jignesh Patel
- Heart Transplant Program, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Heather J. Ross
- Cardiac Transplant Program, Peter Munk Cardiac Centre, Toronto, ON, Canada
| | - Igor Rudež
- Department of Cardiac Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Scott Silvestry
- Thoracic Transplant Program, AdventHealth Transplant Institute, Florida, FL, United States
| | - Sofia Martin Suarez
- Cardiac Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico S. Orsola, Bologna, Italy
| | - Amanda Vest
- Cardiac Transplantation Program, Tufts Medical Center, Boston, MA, United States
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5
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Schreiber PW, Lang BM, Boggian K, Neofytos D, van Delden C, Egli A, Dickenmann M, Hillinger S, Hirzel C, Manuel O, Desgranges F, Koller M, Rossi S, Stampf S, Wilhelm MJ, Kuster SP, Mueller NJ. Incidence and outcome of surgical site infections in thoracic-organ transplant recipients registered in the Swiss Transplant Cohort Study. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Bezinover D, Biancofiore G, Falcone M, Karvellas C, Husain S, Saner FH. Multidrug-resistant infections in solid organ transplant recipients: a focus on risk factors, prevention and treatment strategies. Minerva Anestesiol 2022; 88:735-747. [PMID: 35315621 DOI: 10.23736/s0375-9393.22.16124-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Solid organ transplantation is the best therapeutic option for patients with end-stage organ disease and, according to the data from international registries, there has been a steady increase in numbers and results. However, post-transplant infections remain a fearsome complication with, in the last decade, an increasing incidence of episodes due to antibiotic-resistant bacteria and opportunistic agents. In this paper, we summarize the most relevant and updated knowledge concerning infections from multidrug-resistant germs in solid organ transplant recipients, focusing on risk factors, treatment and prevention strategies, and antimicrobial pharmacokinetics relevant to this particular population of patients.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, AOU Pisana, University of Pisa, Pisa, Italy -
| | - Marco Falcone
- Unit of Infectious Diseases, AOU Pisana, University of Pisa, Pisa, Italy
| | - Costantine Karvellas
- Department of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, Canada
| | - Shaid Husain
- Department of Infectious Diseases, Toronto General Hospital Research Institute, Toronto University, Toronto, ON, Canada
| | - Fuat H Saner
- Department of General- and Visceral- and Transplant Surgery, Essen University Medical Center, Essen, Germany
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7
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Eliminated routine postorthotopic liver transplant antibiotics in uncomplicated patients leads to equivalent safety outcomes. ANTIMICROBIAL STEWARDSHIP AND HEALTHCARE EPIDEMIOLOGY 2022; 2:e13. [PMID: 36310805 PMCID: PMC9614830 DOI: 10.1017/ash.2021.239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 12/11/2022]
Abstract
Objective: The purpose of this retrospective study was to evaluate safety and efficacy end points of a postoperative antibiotic prophylaxis protocol in liver transplant (LT) patients, which was revised to limit antibiotic use. Methods: In the routine antibiotics group (RA), patients routinely received prophylactic antibiotics for around 3 days postoperatively for a variety of rationales, versus the limited antibiotics group (LA), in which patients received antibiotics for the treatment of secondary peritonitis. Patients were included if they were 18 or older and underwent liver transplant between January 2016 and September 2019. In total, 216 patients remained after exclusion: 118 patients in the RA group and 98 patients in the LA group. Results: We detected a significant difference in the primary end point of postoperative antibiotic days of therapy. The median days of therapy was 2 for the RA group and 0 for the LA group (P < 0.005). Significantly fewer patients received only intraoperative antibiotics in the RA group versus the LA group: 42 (35.6%) versus 76 (73.5%) respectively (P < .005). There was no significant difference in secondary or safety outcomes, including surgical site infections. Conclusions: This study provides evidence that limiting the duration of prophylactic antibiotics postoperatively and treating most patients with only intraoperative antibiotics is safe.
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8
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Abstract
Surgical site infections (SSIs) are among the most common and most costly health care-associated infections, leading to adverse patient outcomes and death. Wound contamination occurs with each incision, but proven strategies exist to decrease the risk of SSI. In particular, improved adherence to evidence-based preventive measures related to appropriate antimicrobial prophylaxis can decrease the rate of SSI. Aggressive surgical debridement and effective antimicrobial therapy are needed to optimize the treatment of SSI.
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Affiliation(s)
- Jessica Seidelman
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Durham, NC, USA.
| | - Deverick J Anderson
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Durham, NC, USA
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9
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McCreery RJ, Florescu DF, Kalil AC. Sepsis in Immunocompromised Patients Without Human Immunodeficiency Virus. J Infect Dis 2021; 222:S156-S165. [PMID: 32691837 DOI: 10.1093/infdis/jiaa320] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Sepsis remains among the most common complications from infectious diseases worldwide. The morbidity and mortality rates associated with sepsis range from 20% to 50%. The advances in care for patients with an immunocompromised status have been remarkable over the last 2 decades, but sepsis continues to be a major cause of death in this population Immunocompromised patients who are recipients of a solid organ or hematopoietic stem cell transplant are living longer with a better quality of life. However, some of these patients need lifelong treatment with immunosuppressive medications to maintain their transplant status. A consequence of the need for this permanent immunosuppression is the high risk of opportunistic, community, and hospital-acquired infections, all of which can lead to sepsis. In addition, the detection of serious infections may be more challenging owing to patients' lower ability to mount the clinical symptoms that usually accompany sepsis. This article provides an update on the current knowledge of sepsis in immunocompromised patients without human immunodeficiency virus. It reviews the most pertinent causes of sepsis in this population, and addresses the specific diagnostic and therapeutic challenges in neutropenia and solid organ and hematopoietic stem cell transplantation.
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Affiliation(s)
- Randy J McCreery
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Diana F Florescu
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
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10
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Bhatt PJ, Ali M, Rana M, Patel G, Sullivan T, Murphy J, Pinney S, Anyanwu A, Huprikar S, Taimur S. Infections due to multidrug-resistant organisms following heart transplantation: Epidemiology, microbiology, and outcomes. Transpl Infect Dis 2019; 22:e13215. [PMID: 31765045 DOI: 10.1111/tid.13215] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 10/02/2019] [Accepted: 11/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infections secondary to multidrug-resistant organisms (MDRO) have emerged as a growing problem in solid organ transplantation (SOT). Most of the published data on MDRO infections in SOT pertains to abdominal organ transplantation and data specific to heart transplantation (HT) are limited. METHODS This is a retrospective review of HT recipients at our institution from 2011 to 2016; with the aim to investigate the epidemiology, microbiologic spectrum, and outcomes in patients with post-HT MDRO infections, classified as multidrug-resistant (MDR), extensively drug-resistant (XDR), and pandrug-resistant (PDR) using standardized definitions. RESULTS Of the 149 HT recipients, 82 episodes of bacterial infection were seen in 46 patients (31%) in the year following HT. Thirty (37%) were due to MDR pathogens and 13 (16%) were XDR. The most common gram-negative MDR pathogens were extended-spectrum beta-lactamase (ESBL) Escherichia coli and Klebsiella pneumoniae; while XDR pathogens were most commonly Pseudomonas aeruginosa followed by carbapenem-resistant Klebsiella pneumoniae. Majority of infection episodes were bloodstream (54, 66%) followed by pulmonary infection (20, 24%). Within a year after transplant, HT recipients with any bacterial infection had significantly higher mortality versus those without infection; and XDR infections were associated with a 26-fold greater hazard of death on average compared to those without infection (adjusted HR, 26.1; 95% CI, 6.4-107.0; P < .001). There were no PDR infections. CONCLUSION Bacterial infections were a significant predictor of 1-year post-HT mortality, which was highest among those with XDR infections. This study highlights the burden of MDRO infections in HT recipients and identifies an area of future research.
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Affiliation(s)
- Pinki J Bhatt
- Department of Medicine, Division of Infectious Diseases, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Mohsin Ali
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Meenakshi Rana
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gopi Patel
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Timothy Sullivan
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph Murphy
- Department of Medicine, Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sean Pinney
- Department of Medicine, Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anelechi Anyanwu
- Department of Cardiovascular Surgery at Mount Sinai Hospital, New York, New York
| | - Shirish Huprikar
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sarah Taimur
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
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11
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Abbo LM, Grossi PA. Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13589. [PMID: 31077619 DOI: 10.1111/ctr.13589] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 02/06/2023]
Abstract
These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.
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Affiliation(s)
- Lilian M Abbo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine and Jackson Health System, Miami, Florida
| | - Paolo Antonio Grossi
- Infectious Diseases Section, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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12
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Wallen TJ, Habertheuer A, Gottret JP, Kramer M, Abbas Z, Siki M, Hobbs R, Vasquez C, Molina M, Kanchwala S, Low D, Acker M, Vallabhajosyula P. Sternal wound complications in patients undergoing orthotopic heart transplantation. J Card Surg 2019; 34:186-189. [DOI: 10.1111/jocs.14003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Tyler J. Wallen
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
- The University of Florida Health SystemGainesville Florida
| | | | - Jean P. Gottret
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Matthew Kramer
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Zara Abbas
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Mary Siki
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Reilly Hobbs
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Charlie Vasquez
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Maria Molina
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Suhail Kanchwala
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - David Low
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
| | - Michael Acker
- The University of Pennsylvania Health SystemPhiladelphia Pennsylvania
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13
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Infections in Heart, Lung, and Heart-Lung Transplantation. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7121494 DOI: 10.1007/978-1-4939-9034-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Half a century has passed since the first orthotopic heart transplant took place. Surgical innovations allowed for heart, lung, and heart-lung transplantation to save lives of patients with incurable chronic cardiopulmonary conditions. The complexity of the surgical interventions, chronic host health conditions, and antirejection immunosuppressive medications makes infectious complications common. Infections have remained one of the main barriers for successful transplantation and a source of significant morbidity and mortality. Recognition of infections and its management in this setting require outstanding clinical skills since transplant recipients may not exhibit classic signs or symptoms of disease, and laboratory work has some pitfalls. The prevention, identification, and management of infectious diseases complications in this population are a priority to undertake to improve the medical outcomes of transplantation. Herein, we reviewed the historical aspects, epidemiology, and prophylaxis of infections in heart, lung, and heart-lung transplantation. We also discuss the most prevalent organisms affecting the host and the organ systems involved.
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Foroutan F, Doumouras BS, Ross H, Alba AC. Impact of pretransplant recipient body mass index on post heart transplant mortality: A systematic review and meta-analysis. Clin Transplant 2018; 32:e13348. [DOI: 10.1111/ctr.13348] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 07/03/2018] [Accepted: 07/08/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Farid Foroutan
- Heart Failure/Transplant Program; Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Barbara S. Doumouras
- Heart Failure/Transplant Program; Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Heather Ross
- Heart Failure/Transplant Program; Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Ana C. Alba
- Heart Failure/Transplant Program; Toronto General Hospital; University Health Network; Toronto Ontario Canada
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Deziel PJ, Razonable R. Anti-infective chemoprophylaxis after solid-organ transplantation. Expert Rev Clin Immunol 2018; 14:469-479. [PMID: 29764228 DOI: 10.1080/1744666x.2018.1476852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Solid organ transplant (SOT) recipients are at high risk of opportunistic infections due to bacterial, viral, fungal, and parasitic pathogens. Anti-infective prophylaxis is a time-tested proven strategy for the prevention of these infections after SOT. Areas covered: The current recommendations for the prevention of surgical site infections, herpes simplex, cytomegalovirus, invasive fungal infections, and selected parasitic diseases are highlighted. Recent peer-reviewed publications on the prevention of infection after SOT were reviewed and their significance was discussed in the context of the current recommendations for preventing infectious complications. Expert commentary: The authors comment on the current approaches to infection prevention in transplant recipients, and discuss how these recommendations are implemented in their clinical practice. Notable findings published during the past year were highlighted, and their clinical significance was interpreted in the context of current recommendations. The evolution of diagnostic and immunologic assays was emphasized, with focus on their potential role in optimizing the current antimicrobial approaches to infection prevention after SOT.
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Affiliation(s)
- Paul J Deziel
- a Division of Infectious Diseases, The William J von Liebig Center for Transplantation and Clinical Regeneration , Mayo Clinic College of Medicine and Science, Mayo Clinic , Rochester , MN , USA
| | - Raymund Razonable
- a Division of Infectious Diseases, The William J von Liebig Center for Transplantation and Clinical Regeneration , Mayo Clinic College of Medicine and Science, Mayo Clinic , Rochester , MN , USA
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16
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Perioperative Antibiotic Prophylaxis to Prevent Surgical Site Infections in Solid Organ Transplantation. Transplantation 2018; 102:21-34. [DOI: 10.1097/tp.0000000000001848] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Cardiac Surgery After Heart Transplantation: Elective Operation or Last Exit Strategy? Transplant Direct 2017; 3:e209. [PMID: 29138760 PMCID: PMC5627740 DOI: 10.1097/txd.0000000000000725] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/01/2017] [Accepted: 07/13/2017] [Indexed: 11/27/2022] Open
Abstract
Background Because of improved long-term survival after heart transplantation (HTx), late graft pathologies such as valvular disease or cardiac allograft vasculopathy (CAV) might need surgical intervention to enhance longer survival and ensure quality of life. To this date, there exist no guidelines for indication of cardiac surgery other than retransplantation after HTx. Methods In this retrospective, single-center study, we evaluated patients who underwent cardiac surgery after HTx at our institution. Results Between March 1984 and October 2016, 17 (1.16%) of 1466 HTx patients underwent cardiac surgery other than retransplantation after HTx. Indication were valvular disease (n = 7), CAV (n = 6), and other (n = 4). Of these, 29.4% (n = 5) were emergency procedures and 70.6% were elective cases. Median age at time of surgery was 61 years (interquartile range, 52-66 years); 82.4% (n = 14) were male. Median time to surgery after HTx was 9.3 years (2.7-11.1 years). In-hospital, mortality was 11.8% (n = 2); later need of retransplantation was 11.8% (n = 2) due to progressing CAV 3 to 9 months after surgery. One-year survival was 82.35%; overall survival was 47.1% (n = 8) with a median follow-up of 1477 days (416-2135 days). Overall survival after emergency procedures was 209 days (36-1119.5 days) whereas, for elective procedures, it was 1583.5 days (901.5-4319 days). Conclusions Incidence of cardiac surgery after HTx in our cohort was low (1.16%) compared with that of other studies. In elective cases, long-term survival was good.
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Meza-López LR, Cigarroa-López JA, Hernández-Meneses S, Castán-Flores DA, Mendoza-Zavala GH, Barragán-Zamora JA, Carrillo-Muñoz A, Munguía-Canales DA. [Dissolvable and extended release antibiotic beads in mediastinoscopic management of mediastinitis after heart transplantation]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 87:182-186. [PMID: 28259393 DOI: 10.1016/j.acmx.2017.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 10/05/2016] [Accepted: 01/17/2017] [Indexed: 11/17/2022] Open
Affiliation(s)
- Luis Raúl Meza-López
- Departamento de Cirugía Cardiotorácica, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México.
| | - José Angel Cigarroa-López
- Clínica de Insuficiencia Cardiaca y Trasplante, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Silvia Hernández-Meneses
- Departamento de Cirugía Cardiotorácica, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - David Arturo Castán-Flores
- Clínica de Insuficiencia Cardiaca y Trasplante, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Genaro Hiram Mendoza-Zavala
- Clínica de Insuficiencia Cardiaca y Trasplante, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - José Antonio Barragán-Zamora
- Departamento de Cirugía Cardiotorácica, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Arturo Carrillo-Muñoz
- Clínica de Insuficiencia Cardiaca y Trasplante, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Daniel Alejandro Munguía-Canales
- Departamento de Cirugía Cardiotorácica, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
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Cutrell JB, Barros N, McBroom M, Luby J, Minhajuddin A, Ring WS, Greilich PE. Risk factors for deep sternal wound infection after cardiac surgery: Influence of red blood cell transfusions and chronic infection. Am J Infect Control 2016; 44:1302-1309. [PMID: 27179393 DOI: 10.1016/j.ajic.2016.03.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 03/28/2016] [Accepted: 03/28/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) following cardiac surgery is a serious complication, but risk factors associated with DSWI have not been fully elucidated. METHODS We analyzed all DSWI cases at our institution from 2010-2013 in adult cardiac median sternotomy cases, based on Society of Thoracic Surgeons or National Healthcare Safety Network definitions, but with 1-year surveillance postsurgery. Controls were matched 3:1 per case for procedure, age, and year of surgery. Demographic and operative data were pulled from Society of Thoracic Surgeons database and chart review. Potential variables were evaluated using univariate and multivariate conditional logistic regression. RESULTS Out of 1,894 surgeries performed, 39 DSWI cases (2%) and 117 controls were identified. In univariate analyses, patients with red blood cell (RBC) transfusion ≥ 4 units, any platelet transfusion, previous infections, and chronic infections were associated with higher DSWI. RBC transfusion ≥ 4 units (P = .037) and chronic infections (P = .029) remained significant risk factors for DSWI in multivariate analysis. Preoperative anemia alone was not associated with more DSWI, but its interaction with RBC transfusion ≥ 4 units was significant. CONCLUSIONS High-volume RBC transfusions and chronic infections were strongly associated with DSWI in our population and represent potentially modifiable areas for improvement.
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Willy C, Engelhardt M, Stichling M, Grauhan O. The impact of surgical site occurrences and the role of closed incision negative pressure therapy. Int Wound J 2016; 13 Suppl 3:35-46. [PMID: 27547962 DOI: 10.1111/iwj.12659] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/13/2016] [Indexed: 12/15/2022] Open
Abstract
Surgical site occurrences are observed in up to 60% of inpatient surgical procedures in industrialised countries. The most relevant postoperative complication is surgical site infection (SSI) because of its impact on patient outcomes and enormous treatment costs. Literature reviews ('SSI', 'deep sternal wound infections' (DSWI), 'closed incision negative pressure wound therapy' (ciNPT) were performed by electronically searching MEDLINE (PubMed) and subsequently using a 'snowball' method of continued searches of the references in the identified publications. Search criteria included publications in all languages, various study types and publication in a peer-reviewed journal. The SSI literature search identified 1325, the DSWI search 590 and the ciNPT search 103 publications that fulfilled the search criteria. Patient-related SSI risk factors (diabetes mellitus, obesity, smoking, hypertension, female gender) and operation-related SSI risk factors (re-exploration, emergency operations, prolonged ventilation, prolonged operation duration) exist. We found that patient- and operation-related SSI risk factors were often different for each speciality and/or operative procedure. Based on the evidence, we found that high-risk incisions (sternotomy and incisions in extremities after high-energy open trauma) are principally recommended for ciNPT use. In 'lower'-risk incisions, the addition of patient-related or operation-related risk factors justifies the application of ciNPT.
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Affiliation(s)
- Christian Willy
- Department of Traumatology/Orthopedic Surgery, Septic and Reconstructive Surgery, Research and Treatment Centre for Complex Combat Injuries, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Michael Engelhardt
- Department Vascular and Endovascular Surgery, Center of Vascular Medicine, Bundeswehr Hospital Ulm, Ulm, Germany
| | - Marcus Stichling
- Section Vascular and Thoracic Surgery of Department of Traumatology/Orthopedic Surgery, Septic and Reconstructive Surgery, Research and Treatment Centre for Complex Combat Injuries, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Onnen Grauhan
- Cardiac Surgery, German Heart Center Berlin, Berlin, Germany
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Rashidi M, Esmaily S, Fiane AE, Gude E, A Tønseth K, Ueland T, Gustafsson F, Eiskjær H, Rådegran G, Dellgren G. Wound complications and surgical events in de novo heart transplant patients treated with everolimus: Post-hoc analysis of the SCHEDULE trial. Int J Cardiol 2016; 210:80-4. [PMID: 26938682 DOI: 10.1016/j.ijcard.2016.02.075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/05/2016] [Accepted: 02/07/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The use of mammalian target of rapamycin (mTOR) inhibitors have been limited by adverse events (AE), including delayed wound healing. We retrospectively reviewed all AE and serious AE (SAE) in The Scandinavian heart transplant (HTx) everolimus (EVE) de novo trial with early calcineurin (CNI) avoidance (SCHEDULE). The aim of the study was to compare wound complications between EVE and CNI based regimen. MATERIALS AND METHODS A total of 115 patients (mean age 51 ± 13 years, 73% men) were randomized within five days post-HTx to low dose EVE and reduced dose Cyclosporine (CyA) followed by early CyA withdrawal (EVE group; n=56) or standard CyA regimen (CyA group; n=59). All AE/SAEs were prospectively recorded according to the SCHEDULE study protocol, and re-assessed retrospectively by two independent reviewers. Wound complication as primary endpoint was defined as any complication associated with failure of tissue healing. Secondary endpoint was total number of events involving surgical intervention. RESULTS There were no significant differences between the groups with regards to wound complications (EVE=20, CyA=12)(p=0.08) or total surgical events (EVE=38, CyA=34) (p=0.44). Age>54.5 years (median) was an overall risk factor for surgical wound complications regardless of treatment group (p=0.025). There was no difference in the EVE versus CyA group with regards to other surgical events. Majority of events were in 1/3 of the patients. CONCLUSION De novo initiation of EVE and early CyA withdrawal in HTx patients did not show any significant differences in wound complications or in total surgical events. Majority of complications were seen in a small number of patients.
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Affiliation(s)
- Mitra Rashidi
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway; Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway.
| | - Sorosh Esmaily
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arnt E Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kim A Tønseth
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Thor Ueland
- Faculty of Medicine, University of Oslo, Norway; Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway; K.G. Jebsen Inflammatory Research Center, University of Oslo, Oslo, Norway; K.G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Norway
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Göran Rådegran
- The Clinic for Heart Failure and Valvular Disease, Skåne University Hospital and Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden
| | - Göran Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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Novel Method of Infection Prophylaxis in Heart Transplantation by Retrosternal Gentamycin Sponge Application. Transplant Proc 2015; 47:1954-7. [PMID: 26293080 DOI: 10.1016/j.transproceed.2015.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 02/02/2015] [Accepted: 02/10/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Surgical wound infections are more frequent in patients undergoing heart transplantation than in other heart surgery patients. There is a wide spread of sternal wound infection incidence in transplant patients ranging from 4% to 40%. It is first study describing local gentamicin sponge application during heart transplantation procedure. MATERIALS AND METHODS We enrolled 75 patients in a retrospective, single-center study, including 25 patients who underwent orthotopic heart transplantation (heart transplant group) and 50 in the cardiac surgery group. They were in mean age of 49 ± 12 years and 51 ± 13 years in heart transplantation and cardiac surgery group, respectively. A gentamicin sponge was inserted intraoperatively between sternal borders before chest closure in all heart transplantation patients. RESULTS There was 1 early death (4%) on postoperative day 7 owing to Clostridium difficile infection in the heart transplant group. There was 1 death (2%) in the cardiac surgery group owing to multiorgan failure secondary to perioperative heart ischemia. There was neither bacterial sternal wound infection nor sternal instability in the heart transplant group. None of the patients who had gentamicin sponge applied had wound healing problems. Two patients (4%) had a deep sternal wound infection in the cardiac surgery group, who had no sponge application; 1 (2%) was treated by surgical debridement and active drainage and 1 (2%) by vacuum therapy. There were 11 patients (44%) discharged on insulin therapy in the heart transplant group and 21 (21%) in the cardiac surgery group. Mean overall postoperative hospital stay was 35 ± 19 days in the heart transplant group and 10 ± 4 days in the cardiac surgery group. CONCLUSIONS Gentamicin sponge is an effective local infection prophylaxis in heart transplant patients.
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Dorschner P, McElroy LM, Ison MG. Nosocomial infections within the first month of solid organ transplantation. Transpl Infect Dis 2014; 16:171-87. [PMID: 24661423 DOI: 10.1111/tid.12203] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 10/24/2013] [Accepted: 11/26/2013] [Indexed: 12/11/2022]
Abstract
Infections remain a common complication of solid organ transplantation. Early postoperative infections remain a significant cause of morbidity and mortality in solid organ transplant (SOT) recipients. Although significant effort has been made to understand the epidemiology and risk factors for early nosocomial infections in other surgical populations, data in SOT recipients are limited. A literature review was performed to summarize the current understanding of pneumonia, urinary tract infection, surgical-site infection, bloodstream infection, and Clostridium difficult colitis, occurring within the first 30 days after transplantation.
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Affiliation(s)
- P Dorschner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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25
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Kim HJ, Jung SH, Kim JJ, Kim JB, Choo SJ, Yun TJ, Chung CH, Lee JW. Early postoperative complications after heart transplantation in adult recipients: asan medical center experience. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:426-32. [PMID: 24368968 PMCID: PMC3868689 DOI: 10.5090/kjtcs.2013.46.6.426] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 06/30/2013] [Accepted: 08/05/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart transplantation has become a widely accepted surgical option for end-stage heart failure in Korea since its first success in 1992. We reviewed early postoperative complications and mortality in 239 patients who underwent heart transplantation using bicaval technique in Asan Medical Center. METHODS Between January 1999 and December 2011, a total of 247 patients aged over 17 received heart transplantation using bicaval technique in Asan Medical Center. After excluding four patients with concomitant kidney transplantation and four with heart-lung transplantation, 239 patients were enrolled in this study. We evaluated their early postoperative complications and mortality. Postoperative complications included primary graft failure, cerebrovascular accident, mediastinal bleeding, renal failure, low cardiac output syndrome requiring intra-aortic balloon pump or extracorporeal membrane oxygenation insertion, pericardial effusion, and inguinal lymphocele. Follow-up was 100% complete with a mean follow-up duration of 58.4±43.6 months. RESULTS Early death occurred in three patients (1.3%). The most common complications were pericardial effusion (61.5%) followed by arrhythmia (41.8%) and mediastinal bleeding (8.4%). Among the patients complicated with pericardial effusion, only 13 (5.4%) required window operation. The incidence of other significant complications was less than 5%: stroke (1.3%), low cardiac output syndrome (2.5%), renal failure requiring renal replacement (3.8%), sternal wound infection (2.0%), and inguinal lymphocele (4.6%). Most of complications did not result in the extended length of hospital stay except mediastinal bleeding (p=0.034). CONCLUSION Heart transplantation is a widely accepted option of surgical treatment for end-stage heart failure with good early outcomes and relatively low catastrophic complications.
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Affiliation(s)
- Ho Jin Kim
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Sung-Ho Jung
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jae Joong Kim
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Joon Bum Kim
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Suk Jung Choo
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Tae-Jin Yun
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Cheol Hyun Chung
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jae Won Lee
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
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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: 688] [Impact Index Per Article: 62.5] [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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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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Impact of De Novo Everolimus-Based Immunosuppression on Incisional Complications in Heart Transplantation. Transplantation 2011; 92:594-600. [DOI: 10.1097/tp.0b013e3182279133] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
Surgical wound complications are more frequent in patients undergoing heart transplantation than in other heart surgery patients. This is probably attributed to the presence of additional risk factors in these patients, such as immunosuppression, mechanical support through assist devices and generally poor health. Analyses of wound infections in heart transplantation are based on smaller patient population than those for general heart surgery, and the reported incidences vary largely. The identification of specific risk factors in heart transplant recipients to date is mainly based on retrospective case-control studies in small patient cohorts, the results are controversial, and the comparability of data is limited because of the lack of application of consistent definitions. The impact of immunosuppression and especially immunosuppression with mammalian target of rapamycin (mTOR) inhibitors on the development of surgical wound complications has been widely discussed following reports of increased occurrence with sirolimus. However, nonheart-transplant specific risk factors should also be considered to develop risk profiles and treatment algorithms for individual patients. Data on surgical wound complications in general heart surgery patients and in heart transplant recipients are compared, the impact of modern immunosuppression reviewed, and areas for further investigation discussed.
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Affiliation(s)
- Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
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30
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Mauermann WJ, Sampathkumar P, Thompson RL. Sternal wound infections. Best Pract Res Clin Anaesthesiol 2008; 22:423-36. [DOI: 10.1016/j.bpa.2008.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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