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Eissa MIA, Kaddoura R, Hassan D, Carr CS, Hanoura S, Shouman Y, Almulla A, Omar AS. Early clinical outcomes of two regimens of prophylactic antibiotics in cardiac surgical patients with delayed sternal closure. World J Crit Care Med 2024; 13:92658. [PMID: 39253311 PMCID: PMC11372511 DOI: 10.5492/wjccm.v13.i3.92658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/04/2024] [Accepted: 05/29/2024] [Indexed: 08/30/2024] Open
Abstract
BACKGROUND Delayed sternal closure (DSC) can be a lifesaving approach for certain patients who have undergone cardiac surgery. The value of the type of prophylactic antibiotics in DSC is still debatable. AIM To investigate clinical outcomes of different prophylactic antibiotic regimens in patients who had DSC after cardiac surgery. METHODS This was a retrospective observational single-center study. Fifty-three consecutive patients who underwent cardiac surgery and had an indication for DSC were included. Patients were subjected to two regimens of antibiotics: Narrow-spectrum and broad-spectrum regimens. RESULTS The main outcome measures were length of hospital and intensive care unit (ICU) stay, duration of mechanical ventilation, and mortality. Of the 53 patients, 12 (22.6%) received narrow-spectrum antibiotics, and 41 (77.4%) received broad-spectrum antibiotics. The mean age was 59.0 ± 12.1 years, without significant differences between the groups. The mean duration of antibiotic use was significantly longer in the broad-spectrum than the narrow-spectrum group (11.9 ± 8.7 vs 3.4 ± 2.0 d , P < 0.001). The median duration of open chest was 3.0 (2.0-5.0) d for all patients, with no difference between groups (P = 0.146). The median duration of mechanical ventilation was significantly longer in the broad-spectrum group [60.0 (Δ interquartile range (IQR) 170.0) h vs 50.0 (ΔIQR 113.0) h, P = 0.047]. Similarly, the median length of stay for both ICU and hospital were significantly longer in the broad-spectrum group [7.5 (ΔIQR 10.0) d vs 5.0 (ΔIQR 5.0) d, P = 0.008] and [27.0 (ΔIQR 30.0) d vs 19.0 (ΔIQR 21.0) d, P = 0.031]. Five (9.8%) patients were readmitted to the ICU and 18 (34.6%) patients died without a difference between groups. CONCLUSION Prophylactic broad-spectrum antibiotics did not improve clinical outcomes in patients with DSC post-cardiac surgery but was associated with longer ventilation duration, length of ICU and hospital stays vs narrow-spectrum antibiotics.
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Affiliation(s)
- Mahmoud Ismail Allam Eissa
- Department of Cardiothoracic Surgery, Hamad Medical Cooperation, Doha 3050, Qatar
- Department of Anesthesia and Intensive Care, Al-Azhar University, Cairo 11651, Egypt
| | - Rasha Kaddoura
- Department of Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha 3050, Qatar
| | - Danial Hassan
- Department of Healthcare Profession, Harvard TH Chan School of Public Health, Ministry of Public Health, Boston, MA 3050, United States
| | - Cornelia S Carr
- Department of Cardiothoracic Surgery, Hamad Medical Cooperation, Doha 3050, Qatar
- Department of Surgery, Qatar University, Doha 3050, Qatar
| | - Samy Hanoura
- Department of Anesthesia and Intensive Care, Al-Azhar University, Cairo 11651, Egypt
- Department of Cardiac Anesthesia, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Anesthesia, Weill Cornell Medical College in Qatar, Doha 3050, Qatar
| | - Yasser Shouman
- Department of Cardiothoracic Surgery, Hamad Medical Cooperation, Doha 3050, Qatar
| | - Abdulwahid Almulla
- Department of Cardiothoracic Surgery, Hamad Medical Cooperation, Doha 3050, Qatar
| | - Amr Salah Omar
- Department of Cardiothoracic Surgery, Hamad Medical Cooperation, Doha 3050, Qatar
- Department of Critical Care Medicine, Beni Suef University, Beni Suef 62521, Egypt
- Department of Medicine, Weill Cornell Medical College in Qatar, Doha 3050, Qatar
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Bertoletti L, Lafaie L, LeConte T, Desage AL, Petit B, Ozturk L, Accassat S, Corbaux P, Poenou G. Do all patients with cancer thrombosis have the same risk of bleeding and recurrence? Particularities of lung cancer. Expert Rev Respir Med 2024; 18:5-7. [PMID: 38488035 DOI: 10.1080/17476348.2024.2331750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 03/13/2024] [Indexed: 03/19/2024]
Affiliation(s)
- Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, F-42055, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
| | - Ludovic Lafaie
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
- Service de Gérontologie Clinique, CHU de St Etienne, Saint-Etienne, France
| | - Thibault LeConte
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
| | - Anne-Laure Desage
- Service de Pneumologie et Oncologie Thoracique, CHU de St-Etienne, Saint-Etienne, France
| | - Bastien Petit
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
| | - Lutfi Ozturk
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
| | - Sandrine Accassat
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
| | - Pauline Corbaux
- Medical Oncology, Institut de Cancérologie et d'Hématologie Universitaire de Saint-Étienne (ICHUSE), Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Géraldine Poenou
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
- EA UCBL/HCL 3738, Centre pour l'lnnovation en Cancérologie de Lyon (CICLY), Faculty of Medicine Lyon-Sud, Claude Bernard University Lyon 1, Lyon, France
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Xue L, Ding Y, Qin Q, Liu L, Ding X, Zhou Y, Liu K, Singla RK, Shen K, Din AU, Zhang Y, Shen Z, Shen B, Miao L. Assessment of the impact of intravenous antibiotics treatment on gut microbiota in patients: Clinical data from pre-and post-cardiac surgery. Front Cell Infect Microbiol 2023; 12:1043971. [PMID: 36741975 PMCID: PMC9896080 DOI: 10.3389/fcimb.2022.1043971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/23/2022] [Indexed: 01/21/2023] Open
Abstract
Background and aims Surgical site infection is a common complication after surgery. Periprocedural antibiotics are necessary to prescribe for preventing or treating infections. The present study aimed to explore the effect of intravenous antibiotics on gut microbiota and menaquinone biosynthesis in patients, especially in elderly patients undergoing cardiac surgery. Methods A total of 388 fecal samples were collected from 154 cardiac surgery patients. The V3-V4 hypervariable region of the bacterial 16S rRNA gene was amplified and sequenced on a MiSeq PE300. The gut microbiota diversity of samples was analyzed in terms of α- and β-diversity at the OTU level. The different groups were classified according to antibiotics in combinations and single antibiotics. PICRUSt2 was used for preliminary prediction of the gut microbiota function for menaquinone biosynthesis. Results The intravenously administered antibiotics which are excreted via bile represents the main antibiotics that could disturb the gut microbiota's composition in cardiac surgery patients, especially for elderly patients. The effect of antibiotics on gut microbiota is produced after antibiotics treatments over one week. The recovery of gut microbiota to the state of pre-antibiotics may require over two weeks of antibiotics withdrawal. Sex factor doesn't represent as an influencer in gut microbiota composition. Long-term use of cefoperazone-sulbactam may affect coagulation function. Conclusions The composition of the gut microbiota had a significant change post-intravenous antibiotics treatment in cardiac surgery patients. The richness and diversity of gut microbiota are increased in elderly patients.
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Affiliation(s)
- Ling Xue
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China,Department of Pharmacology, Faculty of Medicine, University of the Basque Country UPV/EHU, Leioa, Spain
| | - Yinglong Ding
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qiong Qin
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Linsheng Liu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoliang Ding
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yi Zhou
- Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Kun Liu
- Reproductive Medicine Centre, The First Hospital of Lanzhou University, Lanzhou, China
| | - Rajeev K. Singla
- Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China,School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
| | - Ke Shen
- Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Ahmad Ud Din
- Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Zhang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhenya Shen
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Soochow University, Suzhou, China,*Correspondence: Liyan Miao, ; Bairong Shen, ; Zhenya Shen,
| | - Bairong Shen
- Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Liyan Miao, ; Bairong Shen, ; Zhenya Shen,
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China,National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China,Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China,*Correspondence: Liyan Miao, ; Bairong Shen, ; Zhenya Shen,
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Kopanczyk R, Lester J, Long MT, Kossbiel BJ, Hess AS, Rozycki A, Nunley DR, Habib A, Taylor A, Awad H, Bhatt AM. The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:47. [PMID: 36676669 PMCID: PMC9867461 DOI: 10.3390/medicina59010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jesse Lester
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Briana J. Kossbiel
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aaron S. Hess
- Department of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Alan Rozycki
- Department of Pharmacology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Alim Habib
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Ashley Taylor
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Kusne S, Irish W, Arabia F. Extended systemic antibiotic prophylaxis in ventricular assist device recipients, an infectious disease perspective. J Card Surg 2022; 37:1819-1823. [PMID: 35655403 DOI: 10.1111/jocs.16487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether mediastinitis/deep sternal wound infection (Med/DSWI) is more common in ventricular assist device (VAD) with delayed sternal closure (DSC) compared to VAD with primary sternal closure (PSC). METHODS A literature search was done over the last four decades for studies that addressed this comparison. RESULTS Two studies met our inclusion criteria, and their results are contradictory. The first study compared 184 VAD recipients with PSC to 180 VAD recipients with DSC. There was no difference in VAD-related infections between DSC and PSC (15% vs. 16%, respectively; odds ratio = 0.965, 95% confidence interval [CI] = 0.525-1.635). The second study compared 464 VAD recipients with PSC to 94 VAD recipients with DSC. The rate of surgical site infection was higher in the DSC patients (12.5% vs. 1.4%, respectively; odds ratio = 10.1; 95% CI = 3.8-27.0). DSC was identified as an independent risk factor for postoperative mortality, but no detailed infection information was given. CONCLUSIONS There is no clear evidence of the association between DSC, compared to PSC, and Med/DSWI. Therefore, DSC is not an absolute indication for extended systemic antibiotic prophylaxis. The decision to extend the duration of systemic antibiotic prophylaxis should be made on a case-by-case basis, in collaboration with an infectious disease specialist.
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Affiliation(s)
- Shimon Kusne
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - William Irish
- Department of Surgery, The Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Francisco Arabia
- Departments of Surgery and Medicine, Banner-University Medical Center Phoenix, Phoenix, Arizona, USA
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Xie J, Jin D, Qiu J, Cui J, Yin M, Qu X. The solvent effect modulates the formation of homogeneous polyphenol composite hydrogels with improved transparency and mechanical strength for antibacterial delayed sternal closure films. J Mater Chem B 2022; 10:795-805. [PMID: 35040841 DOI: 10.1039/d1tb02101j] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The usage of delayed sternal closure films after thoracotomy surgery helps doctors deal with emergency conveniently. There is a growing demand to develop suturable, antibacterial and transparent films for delayed sternal closure. Although polyphenol incorporated hydrogels provide good suture ability, they lose transparency because of the heterogeneous distribution of polyphenols during the post-immersion process. Here, a solvent exchange method is proposed to fabricate homogeneous polyphenol composite hydrogels in a bottom-up manner, which utilizes the distinct solvent effect of DMSO and H2O to modulate the association and disassociation between polyphenols and the polymer backbones on demand. DMSO first provides a protective environment to turn off the intermolecular interactions and allows tannic acid (TA) to be dispersed into the polymer network PEG-lysozyme (PEG-LZM) homogeneously. The following water rehydration turns on the intermolecular interactions between titanic acid and PEG-lysozymes, and results in a homogeneous titanic acid toughened composite hydrogel (PEG-LZM-TA (DH)), which has an improved transparency and mechanical properties than those of the materials prepared by the post-immersion method. In addition, the TA integration provides antibacterial function to the hydrogels. We establish a rabbit delayed sternal closure model to demonstrate that PEG-LZM-TA (DH) films can be sutured to temporarily close the thoracic cavity of rabbits, provide a transparent window to inspect the wound at any time, and control the bacterial contamination efficiently. We further explore the solvent exchange method to other polyphenols and polymeric hydrogel composites. The results suggest that the solvent exchange method provides generic opportunities to fabricate homogeneous polyphenol strengthened hydrogel systems with high performance.
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Affiliation(s)
- Jiahui Xie
- Key Laboratory for Ultrafine Materials of Ministry of Education, Frontiers Science Center for Materiobiology and Dynamic Chemistry, School of Material Science and Engineering, East China University of Science and Technology, Shanghai 200237, China.
| | - Dawei Jin
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dong Fang Road, Shanghai, 200127, China
| | - Jiaqi Qiu
- Key Laboratory for Ultrafine Materials of Ministry of Education, Frontiers Science Center for Materiobiology and Dynamic Chemistry, School of Material Science and Engineering, East China University of Science and Technology, Shanghai 200237, China.
| | - Jingyuan Cui
- Key Laboratory for Ultrafine Materials of Ministry of Education, Frontiers Science Center for Materiobiology and Dynamic Chemistry, School of Material Science and Engineering, East China University of Science and Technology, Shanghai 200237, China.
| | - Meng Yin
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dong Fang Road, Shanghai, 200127, China
| | - Xue Qu
- Key Laboratory for Ultrafine Materials of Ministry of Education, Frontiers Science Center for Materiobiology and Dynamic Chemistry, School of Material Science and Engineering, East China University of Science and Technology, Shanghai 200237, China.
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Abstract
Healthcare-associated infections contribute to morbidity, mortality, and increased cost in intensive care unit patients. Understanding evidence-based prevention strategies can help to optimize patient outcomes.
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Jha P, Woodward CS, Gardner H, Pietz C, Husain SA. A Quality Improvement Initiative to Reduce Surgical Site Infections in Patients Undergoing Delayed Sternal Closure After Pediatric Cardiac Surgery. Pediatr Cardiol 2020; 41:1402-1407. [PMID: 32556486 DOI: 10.1007/s00246-020-02396-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/12/2020] [Indexed: 11/30/2022]
Abstract
Sternal wound infections (SWI) in delayed sternal closure (DSC) patients are a healthcare burden after congenital heart surgery. There are no guidelines specific for pediatric DSC patients to prevent this costly complication. The hypothesis was that the modifications to a bundled approach for DSC patients would decrease the SWI rate. For this prospective cohort study, DSC patients were postoperatively admitted to a pediatric cardiac care unit from February 2017 to January 2018. Using a modified protocol for prevention of SWI, the infection rates pre- and post-modified protocol were compared. The primary outcome measure was SWI. Secondary outcome measures were compliance with modifications. Retrospective review of cases in pre-protocol modification era from January 1, 2014 to December 31, 2016 showed 377 pediatric cardiopulmonary bypass cases and 39 (10.4%) underwent DSC. During the post-protocol modification era, there were 129 cardiopulmonary bypass cases and 17 (13%) DSC cases. The SWI rate in DSC were 7.7% and 0% for pre-intervention and post-intervention, respectively (p = 0.52). The Bayesian confidence interval with Jeffreys prior gives a 95% confidence interval of 1.5% to 18.3% for pre-intervention and 0 to 13.5% for post-intervention. Compliance with the protocol bundle during the post protocol era was 93-100%. Although preliminary results are not statistically significant due to cohort size, the economic burden and increased LOS for each SWI is clinically significant. The early results of reduced infections for DSC patients using a modified bundle approach appear promising. Continued study and a multicenter project would be beneficial.
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Affiliation(s)
- Prashant Jha
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Nevada, University Medical Center, 1800 W Charleston Blvd, Las Vegas, NV, 89128, USA.
- Department of Pediatrics, University of Nevada at Las Vegas, Las Vegas, NV, USA.
| | - Cathy S Woodward
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Heather Gardner
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Clinton Pietz
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - S Adil Husain
- Division of Pediatric Cardiothoracic Surgery, The University of Utah's School of Medicine, Salt Lake City, UT, USA
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Li M, Mazzeffi MA, Gammie JS, Banoub M, Pazhani Y, Herr D, Madathil R, Pousatis S, Bathula A. Characterization of Postoperative Infection Risk in Cardiac Surgery Patients With Delayed Sternal Closure. J Cardiothorac Vasc Anesth 2020; 34:1238-1243. [PMID: 32127277 DOI: 10.1053/j.jvca.2020.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the incidence of postoperative infection in cardiac surgery patients who had delayed sternal closure (DSC) with those who had primary sternal closure (PSC) and evaluate the effectiveness of antibiotic prophylaxis in DSC patients. DESIGN Retrospective, observational cohort study with propensity score matching. SETTING Single academic medical center. PARTICIPANTS Cardiothoracic surgery patients, excluding transplantation patients, from a single academic medical center who had DSC or PSC between November 2015 and November 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 2,685 patients who had cardiac surgery with cardiopulmonary bypass, 99 had DSC. Fifty-nine DSC patients met study inclusion criteria, and the final propensity score matched cohort included 57 patients with DSC and 57 patients with PSC. Propensity score matching reduced bias but was unable to balance all covariates. The most common indication for DSC was coagulopathy in 32 of the 57 patients. All patients in the PSC group received routine antibiotic prophylaxis for 48 hours after surgery. Patients in the DSC group received prolonged broadened prophylaxis until 48 hours after sternal closure. Despite prolonged broadened antibiotic prophylaxis, the DSC group had a higher rate of postoperative infection (31.6% v 3.5%; p < 0.005), mainly pneumonia (19.3% v 1.8%; p < 0.005), in the first 30 days after surgery. There was no difference in the incidence of sepsis (5.3% v 0%; p = 0.24), superficial skin and soft tissue infection (1.8% v 1.8%; p = 1), or mediastinitis/deep tissue infection (5.3% v 0%; p = 0.24) in patients with DSC. Seventy-seven percent of causative organisms for infection were Gram-negative bacteria in the matched cohort. CONCLUSION The incidence of postoperative infection, particularly pneumonia, is high in cardiothoracic surgery patients with DSC, even with prolonged broadened antibiotic prophylaxis, but the rate of mediastinitis/deep tissue infection did not appear to be greater with DSC. Additional research is needed into optimal antibiotic prophylaxis in this high-risk group of patients.
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Affiliation(s)
- Matthew Li
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD.
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | | | - Daniel Herr
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Ronson Madathil
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Sheelagh Pousatis
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Allison Bathula
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
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Commentary: Delayed sternal closure-an open and not-so-shut case. JTCVS Tech 2020; 2:80-81. [PMID: 34317760 PMCID: PMC8298877 DOI: 10.1016/j.xjtc.2020.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 02/14/2020] [Accepted: 02/20/2020] [Indexed: 11/17/2022] Open
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Rafiroiu S, Hassouna H, Ahmad U, Koval C, McCurry KR, Pettersson GB, Ibrahim M, Johnston DR, Budev M, Murthy SC, Toth AJ, Blackstone EH, Tong MZ. Consequences of Delayed Chest Closure During Lung Transplantation. Ann Thorac Surg 2020; 109:277-284. [DOI: 10.1016/j.athoracsur.2019.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 07/25/2019] [Accepted: 08/08/2019] [Indexed: 10/26/2022]
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Yabrodi M, Hermann JL, Brown JW, Rodefeld MD, Turrentine MW, Mastropietro CW. Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2019; 10:400-406. [PMID: 31307311 DOI: 10.1177/2150135119846040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) following pediatric cardiac surgery is commonly implemented at many centers. Infectious complications occur in 18.7% of these patients based on recent multicenter data. We aimed to describe our experience with DSC, hypothesizing that our practices surrounding the implementation and maintenance of the open sternum during DSC minimize the risk of infectious complications. METHODS We reviewed patients less than 365 days who underwent DSC between 2012 and 2016 at our institution. Infectious complications as defined by the Society of Thoracic Surgeons Congenital Heart Surgery Database were recorded. Patients with and without infectious complications were compared using Wilcoxon rank sum tests or Fisher exact tests as appropriate. RESULTS We identified 165 patients less than 365 days old who underwent DSC, 135 (82%) of whom had their skin closed over their open sternum. Median duration of open sternum was 3 days (range: 1-32 days). Infectious complications occurred in 15 (9.1%) patients-13 developed clinical sepsis with positive blood cultures, one patient developed ventilator-associated pneumonia, and one patient developed wound infection (0.6%). No cases of mediastinitis occurred. No statistical differences in characteristics between patients with and without infectious complications could be identified. CONCLUSION Infectious complications after DSC at our institution were notably less than reported in recent literature, primarily due to minimization of surgical site infections. Practices described in the article, including closing skin over the open sternum whenever possible, could potentially aid other institutions aiming to reduce infectious complications associated with DSC.
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Affiliation(s)
- Mouhammad Yabrodi
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeremy L Hermann
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John W Brown
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark D Rodefeld
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark W Turrentine
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
OBJECTIVES Although open chest management optimizes hemodynamics after cardiac surgery, it increases postoperative infections and leads to increased mortality. Despite the importance of antibiotic prophylaxis during open chest management, no specific recommendations exist. We aimed to compare the occurrence rates of bloodstream infection and surgical site infection between the different prophylactic antibiotic regimens for open chest management after pediatric cardiac surgery. DESIGN Retrospective, single-center, observational study. SETTING PICU at a tertiary children's hospital. PATIENTS Consecutive patients younger than or equal to 18 years old with open chest management after cardiac surgery followed by delayed sternal closure, between January 2012 and June 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared the composite occurrence rate of postoperative bloodstream infection and surgical site infection within 30 days after cardiac surgery between three prophylactic antibiotic regimens: 1) cefazolin, 2) cefazolin + vancomycin, and 3) vancomycin + meropenem. In 63 pediatric cardiac surgeries with open chest management, 17 bloodstream infections, and 12 surgical site infections were identified postoperatively. The composite occurrence rates of bloodstream infection and surgical site infection were 10 of 15 (67%), 10 of 19 (53%), and nine of 29 (31%) in the cefazolin, cefazolin + vancomycin, and vancomycin + meropenem regimens, respectively (p = 0.07). After adjusting for age, open chest management duration, extracorporeal membrane oxygenation use, and nasal methicillin-resistant Staphylococcus aureus colonization in multivariable analysis, there was no significant difference between the cefazolin and the cefazolin + vancomycin regimens (p = 0.19), while the vancomycin + meropenem regimen had a lower occurrence rate of bloodstream infection and surgical site infection than the cefazolin regimen (odds ratio, 0.0885; 95% CI, 0.0176-0.446; p = 0.003). CONCLUSIONS In this study, a lower occurrence rate of postoperative bloodstream infection and surgical site infection was observed among patients with broad-spectrum antibiotic regimen after pediatric cardiac surgery with open chest management. Further studies, ideally randomized controlled studies investigating the efficacy of broad-spectrum antibiotics and their complications, are warranted before routine implementation of broad-spectrum prophylactic antibiotic regimen.
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Silvetti S, Landoni G, Castagnola E, Nuri H, Pomé G, Moscatelli A. Antibiotic Management for Delayed Sternal Closure Following Pediatric Cardiac Surgery: A Systematic Review of Recent Literature. J Cardiothorac Vasc Anesth 2019; 34:1333-1340. [PMID: 31420313 DOI: 10.1053/j.jvca.2019.07.134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 12/21/2022]
Abstract
Delayed sternal closure after pediatric cardiac surgery is a management option for the treatment of patients with severely impaired heart function. The optimal antimicrobial treatment strategy for this condition is unknown. The aim of this systematic review was to evaluate the current antibiotic administration attitudes in pediatric cardiac surgery patients needing an open chest in terms of infection with a focus on surgical site infection rate. The authors performed a systematic review and meta-analysis of all articles, which described the antibiotic administration strategy and surgical site infection rate in pediatric patients with an open chest after cardiac surgery. The authors performed a subgroup analysis on "standard" versus "non-standard" (defined as any antimicrobial drugs different from the adult guidelines recommendations) therapy for one-proportion meta-analysis with a random effect model. The authors identified 12 studies published from January 1, 2000 to July 1, 2019 including a total of 2,203 patients requiring an open chest after cardiac surgery, 350 of whom (15.9%) developed infections and 182 (8.3%) developed a surgical site infection. The surgical site infection rate in patients with "non-standard" strategy was higher than in patients with "standard" strategy: 8.8% (140 reported infections/1,582 patients) versus 6.8% (42 reported infections/621 patients), p = 0.001. The "standard" antibiotic management proposed by guidelines for adult cardiac surgery patients could be used an acceptable strategy to treat pediatric patients with an open chest after cardiac surgery.
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Affiliation(s)
- Simona Silvetti
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, University Vita-Salute San Raffaele, Milano, Italy.
| | - Elio Castagnola
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Halkawt Nuri
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuseppe Pomé
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
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