Management practices and major infections after cardiac surgery

Practitioner dashboard feedback improves glycemic but not temperature compliance during cardiac surgery: A single center retrospective analysis

STUDY OBJECTIVE

To determine the association of practitioner dashboard feedback of intraoperative glycemic and temperature control on maintenance of normoglycemia and normothermia.

DESIGN

Retrospective review.

SETTING

Single tertiary care institution.

PATIENTS

Patients over the age of 18 undergoing cardiac surgery from February 17, 2021 through February 16, 2023. During the study interval, 15 anesthesiologists providing care during 2255 procedures were analyzed: 1114 prior to the individual faculty dashboard distribution and 1141 after commencement of dashboard distribution.

INTERVENTIONS

On February 17, 2022, anesthesia faculty members began receiving monthly individualized dashboards indicating their personal intraoperative glycemic and temperature compliance rates.

MEASUREMENTS

Baseline patient demographic characteristics, surgical and cardiopulmonary bypass times, perioperative temperature and glucose concentrations, and the incidence of sternal wound infections. Glycemic compliance was defined as final serum glucose between 80 and 180 mg/dL. Temperature compliance was defined as an average temperature during the final 30 min of the surgical procedure between 35 and 37.3 °C inclusive.

MAIN RESULTS

Dashboard distribution was associated with a significant decrease in the average glucose concentration (median location shift by -6 mg% (95% confidence interval (CI) -8, -4), p < 0.001) from 157 mg/dL to 152 mg/dL and final glucose concentration (median location shift by -17 mg/dL (95% CI -19, -14, p < 0.001) from 161 mg/dL to 145 mg/dL. The intervention was associated with an improvement in glycemic compliance from 71.4% to 87.1% (odds ratio (OR): 2.71(95% CI 2.19, 3.37, p < 0.001)). There were no significant differences in final temperature (36.3 °C [Q1, Q3: 36.0, 36.6] vs. 36.3 °C [Q1, Q3: 36.0, 36.7] (p = 0.232)) with the intervention nor were there any statistically significant differences in temperature compliance (93.9% vs. 92.9%, OR: 0.79 (95% CI 0.55-1.14, p = 0.25). There were no statistically significant changes in the incidence of superficial, deep, or any wound infections with the intervention.

CONCLUSIONS

Individualized practitioner dashboard distribution may be an effective tool to increase intraoperative glycemic control.

Association of adherence to individual components of Society of Thoracic Surgeons cardiac surgery antibiotic guidelines and postoperative infections

OBJECTIVES

The study objectives were to measure the association among the 4 components of Society of Thoracic Surgeons antibiotic guidelines and postoperative complications in a cohort of patients undergoing valve or coronary artery bypass grafting requiring cardiopulmonary bypass.

METHODS

In this retrospective observational study, adult patients undergoing coronary revascularization or valvular surgery who received a Surgical Care Improvement Project-compliant antibiotic from January 1, 2016, to April 1, 2021, at a single, tertiary care hospital were included. The primary exposures were adherence to the 4 individual components of Society of Thoracic Surgeons antibiotic best practice guidelines. The association of each component and a combined metric was tested in its association with the primary outcome of postoperative infection as determined by Society of Thoracic Surgeons data abstractors, controlling for several known confounders.

RESULTS

Of the 2829 included patients, 1084 (38.3%) received care that was nonadherent to at least 1 aspect of Society of Thoracic Surgeons antibiotic guidelines. The incidence of nonadherence to the 4 individual components was 223 (7.9%) for timing of first dose, 639 (22.6%) for antibiotic choice, 164 (5.8%) for weight-based dose adjustment, and 192 (6.8%) for intraoperative redosing. In adjusted analyses, failure to adhere to first dose timing guidelines was directly associated with Society of Thoracic Surgeons-adjudicated postoperative infection (odds ratio, 1.9; 95% confidence interval, 1.1-3.3; P = .02). Failure of weight-adjusted dosing was associated with both postoperative sepsis (odds ratio, 6.9; 95% confidence interval, 2.5-8.5; P < .01) and 30-day mortality (odds ratio, 4.3; 95% confidence interval, 1.7-11.4; P < .01). No other significant associations among the 4 Society of Thoracic Surgeons metrics individually or as a combination were observed with postoperative infection, sepsis, or 30-day mortality.

CONCLUSIONS

Nonadherence to Society of Thoracic Surgeons antibiotic best practices is common. Failure of antibiotic timing and weight-adjusted dosing is associated with odds of postoperative infection, sepsis, and mortality after cardiac surgery.

Coronavirus Disease 2019 Pandemic and Reduced Surgical Site Infection After Cardiac Surgery: A Potential Blessing in Disguise

Background: The coronavirus disease 2019 (COVID-19) pandemic has brought about drastic hygienic measures, one upside of which might be the mitigated occurrence of surgical site infection (SSI). This study investigated the association of the pandemic with SSI occurrence after cardiac surgeries. Patients and Methods: From 2014 to 2022, patients undergoing cardiac surgery were included and categorized into pre-pandemic and during-pandemic groups. Surgical site infections were classified into harvest-site, superficial sternal, and complex sternal infection. Multiple logistic regression and inverse probability weighting assessed the association of the pandemic with SSI. Results: Among a total of 26,143 patients, 793 SSIs occurred. The during-pandemic patients were younger (61.87 ± 10.58 vs. 65.64 ± 11.82) with a higher male proportion (70.1% vs. 67.4%) and a higher prevalence of all studied comorbidities/risk factors (expect cigarette smoking). Total SSI rate decreased substantially from 3.3% before COVID-19 to 1.8% afterward (p < 0.001). Inverse probability weights analyses evinced an independent association of the pandemic with a reduced risk of total (adjusted odds ratio [OR]; 0.59; 95% confidence interval [CI], 0.45-0.78), harvest-site (adjusted OR, 0.36; 95% CI, 0.19-0.70), and superficial sternal infection (adjusted OR, 0.60; 95% CI, 0.43-0.81). No significant association was observed with complex sternal site infection (adjusted OR, 1.05; 95% CI, 0.55-2.01). Multivariable regression recapitulated these findings. Conclusions: The COVID-19 pandemic independently pertained to more than a 40% reduction in SSI occurrence, particularly affecting harvest-site and superficial sternal infections. However, there remains the possibility of the implications of other known and unknown confounders on the observed association. To some extent, the decrease in SSIs after the pandemic can be justified by reinforced hygienic precautions, emphasizing the necessity of extending the adherence to these measurements into the post-COVID-19 era to maintain the status quo.

A nomogram predicting pneumonia after cardiac surgery: a retrospective modeling study

BACKGROUND

Postoperative pneumonia (POP) is the most prevalent of all nosocomial infections in patients who underwent cardiac surgery. The aim of this study was to identify independent risk factors for pneumonia after cardiac surgery, from which we constructed a nomogram for prediction.

METHODS

The clinical data of patients admitted to the Department of Cardiothoracic Surgery of Nanjing Drum Tower Hospital from October 2020 to September 2021 who underwent cardiac surgery were retrospectively analyzed, and the patients were divided into two groups according to whether they had POP: POP group (n=105) and non-POP group (n=1083). Preoperative, intraoperative, and postoperative indicators were collected and analyzed. Logistic regression was used to identify independent risk factors for POP in patients who underwent cardiac surgery. We constructed a nomogram based on these independent risk factors. Model discrimination was assessed via area under the receiver operating characteristic curve (AUC), and calibration was assessed via calibration plot.

RESULTS

A total of 105 events occurred in the 1188 cases. Age (>55 years) (OR: 1.83, P=0.0225), preoperative malnutrition (OR: 3.71, P<0.0001), diabetes mellitus(OR: 2.33, P=0.0036), CPB time (Cardiopulmonary Bypass Time) > 135 min (OR: 2.80, P<0.0001), moderate to severe ARDS (Acute Respiratory Distress Syndrome )(OR: 1.79, P=0.0148), use of ECMO or IABP or CRRT (ECMO: Extra Corporeal Membrane Oxygenation; IABP: Intra-Aortic Balloon Pump; CRRT: Continuous Renal Replacement Therapy )(OR: 2.60, P=0.0057) and MV( Mechanical Ventilation )> 20 hours (OR: 3.11, P<0.0001) were independent risk factors for POP. Based on those independent risk factors, we constructed a simple nomogram with an AUC of 0.82. Calibration plots showed good agreement between predicted probabilities and actual probabilities.

CONCLUSION

We constructed a facile nomogram for predicting pneumonia after cardiac surgery with good discrimination and calibration. The model has excellent clinical applicability and can be used to identify and adjust modifiable risk factors to reduce the incidence of POP as well as patient mortality.

Post-operative infections after cardiothoracic surgery and vascular procedures: a bibliometric and visual analysis of the 100 most-cited articles in the past 2 decades

Aim

To recognize and analyze the 100 most-cited articles on post-operative infections following cardiothoracic surgery and vascular procedures in the past 20 years.

Methods

Articles published on post-operative infections following cardiothoracic surgery and vascular procedures from inception 1986 till 2020 were reviewed and selected by two authors, based on their number of citations using the Scopus database. Their characteristics were recorded, i.e., title, authors, publication date, total no. of citations, citations per year (CPY), country of research, institutional affiliation, journal, research subject, and article type.

Results

The top 100 most influential articles were published between 1968 and 2017, with the peak in 2002. The mean number of total citations was 236.79 (range: 108-1,157). Areas with a medical focus were predominant in the studied research articles on the researched topic. The top-most journals in which these articles were published include Annals of Thoracic Surgery (14), followed by Circulation (8), and the New England Journal of Medicine (8). The number of publications affiliated with an institution were highest in the United States, with the Cleveland Clinic Foundation (6) having the most.

Conclusion

These findings highlight that there is a great potential to conduct research and publish the prevalence, causes, risk factors, pathogenesis and molecular biology of post-cardiac and -vascular surgery infections to prevent their adverse effects. The results can be taken into consideration for policy making to improve post-cardiac-surgery outcomes.

A comprehensive qualitative investigation of the factors that affect surgical site infection prevention in cardiac surgery in England using observations and interviews

BACKGROUND

Interview and questionnaire studies have identified barriers and challenges to preventing surgical site infections (SSIs) by focusing on compliance with recommendations and care bundles using interviews, questionnaires and expert panels. This study proposes a more comprehensive investigation by using observations of clinical practice plus interviews which will enable a wider focus.

AIM

To comprehensively identify the factors which affect SSI prevention using cardiac surgery as an exemplar.

METHODS

The study consisted of 130 h of observed clinical practice followed by individual semi-structured interviews with 16 surgeons, anaesthetists, theatre staff, and nurses at four cardiac centres in England. Data were analysed thematically.

FINDINGS

The factors were complex and existed at the level of the intervention, the individual, the team, the organization, and even the wider society. Factors included: the attributes of the intervention; the relationship between evidence, personal beliefs, and perceived risk; power and hierarchy; leadership and culture; resources; infrastructure; supplies; organization and planning; patient engagement and power; hospital administration; workforce shortages; COVID-19 pandemic; 'Brexit'; and the war in Ukraine.

CONCLUSION

This is one of the first studies to provide a comprehensive overview of the factors affecting SSI prevention. The factors are complex and need to be fully understood when trying to reduce SSIs. A strong evidence base was insufficient to ensure implementation of an intervention.

Epidemiology and Risk Factors for Nosocomial Infections in Left Ventricular Assist Device Recipients

Left ventricular assist devices (LVADs) have been increasingly used as a valid option to improve the prognosis and reduce the symptoms of end-stage heart failure. However, long-term complications, mostly infections and coagulation disorders, are frequent. We described the epidemiology and risk factors for nosocomial infections (NIs) in a cohort of adult patients who underwent continuous-flow LVAD implant between January 2010 and December 2017 in Turin, Italy. Secondary outcomes were the prevalence of multidrug-resistant (MDR) bacteria and mortality. Results: Overall, 64 LVADs were implanted. A total of 32 (50%) patients experienced at least one episode of NI, with a total of 46 infectious events. VAD-related infections occurred in 22 patients (68.8%). Non VAD-related NIs occurred in 12 patients (37.5%), mainly low respiratory tract infections. Length of intensive care unit admission was a risk factor for NI (OR 1.224, 95%CI; 1.049, 1.429). Gram-negative bacilli were responsible for 58.8% of VAD-related infections and 79.5% of non-VAD related infections. In sixteen patients (50%), at least one episode of infection was related to an MDR strain. INTERMACS class and length of MV were independent risk factors for NIs by MDR strains (respectively, OR 2.12, 95%CI: 1.08, 6.80; p = 0.02 and OR 1.46, 95%CI: 1.07, 5.52, p = 0.047). In-hospital mortality was 6.3%. No differences in mortality were observed between infected and non-infected patients (p = 0.61) even when caused by MDR strains (p = 0.143). Conclusion: the rate of nosocomial infections in LVAD patients is associated with the length of ICU admission, and the etiology of nosocomial infection after LVAD implant is mainly due to GNB, including a high rate of MDR strains, especially KPC-KP and MDR PA.

Analysis and evaluation of patient-specific three-dimensional printing in complex septal myectomy

OBJECTIVES

This study aimed to assess the effectiveness of three-dimensional printing (3DP) in patients with complex hypertrophic cardiomyopathy requiring combined transaortic and transapical septal myectomy.

METHODS

We created 3DP models for 7 patients undergoing this surgery approach between June and October 2022 using silicone-like resin and conducted mock operations. The models were compared with echocardiography to identify abnormal muscle bundles and heart structures. These patients were then compared with a 1:2 matched group without 3DP, considering age, sex and additional operations.

RESULTS

The models mostly presenting with midventricular obstruction showed high consistency with original computed tomography data (r = 0.978, P < 0.001). 3DP identified more abnormal muscle bundles than echocardiography, primarily between the interventricular septum and apex. Excised specimens in mock operations mirrored those in actual myectomies. While cardiopulmonary bypass time was not significantly different, a near-20-min decrease was observed in the 3DP group (135.5 ± 31.1 vs 154.4 ± 36.6 min, P = 0.054).

CONCLUSIONS

While no significant differences in surgical outcomes were observed, 3DP appeared to enhance the visualization and understanding of spatial structures (average Likert scale score 4.0), potentially contributing to surgical proficiency (overall rating score 3.9). The use of 3DP may offer additional value in the preparation and execution of operations for complex hypertrophic cardiomyopathy cases.

Diagnosis of Early Bacterial Pneumonia and Sepsis After Cardiovascular Surgery: A Diagnostic Prediction Model Based on LASSO Logistic Regression

Background

Early postoperative bacterial pneumonia and sepsis (ePOPS), which occurs within the first 48 hours after cardiovascular surgery, is a serious life-threatening complication. Diagnosis of ePOPS is extremely challenging, and the existing diagnostic tools are insufficient. The purpose of this study was to construct a novel diagnostic prediction model for ePOPS.

Methods

Least Absolute Shrinkage and Selection Operator (LASSO) with logistic regression was used to construct a model to diagnose ePOPS based on patients' comorbidities, medical history, and laboratory findings. The area under the receiver operating characteristic curve (AUC) was used to evaluate the model discrimination.

Results

A total of 1203 patients were recruited and randomly split into a training and validation set in a 7:3 ratio. By early morning on the 3rd postoperative day (POD3), 103 patients had experienced 133 episodes of bacterial pneumonia or sepsis (15 patients had both). LASSO logistic regression model showed that duration of mechanical ventilation (P=0.015), NYHA class ≥ III (P=0.001), diabetes (P<0.001), exudation on chest radiograph (P=0.011) and IL-6 on POD3 (P<0.001) were independent risk factors. Based on these factors, we created a nomogram named DICS-I with an AUC of 0.787 in the training set and 0.739 in the validation set.

Conclusion

The DICS-I model may be used to predict the risk of ePOPS after cardiovascular surgery, and is also especially suitable for predicting the risk of IRAO. The DICS-I model could help clinicians to adjust antibiotics on the POD3.

Effect of an E-Prescription Intervention on the Adherence to Surgical Chemoprophylaxis Duration in Cardiac Surgery: A Single Centre Experience

In our hospital, adherence to the guidelines for peri-operative antimicrobial prophylaxis (PAP) is suboptimal, with overly long courses being common. This practice does not offer any incremental benefit, and it only adds to the burden of antimicrobial consumption, promotes the emergence of antimicrobial resistance, and it is associated with adverse events. Our objective was to study the effect of an electronic reminder on the adherence to each element of PAP after cardiac surgery. We conducted a single center, before and after intervention, prospective cohort study from 1 June 2014 to 30 September 2017. The intervention consisted of a reminder of the hospital guidelines when ordering PAP through the hospital information system. The primary outcome was adherence to the suggested duration of PAP, while secondary outcomes included adherence to the other elements of PAP and incidence of surgical site infections (SSI). We have studied 1080 operations (400 pre-intervention and 680 post-intervention). Adherence to the appropriate duration of PAP increased significantly after the intervention [PRE 4.0% (16/399) vs. POST 15.4% (105/680), chi-square p < 0.001]; however, it remained inappropriately low. Factors associated with inappropriate duration of PAP were pre-operative hospitalization for <3 days, and duration of operation >4 h, while there were significant differences between the chief surgeons. Unexpectedly, the rate of SSIs increased significantly during the study (PRE 2.8% (11/400) vs. POST 5.9% (40/680), chi-square p < 0.019). The implemented intervention achieved a relative increase in adherence to the guideline-recommended PAP duration; however, adherence was still unacceptably low and further efforts to improve adherence are needed.

Identification of risk factors for infection after mitral valve surgery through machine learning approaches

Background

Selecting features related to postoperative infection following cardiac surgery was highly valuable for effective intervention. We used machine learning methods to identify critical perioperative infection-related variables after mitral valve surgery and construct a prediction model.

Methods

Participants comprised 1223 patients who underwent cardiac valvular surgery at eight large centers in China. The ninety-one demographic and perioperative parameters were collected. Random forest (RF) and least absolute shrinkage and selection operator (LASSO) techniques were used to identify postoperative infection-related variables; the Venn diagram determined overlapping variables. The following ML methods: random forest (RF), extreme gradient boosting (XGBoost), Support Vector Machine (SVM), Gradient Boosting Decision Tree (GBDT), AdaBoost, Naive Bayesian (NB), Logistic Regression (LogicR), Neural Networks (nnet) and artificial neural network (ANN) were developed to construct the models. We constructed receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) was calculated to evaluate model performance.

Results

We identified 47 and 35 variables with RF and LASSO, respectively. Twenty-one overlapping variables were finally selected for model construction: age, weight, hospital stay, total red blood cell (RBC) and total fresh frozen plasma (FFP) transfusions, New York Heart Association (NYHA) class, preoperative creatinine, left ventricular ejection fraction (LVEF), RBC count, platelet (PLT) count, prothrombin time, intraoperative autologous blood, total output, total input, aortic cross-clamp (ACC) time, postoperative white blood cell (WBC) count, aspartate aminotransferase (AST), alanine aminotransferase (ALT), PLT count, hemoglobin (Hb), and LVEF. The prediction models for infection after mitral valve surgery were established based on these variables, and they all showed excellent discrimination performance in the test set (AUC > 0.79).

Conclusions

Key features selected by machine learning methods can accurately predict infection after mitral valve surgery, guiding physicians in taking appropriate preventive measures and diminishing the infection risk.

Prolonged cardiopulmonary bypass time as predictive factor for bloodstream infection

Objectives

To evaluate the correlation between patient characteristics, operative variables and the risk of blood stream infection as well as the association of primary blood stream infection and adverse outcomes.

Methods

Clinical records of 6500 adult patients who underwent open heart surgery between February 2008 and October 2020 were analyzed. The microbiological pattern of the primary BSI and its association with adverse events, such as mortality and major cardiovascular events, were evaluated.

Results

Primary bloodstream infection was diagnosed in 1.7% (n = 108) of patients following cardiac surgery with the application of cardiopulmonary bypass. Most isolated bacteria were gram-negative bacillus groups, such as the Enterobacteriaceae family with Serrata marcescens in 26.26%, followed by the Enterococcaceae family with the Enterococcus faecalis in 7.39% and Enterococcus faecium in 9.14% as the most frequently identified bacteria. The postprocedural mortality, stroke rate p < 0.001, the incidence of postoperative new renal failure p < 0.001, and the renal replacement therapy p < 0.001 were significantly higher in the primary BSI group. Aortic cross-clamp time >120 min, OR 2.31 95%CI 1.34 to 3.98, perfusion time >120 min, OR 2.45 95%CI 1.63 to 3.67, and duration of the intervention >300min, OR 2.78 95%CI 1.47 to 5.28, were significantly related to the primary BSI.

Conclusion

The gram-negative bacillus was the most common microorganism identified in BSI after cardiovascular operations using cardiopulmonary bypass. Patients on dialysis prior to cardiac surgery are at higher risk for having BSI. Enteric bacterial translocation after prolonged cardiopulmonary bypass is a possible mechanism of early primary bloodstream infection in these patients. In patients at high risk, prophylactic use of an antibiotic regimen with broader gram-negative bacteria coverage should be considered, especially in those with prolonged cardiopulmonary bypass and intervention time.

Postoperative glucocorticoids in patients with acute type A aortic dissection (GLAD): study protocol for a prospective, single-center, randomized controlled trial

BACKGROUND

Patients receiving surgical treatment of acute type A Aortic Dissection (aTAAD) are common to suffer organ dysfunction in the intensive care unit due to overwhelming inflammation. Previous studies have revealed that glucocorticoids may reduce complications in certain patient groups, but evidence between postoperative glucocorticoids administration and improvement in organ dysfunction after aTAAD surgery are lacking.

METHODS

This study will be an investigator-initiated, prospective, single-blind, randomized, single-center study. Subjects with confirmed diagnosis of aTAAD undergoing surgical treatment will be enrolled and 1:1 randomly assigned to receive either glucocorticoids or normal treatment. All patients in the glucocorticoids group will be given methylprednisolone intravenously for 3 days after enrollment. The primary endpoint will be the amplitude of variation of Sequential Organ Failure Assessment score on post-operative day 4 compared to baseline.

DISCUSSION

The trial will explore the rationale for postoperative application of glucocorticoids in patients after aTAAD surgery.

TRIAL REGISTRATION

This study has been registered on ClinicalTrials.gov (NCT04734418).

Microbiota Metabolism Failure as a Risk Factor for Postoperative Complications after Aortic Prosthetics

Postoperative complications in cardiovascular surgery remain an important unresolved problem, in particular in patients with aortic aneurysm. The role of the altered microbiota in such patients is of great interest. The aim of this pilot study was to determine whether the development of postoperative complications in patients with aortic aneurysm is related with initial or acquired disorders of microbiota metabolism by monitoring the level of some aromatic microbial metabolites (AMMs) circulating in the blood before the surgery and in the early postoperative period. The study comprised patients with aortic aneurysm (n = 79), including patients without complications (n = 36) and patients with all types of complications (n = 43). The serum samples from the patients were collected before and 6 h after the end of the surgery. The most significant results were obtained for the sum of three sepsis-associated AMMs. This level was higher before the surgery in comparison with that of healthy volunteers (n = 48), p < 0.001, and it was also higher in the early postoperative period in patients with all types of complications compared to those without complications, p = 0.001; the area under the ROC curve, the cut-off value, and the odds ratio were 0.7; 2.9 µmol/L, and 5.5, respectively. Impaired microbiota metabolism is important in the development of complications after complex reconstructive aortic surgery, which is the basis for the search for a new prevention strategy.

Development of a nomogram for predicting nosocomial infections among patients after cardiac valve replacement surgery

AIMS AND OBJECTIVES

To construct a predictive nomogram of the risk of nosocomial infections among patients after cardiac valve replacement surgery.

BACKGROUND

Nosocomial infections are a standout challenge that worsens the prognosis of patients after valve replacement surgery. However, studies on the nomogram of nosocomial infections in these patients have remained scarce.

DESIGN

A retrospective cohort study.

METHODS

Patients (n = 720) following valve replacement surgery from 2018 to 2019 were selected. LASSO regression and multivariate logistic regression were utilised to ascertain predictors of nosocomial infections. The predictive performance of the nomogram was appraised by calibration and discrimination. Decision and impact curves were used to assess the clinical utility. Internal validation was implemented via 1000 bootstrap samples to mitigate overfitting. TRIPOD guidelines were used in this study.

RESULTS

One hundred and fifty one patients (20.97%) experienced nosocomial infections following valve replacement surgery. Heart failure, preoperative anaemia, valve material, American Society of Anesthesiologists score ≥ IV, prolonged duration of surgery, duration of mechanical ventilation ≥ 24 h and indwelling nasogastric tube were predictors of nosocomial infections. Using these variables, we developed a predictive nomogram of the occurrence of nosocomial infections and the internal validation results demonstrated good discrimination and calibration of the nomogram. The clinical decision and impact curve revealed significant clinical utility.

CONCLUSIONS

The present study constructed a nomogram for predicting the risk of nosocomial infections in patients following cardiac valve replacement surgery. This nomogram may strengthen the effective screening of patients at high risk of nosocomial infections.

RELEVANCE TO CLINICAL PRACTICE

This risk warning tool can assist clinical staff in making decisions and providing individualised infection control measures for patients, which has a significant reference value for clinical practice.

NO PATIENT OR PUBLIC CONTRIBUTION

The data for this study were obtained from the hospital database, and the entire process of the study did not involve patient participation.

Effect of perioperative oral management on postoperative bloodstream infection in heart valve surgery patients

OBJECTIVE

There is a well-known relationship between oral hygiene and infective endocarditis. Epidemiological evidence regarding perioperative oral management (POM) for cancer surgery has been accumulated, but this evidence is not sufficient for cardiac surgery. Therefore, our purpose was to investigate whether POM can prevent postoperative complications in patients undergoing heart valve surgery.

SUBJECTS AND METHODS

Using single-arm medical information, we retrospectively enrolled 301 patients who underwent heart valve surgery between April 2010 and March 2019. The patient background was adjusted by the propensity score (PS). We then analyzed the impact of POM on postoperative bloodstream infection (PBSI), postoperative pneumonia, and mortality using PS inverse probability of treatment weighting (IPTW).

RESULTS

IPTW revealed that the POM group had a lower incidence of PBSI than the control group, with an odds ratio of 0.316 (p = 0.003). The mortality in the POM group was significantly lower than that in the control group (p = 0.023). Fourteen patients died in the present study and 6 of them were infection-related.

CONCLUSIONS

POM was significantly associated with decreased incidence of PBSI and mortality. The results suggest that POM is beneficial for the prevention of PBSI and mortality in patients undergoing heart valve surgery.

Radionuclide Imaging of Infective Endocarditis

Infective endocarditis (IE) is associated with high morbidity and mortality. Early diagnosis is crucial for adequate patient management. Due to difficulties in the diagnosis, a multidisciplinary discussion in addition to the integration of clinical signs, microbiology data, and imaging data is used. Imaging, including echocardiography, molecular imaging techniques, and coronary CT angiography (CTA) is central to detect infections involving heart valves and implanted cardiovascular devices, also allowing for early detection of septic emboli and metastatic. This article describes the main clinical application of white blood cell SPECT/CT and [¹⁸F]FDG-PET/CT and CTA in IE and infections associated with cardiovascular implantable electronic devices.

Assessment of the impact of intravenous antibiotics treatment on gut microbiota in patients: Clinical data from pre-and post-cardiac surgery

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.

Association of intraoperative hyperglycemia with postoperative composite infection after cardiac surgery with cardiopulmonary bypass: A retrospective cohort study

Background

The association between intraoperative hyperglycemia (IH) and postoperative infections in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) is inadequately studied.

Methods

A total of 3,428 patients who underwent cardiac surgery with CPB at our institution between June 1, 2019 and July 30, 2021 were enrolled to evaluate the association of IH (blood glucose ≥ 180 mg/dL) with postoperative infection in patients. The new onset of any type of infection and the optimal cutoff values of intraoperative glucose to predict in-hospital infection were determined.

Results

The composite outcome occurred in 497 of 3,428 (14.50%) patients. IH was associated with an increased risk of postoperative composite infection [adjusted odds ratio: 1.39, (95% confidence interval), 1.06-1.82, P = 0.016]. Restricted cubic splines were applied to flexibly model and visualize the association of intraoperative peak glucose with infection, and a J-shaped association was revealed. Besides, it was demonstrated that the possibility of infection was relatively flat till 150 mg/dL glucose levels which started to rapidly increase afterward.

Conclusion

We summarize that IH is associated with an elevated risk of postoperative new-onset composite infections and perioperative blood glucose management should be more stringent, i.e., lesser than 150 mg/dL in patients undergoing cardiac surgery.

Risk factors associated with positive bacterial culture in salvaged red blood cells during cardiac surgery and postoperative infection incidence: A prospective cohort study

Background

This study was designed to explore factors associated with the incidence of positive bacterial culture of salvaged red blood cells (sRBCs) recovered with a Cell Saver instrument during cardiac surgery and the impact of such positive outcomes on postoperative infection-related morbidity.

Methods

The cohort study enrolled 204 patients scheduled for cardiac surgery with intraoperative blood cell salvage and retransfusion from July 2021 to July 2022. These patients were stratified into two groups based on intraoperative sRBCs bacterial culture results: culture (+) and culture (-) groups. Preoperative and intraoperative variables were compared between these groups aim to detect possible predictors of positive culture in sRBCs. In addition, differences in postoperative infection-related morbidity and other clinical outcomes were compared between these groups.

Results

Of these patients, 49% were sRBCs culture (+), with Staphylococcus epidermidis as the most commonly identified pathogen. Risk factors independently associated with the risk of positive culture in sRBCs included BMI ≥25 kg/m², a history of smoking, an operative duration ≥277.5 min, the higher number of staff in the operating room and higher surgical case order. Patients in the sRBCs culture (+) group exhibited a longer average ICU stay [3.5 days (2.0-6.0) vs. 2 days (1.0-4.0), P < 0.01], a longer duration of ventilation [20.45 h (12.0-17.8) vs. 13 h (11.0-17.0, P = 0.02)], underwent more allogeneic blood transfusions, exhibited higher transfusion-related costs [2,962 (1,683.0-5,608.8) vs. 2,525 (1,532.3-3,595.0), P = 0.01], and had higher rates of postoperative infections (22 vs. 9.6%, P = 0.02) as compared to patients in the sRBCs culture (-) group. In addition, culture (+) in sRBCs was an independent risk factor for postoperative infection (OR 2.62, 95% CI 1.16-5.90, P = 0.02).

Conclusion

Staphylococcus epidermidis was the most common pathogen detected in sRBCs in the culture (+) group in this study, identifying it as a potential driver of postoperative infection. Positive sRBCs culture may contribute to postoperative infection and its incidence was significantly associated with patient BMI, history of smoking, operative duration, the number of staff in the operating room and surgical case order.

Combined pectoralis and rectus abdominis flaps are associated with improved outcomes in sternal reconstruction

BACKGROUND

Mortality increases nearly 5-fold in the approximately 5% of patients who develop sternal wound complications after cardiothoracic surgery. Flap-based reconstruction can improve outcomes by providing well-vascularized soft tissue for potential space obliteration, antibiotic delivery, and wound coverage; however, reoperation and readmission rates remain high. This study used the high case volume at a tertiary referral center and a diverse range of reconstructive approaches to compare various types of flap reconstruction. Combined (pectoralis and rectus abdominis) flap reconstruction is hypothesized to decrease sternal wound complication-related adverse outcomes.

METHODS

A retrospective cohort study of consecutive adult patients treated for cardiothoracic surgery sternal wound complications between 2008 and 2018 was performed. Patient demographics, comorbidities, wound characteristics, surgical parameters, and perioperative data were collected. Multivariable regression modeling with stepwise forward selection was used to characterize predictive factors for sternal wound-related readmissions and reoperations.

RESULTS

In total, 215 patients were assessed for sternal wound reconstruction. Patient mortality at 1 year was 12.4%. Flap selection was significantly associated with sternal wound-related readmissions (P = .017) and reoperations (P = .014). Multivariate regression demonstrated rectus abdominis flap reconstruction independently predicted increased readmissions (odds ratio 3.4, P = .008) and reoperations (odds ratio 2.9, P = .038). Combined pectoralis and rectus abdominis flap reconstruction independently predicted decreased readmissions overall (odds ratio 0.4, P = .031) and in the deep sternal wound subgroup (odds ratio 0.1, P = .033).

CONCLUSION

Although few factors can be modified in this complex highly comorbid population with a challenging and rare surgical problem, consideration of a more surgically aggressive multiflap reconstructive approach may be justified to improve outcomes.

Surgical Site Infection in Cardiac Surgery

Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy.

Risk Factors for Post-cardiac Surgery Infections

Background Cardiac surgery infection is a life-threatening complication associated with high morbidity and mortality. One of the main types of these infections, surgical site infections (SSIs), also called postoperative wound infections basically delayed the post-surgical recovery in many patients. These infections rarely happen within 30 days after surgery due to different risk factors. Objectives The purpose of this study is to determine the risk factors that are involved in causing post-cardiac surgical infections. Methods This study was a retrospective study. The data of postoperative cardiac patients was obtained from the Cardiology and Cardiac Surgery Center in King Fahad Armed Force Hospital, Jeddah. Data on the patients were collected from 2016 to 2021. Eligible patients were those of age 18 and greater. These patients were evaluated on basis of the pre and postoperative risk factors and were analyzed for 30 days after discharge and those that developed SSIs were identified. Results Out of the total number of 2366 patients, 151 patients (6.4%) were identified with post-surgery infections out of which 107 (4.5%) had developed superficial wound infections (SSWIs) and 44 (1.9%) had developed deep wound infections (DSWIs). Infection mainly occurs in the male population (n=88, 58.3%). Major risk factors that were the main cause of post-cardiac surgery infections were diabetes (61.5%), hypertension (56.9%), smoking (38.4%), renal failure (27.1%), and re-do operation (25.1%). Conclusion Our study has demonstrated major risk factors that are involved in the occurrence of post-cardiac surgery infections like smoking, diabetes mellitus, sex, more than one operation during a single stay, etc. In the future, the contribution of various other factors involved in the occurrence of surgical site infections and best practices and methods should be studied and implemented to prevent the occurrence of post-cardiac surgery infections. Various simple techniques can still be utilized to prevent these sorts of infections, which will decrease the mortality rate.

Nosocomial Extracardiac Infections After Cardiac Surgery

Purpose of Review

Nosocomial extracardiac infections after cardiac surgery are a major public health issue affecting 3–8.2% of patients within 30–60 days following the intervention.

Recent Findings

Here, we have considered the most important postoperative infective complications that, in order of frequency, are pneumonia, surgical site infection, urinary tract infection, and bloodstream infection. The overall picture that emerges shows that they cause a greater perioperative morbidity and mortality with a longer hospitalization time and excess costs. Preventive interventions and corrective measures, diminishing the burden of nosocomial extracardiac infections, may reduce the global costs. A multidisciplinary team may assure a more appropriate management of nosocomial extracardiac infections leading to a reduction of hospitalization time and mortality rate.

Summary

The main and most current data on epidemiology, prevention, microbiology, diagnosis, and management for each one of the most important postoperative infective complications are reported. The establishment of an antimicrobial stewardship in each hospital seems to be, at the moment, the more valid strategy to counteract the challenging problems.

Rates and Determinants of Hospital-Acquired Infection among ICU Patients Undergoing Cardiac Surgery in Developing Countries: Results from EMERGENCY'NGO's Hospital in Sudan

Introduction. Knowledge of local and regional antimicrobial resistance (AMR) is crucial in clinical decision-making, especially with critically ill patients. The aim of this study was to investigate the rate and pattern of infections in valvular heart disease patients admitted to the intensive care unit (ICU) at the Salam Centre for Cardiac Surgery in Khartoum, Sudan (run by EMERGENCY NGO). Methods. This is a retrospective, observational study from a single, large international referral centre (part of a Regional Programme), which enrolled patients admitted to the ICU between 1 January and 31 December 2019. Data collected for each patient included demographic data, operating theatre/ICU data and microbiological cultures. Results. Over the study period, 611 patients were enrolled (elective surgery n = 491, urgent surgery n = 34 and urgent medical care n = 86). The infection rate was 14.2% and turned out to be higher in medical than in surgical patients (25.6% vs. 12.4%; p = 0.002; OR = 2.43) and higher in those undergoing urgent surgery than those undergoing elective (29.4% vs. 11.2%; p = 0.004; OR = 3.3). Infection was related to (a) SOFA score (p < 0.001), (b) ICU length of stay (p < 0.001) and (c) days from ICU admission to OT (p = 0.003). A significant relationship between the type of admission (elective, urgent surgery or medical) and the presence of infections was found (p < 0.001). The mortality rate was higher among infected patients (infected vs. infection-free: 10.3% vs. 2.1%; p < 0.001; OR = 5.38; 95% CI: 2.16−13.4; p < 0.001). Conclusions. Hospital-acquired infections remain a relevant preventable cause of mortality in our particular population.

Extended systemic antibiotic prophylaxis in ventricular assist device recipients, an infectious disease perspective

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.

[Local infectious complications in cardiac surgery: etiology and the role of antimicrobial prophylaxis]

OBJECTIVE

To investigate the relationship between antimicrobial prophylaxis protocol, prevalence and etiology of local infectious complications after open cardiac surgery.

MATERIAL AND METHODS

A retrospective cohort observational study was performed between 2010 and 2019 at the Ural Institute of Cardiology. Antimicrobial prophylaxis was performed using the main (cefuroxime 1.5 g IV every 6 hours) and alternative protocols (vancomycin 15 mg/kg IV every 12 hours).

RESULTS

The prevalence of local infectious complications throughout the entire follow-up period was 4.5±0.3% [95% CI 4.45-4.54]. There were 42 cases of deep infection (0.9±0.13%). Coagulase-negative staphylococci prevailed (15.9±2.5% of cases, 35 cultures). Resistant flora included coagulase-negative methicillin-resistant staphylococci (13 cultures, 37.1±8.2%) and representatives of Enterobacteriaceae family, producers of extended-spectrum beta-lactamase (8 cultures, 50.0±18.2%). Antimicrobial prophylaxis with vancomycin increases the risk of local infectious complications (OR 1.75, 95% CI 1.20, 2.55, p=0.001). Both protocols of antimicrobial prophylaxis demonstrated comparable efficacy against gram-positive and gram-negative microorganisms.

CONCLUSION

Coagulase-negative staphylococci are the most common cause of local infectious complications in cardiac surgery. Modern antimicrobial prophylaxis regimens are relevant despite resistant flora.

Perioperative Oral Management Prevents Complications of Heart Valve Surgery

OBJECTIVES

The effect of perioperative oral management on the prevention of postoperative complications remains unclear in cardiac surgery. Exploratory factor analysis was performed to examine whether a lack of perioperative oral management was associated with postoperative complications of heart valve surgery.

MATERIALS AND METHODS

We retrospectively enrolled 365 patients who underwent heart valve surgery between April 2010 and March 2019. We extracted data on patient characteristics and set postoperative pneumonia and postoperative bloodstream infection as outcomes. A logistic regression analyses were performed to examine the effect of factors on the incidence of postoperative complications.

RESULTS

Significant risk factors for postoperative pneumonia included dialysis, long operative time, and long-term intubation. Similarly, risk factors for postoperative bloodstream infection were long-term intubation and lack of perioperative oral management. Subsequently, we identified the risk factors for long-term intubation, which were common to both complications, and found they were emergency status, combined valvular disease, long operative time, and lack of perioperative oral management.

CONCLUSIONS

We demonstrated that a lack of perioperative oral management could be a risk factor for postoperative bloodstream infection and long-term intubation in heart valve surgery. The results suggest that perioperative oral management is effective in preventing postoperative complications of heart valve surgery.

Establishment and Validation of a Nomogram to Predict Hospital-Acquired Infection in Elderly Patients After Cardiac Surgery

Background

Hospital-acquired infection (HAI) after cardiac surgery is a common clinical concern associated with adverse prognosis and mortality. The objective of this study is to determine the prevalence of HAI and its associated risk factors in elderly patients following cardiac surgery and to build a nomogram as a predictive model.

Methods

We developed and internally validated a predictive model from a retrospective cohort of 6405 patients aged ≥70 years, who were admitted to our hospital and underwent cardiac surgery. The primary outcome was HAI. Multivariable logistic regression analysis was used to identify independent factors significantly associated with HAI. The performance of the established nomogram was assessed by calibration, discrimination, and clinical utility. Internal validation was achieved by bootstrap sampling with 1000 repetitions to reduce the overfit bias.

Results

Independent factors derived from the multivariable analysis to predict HAI were smoking, myocardial infarction, cardiopulmonary bypass use, intraoperative erythrocytes transfusion, extended preoperative hospitalization days and prolonged duration of mechanical ventilation postoperatively. The derivation model showed good discrimination, with a C-index of 0.706 [95% confidence interval 0.671–0.740], and good calibration [Hosmer–Lemeshow test P = 0.139]. Internal validation also maintained optimal discrimination and calibration. The decision curve analysis revealed that the nomogram was clinically useful.

Conclusions

We developed a predictive nomogram for postoperative HAIs based on routinely available data. This predictive tool may enable clinicians to achieve better perioperative management for elderly patients undergoing cardiac surgery but still requires further external validation.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

The value of prophylactic antibiotics in coronary artery bypass graft surgery: A review of literature

Infections have a significant impact on increasing both the morbidity and mortality rate of patients who have undergone coronary artery bypass graft (CABG) surgery. Infection after CABG imposes a clinical and economic burden on patients and health care organizations; therefore, prevention should be on the agenda. This review will focus on the value of using prophylactic antibiotics in coronary artery bypass graft surgery (CABG). Prophylactic antibiotics like cephalosporin and vancomycin are more commonly used antibiotics and are strongly associated with reduced infection risk in patients. The results showed that using antibiotics during the perioperative period and after CABG is an effective strategy for reducing post-infection problems without compromising the patients' clinical outcomes. Diabetic patients are prone to postoperative infection after CABG, however, prophylactic antibiotics should not be the only strategy used to reduce the risk of postoperative infection in diabetic patients. Perioperative glycaemic control is essential for diabetic patients undergoing CABG. Appropriate antibiotic prophylaxis has a great impact on preventing infection after CABG but duration and selecting appropriate antibiotic is important. Standardizing the use of antibiotic prophylaxis reduces the rate of infection and unwanted bacterial resistance, which could subsequently reduce economic costs to patients and public health.

Impact of preoperative nasopharyngeal cultures on surgical site infection after open heart surgery

Objectives

Despite advances in surgical techniques and management, surgical site infection (SSI) is still important after cardiovascular surgery. We investigated to determine whether or not preoperative nasopharyngeal cultures (NCx) can predict SSI and its microbial spectrum.

Methods

A retrospective review was done in 1226 consecutive patients undergoing NCx and cardiac and thoracic aortic surgery via median sternotomy who were cared for with the standard SSI bundle between 2013 and 2018. Microorganisms isolated from the NCx and SSI pathogens were counted to explore the microbial pattern and associated variables in patients with and without postoperative SSI. Perioperative management was not changed by collection of preoperative NCx.

Results

There were 1281 and 127 microorganisms, including coagulase-negative Staphylococcus as the most prevalent, isolated from 784 nasal and 111 pharyngeal specimens, respectively. Postoperative SSI occurred in 31 patients (2.47%), including chest, groin, and leg SSI. Significant coincidence of the SSI pathogens with the NCx microorganisms was not observed. However, the patients with SSI showed significantly higher positive rates of preoperative NCx than those without SSI. The sensitivity/specificity of NCx for SSI were 81%/37% for nasal and 45%/92% for pharyngeal, respectively. The negative predictive value of NCx for ruling out SSI was 98.6% for nasal and 98.4% for pharyngeal, respectively. Independent risk factors for postoperative SSI included female sex, diabetes mellitus, positive preoperative NCx, and postoperative use of Portex Mini-Trach (Smiths Medical, Minneapolis, Minn) or tracheostomy on multivariate analysis.

Conclusions

Preoperative NCx may be useful to predict SSI after open heart surgery via median sternotomy, as well as screening for methicillin-resistant Staphylococcus aureus.

Gut Microbiota as Early Predictor of Infectious Complications before Cardiac Surgery: A Prospective Pilot Study

Cardiac surgery remains a field of medicine with a high percentage of postoperative complications, including infectious ones. Modern data indicate a close relationship of infectious disorders with pathological changes in the composition of the gut microbiome; however, the extent of such changes in cardiac surgery patients is not fully clarified. In this prospective, observational, single center, pilot study, 72 patients were included, 12 among them with the infectious complications. We analyzed the features of the fecal microbiota before and in the early postoperative period, as one of the markers for predicting the occurrence of bacterial infection. We also discovered the significant change in microbial composition in the group of patients with infectious complications compared to the non-infectious group before and after cardiac surgery, despite the intra-individual variation in composition of gut microbiome. Our study demonstrated that the group of patients that had a bacterial infection in the early postoperative period already had an altered microbial composition even before the surgery. Further studies will evaluate the clinical significance of the identified proportions of individual taxa of the intestinal microbiota and consider the microbiota as a novel target for reducing the risk of infectious complications.

Effectiveness of chlorhexidine in preventing infections among patients undergoing cardiac surgeries: a meta-analysis and systematic review

Background

Although several meta-analyses reported the impact of chlorhexidine (CHX) use in patients undergoing various types of surgery, no meta-analysis summarized the overall effectiveness of CHX specifically for cardiac surgery. This meta-analysis aimed to examine the impact of CHX on infections after cardiac surgery compared with other cleansers or antiseptics.

Methods

PubMed, Embase, and the Cochrane Library were searched from inception up to October 2020 for potentially eligible studies: (1) population: patients who underwent cardiac surgery; (2) intervention or exposure: any type of CHX use in the treatment or exposed group; (3) outcome: number of patients with infections; (4) comparison: placebo or other antiseptic agents; (5) English. The primary outcome was surgical site infection (SSI).

Results

Fourteen studies were included, with 8235 and 6901 patients in the CHX and control groups. CHX was not protective against SSI (OR = 0.77, 95% CI: 0.57–1.04, P = 0.090). CHX was protective for superficial wound infection (OR = 0.42, 95% CI: 0.26–0.70, P = 0.001), but not with deep wound infection (P = 0.509). CHX was not protective against urinary tract of infection (P = 0.415) but was protective for bloodstream infection (OR = 0.36, 95% CI: 0.16–0.80, P = 0.012), nosocomial infections (OR = 0.55, 95% CI: 0.44–0.69, P < 0.001), and pneumonia (OR = 0.26, 95% CI: 0.11–0.61, P = 0.002).

Conclusions

In patients undergoing cardiac surgery, CHX does not protect against SSI, deep wound infection, and urinary tract infections but might protect against superficial SSI, bloodstream infection, nosocomial infections, and pneumonia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-01009-3.

Early onset of deep sternal wound infection after cardiac surgery is associated with decreased survival: A propensity weighted analysis

OBJECTIVES

To compare outcomes after the development of early (≤30 days) versus delayed (>30 days) deep sternal wound infection (DSWI) after cardiac surgery.

METHODS

Between 2005 and 2016, 64 patients were treated surgically for DSWI following cardiac surgery. Thirty-three developed early DSWI, while 31 developed late DSWI. The mean follow-up was 34.1 ± 32.3 months.

RESULTS

Survival for the entire cohort at 1, 3, and 5 years was 93.9%, 85.1%, and 80.8%, respectively. DSWI diagnosed early and attempted medical management was strongly associated with overall mortality (hazard ratio [HR], 25.0 and 9.9; 95% confidence intervals [CIs], 1.18-52.8 and 1.28-76.5; p-value .04 and .04, respectively). Survival was 88.1%, 77.0%, 70.6% and 100%, 94.0% and 94.0% at 1, 3, and 5 years in the early and late DSWI groups, respectively (log-rank = 0.074). Those diagnosed early were more likely to have a positive wound culture (odds ratio [OR], 0.06; 95% CI, 0.01-0.69; p = .024) and diagnosed late were more likely to be female (OR, 8.75; 95% CI, 2.0-38.4; p = .004) and require an urgent DSWI procedure (OR, 9.25; 95% CI, 1.86-45.9; p = .007). Both early diagnosis of DSWI and initial attempted medial management were strongly associated with mortality (HR, 7.48; 95% CI, 1.38-40.4; p = .019 and HR, 7.76; 95% CI, 1.67-35.9; p = .009, respectively).

CONCLUSIONS

Early aggressive surgical therapy for DSWI after cardiac surgery results in excellent outcomes. Those diagnosed with DSWI early and who have failed initial medical management have increased mortality.

Plasma and Lung Tissue Pharmacokinetics of Ceftaroline Fosamil in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass: an In Vivo Microdialysis Study

Ceftaroline fosamil, a fifth-generation cephalosporin antibiotic with activity against methicillin-resistant Staphylococcus aureus (MRSA), is currently approved for the treatment of pneumonia and complicated skin and soft tissue infections. However, pharmacokinetics data on free lung tissue concentrations in critical patient populations are lacking. The aim of this study was to evaluate the pharmacokinetics of the high-dose regimen of ceftaroline in plasma and lung tissue in cardiac surgery patients during intermittent and continuous administration. Nine patients undergoing elective cardiac surgery on cardiopulmonary bypass were included in this study and randomly assigned to intermittent or continuous administration. Eighteen hundred milligrams of ceftaroline fosamil was administered intravenously as either 600 mg over 2 h every 8 h (q8h) (intermittent group) or 600 mg over 2 h (loading dose) plus 1,200 mg over 22 h (continuous group). Interstitial lung tissue concentrations were measured by in vivo microdialysis. Relevant pharmacokinetics parameters were calculated for each group. Plasma exposure levels during intermittent and continuous administration were comparable to those of previously published studies and did not differ significantly between the two groups. In vivo microdialysis demonstrated reliable and adequate penetration of ceftaroline into lung tissue during intermittent and continuous administration. The steady-state area under the concentration-time curve from 0 to 8 h (AUCss 0-8) and the ratio of AUCSS 0-8 in lung tissue and AUC in plasma (AUClung/plasma) were descriptively higher in the continuous group. Continuous administration of ceftaroline fosamil achieved a significantly higher proportion of time for which the free drug concentration remained above 4 times the minimal inhibitory concentration (MIC) during the dosing interval (% fT>4xMIC) than intermittent administration for pathogens with a MIC of 1 mg/liter. Ceftaroline showed adequate penetration into interstitial lung tissue of critically ill patients undergoing major cardiothoracic surgery, supporting its use for pneumonia caused by susceptible pathogens.

Surgical site infection after delayed sternal closure in neonates with congenital heart disease: retrospective case-control study

Objectives

To determine the prevalence of surgical site infections (SSIs) in neonatal congenital heart disease patients undergoing delayed sternal closure (DSC) and evaluate risk factors for SSI.

Methods

Hospital records of 483 consecutive neonates who underwent surgical intervention between January 2013 and December 2017 were reviewed, and perioperative variables were recorded.

Results

We found that the prevalence of SSI was 87.5% when the body weight was less than 1500 g. When the operative age was between seven and 14 days, the probability of no SSI is about 93.9%. When the duration of the aortic cross-clamp was more than 60 min, the prevalence of SSI was 91.2%. The prevalence without SSI was 96.6% when the duration of DSC was less than 24 h. However, when the duration of DSC was more than 120 h, the prevalence of SSI was 88.9% (p = 0.000).

Conclusions

With the prolongation of aortic clamping duration, the probability of occurrence of SSI increased in neonatal CHD with DSC. The age at operation and body weight are closely related to the occurrence of SSI in neonatal CHD patients with DSC.

Impact of Postoperative Infections on Readmission and Resource Use in Elective Cardiac Surgery

BACKGROUND

Efforts to reduce postoperative infections have garnered national attention, leading to practice guidelines for cardiac surgical perioperative care. The present study characterized the impact of healthcare-acquired infection (HAI) on index hospitalization costs and post-discharge healthcare utilization.

METHODS

Adults undergoing elective coronary artery bypass grafting (CABG) and/or valve operations were identified in the 2016-2018 Nationwide Readmissions Database. Infections were categorized into bloodstream, gastrointestinal, pulmonary, surgical site, or urinary tract infections. Generalized linear or flexible hazard models were used to assess associations between infections and outcomes. Observed-to-expected (O/E) ratios were generated to examine inter-hospital variation in HAI.

RESULTS

Of an estimated 444,165 patients, 8.0% developed HAI. Patients with HAI were older, had a greater burden of chronic diseases, and more commonly underwent CABG/valve or multi-valve operations (all p<0.001). HAI was independently associated with mortality (odds ratio 4.02, 95% CI 3.67-4.40), non-home discharge (3.48, 95% CI 3.21-3.78), and a cost increase of $23,000 (95% CI 20,900-25,200). At 90 days, HAI was associated with greater hazard of readmission (1.29, 95% CI 1.24-1.35). Pulmonary infections had the greatest incremental impact on patient-level ($24,500, 95% CI 23,100-26,00) and annual cohort costs ($121.8 million, 95% CI 102.2-142.9 million). Significant hospital level variation in HAI was evident, with O/E ranging from 0.17 to 4.3 for cases performed in 2018.

CONCLUSIONS

Infections following cardiac surgery remain common and are associated with inferior outcomes and increased resource use. The presence of inter-hospital variation in this contemporary cohort emphasizes the ongoing need for systematic approaches in their prevention and management.

Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP)

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

Early infections after successful transcatheter aortic valve replacement are associated with increased short- and long-term mortality: A single-center study

BACKGROUND

We reviewed frequency, microbiological pattern, predictors, and outcomes of early infections following transcatheter aortic valve replacement (TAVR).

METHODS

Five hundred thirty-nine patients who underwent successful TAVR at a single, high-volume center between January 2014 and December 2019 were enrolled. We defined early infections as occurring within 30-day from TAVR.

RESULTS

Mean age was 83.5 ± 5.4 years; 230 (42.7%) patients were men. Median follow-up was 12.0 (5.7-18.3) months; 30-day and 1-year death rates were 8/539 (1.5%) and 30/539 (5.6%), respectively. Early infections occurred in 61/539 (11.3%) patients, of whom 2 had infections in two sites. Of the 63 infections, 10 were bloodstream infections (BSI), 5 urinary tract, 27 pulmonary (2 with sepsis), 6 access site infections, 1 enterocolitis, and 14 were clinically diagnosed (no specific site). We observed 31/63 (49.2%) microbiologically-documented infections: Gram+ bacteria were isolated in 12/31 (38.7%), Gram- in 17/31 (54.3%), both Gram+ and Gram- in 2/31 (6.5%); in thirty-two infections no specific pathogen could be isolated (clinically-documented infections). Early infections were more prevalent in patients who died within 30-day (8.2% vs. 0.6%, p < 0.001) or 1-year (14.8% vs. 4.4%, p < 0.001) from TAVR. At multivariable analysis, early infections were independently associated with 30-day (HR: 8.82, 95% CI: 1.11-19.83, p = 0.035) and 1-year mortality (HR: 2.10, 95%CI: 1.28-6.21, p = 0.041). The predictive value for 1-year mortality was maintained even restricting the analysis to documented infections only, or to more severe infections (BSI and pneumonia only) (all p < 0.05).

CONCLUSIONS

Early infections occur in 1/10th of TAVR and are associated with increased short- and long-term mortality. Whereas a causal relationship between early infections and the risk of death cannot be unequivocally proven, careful surveillance of infected patients may improve TAVR results.

Ventricular Assist Device-Specific Infections

Ventricular assist device (VAD)-specific infections, in particular, driveline infections, are a concerning complication of VAD implantation that often results in significant morbidity and even mortality. The presence of a percutaneous driveline at the skin exit-site and in the subcutaneous tunnel allows biofilm formation and migration by many bacterial and fungal pathogens. Biofilm formation is an important microbial strategy, providing a shield against antimicrobial treatment and human immune responses; biofilm migration facilitates the extension of infection to deeper tissues such as the pump pocket and the bloodstream. Despite the introduction of multiple preventative strategies, driveline infections still occur with a high prevalence of ~10-20% per year and their treatment outcomes are frequently unsatisfactory. Clinical diagnosis, prevention and management of driveline infections are being targeted to specific microbial pathogens grown as biofilms at the driveline exit-site or in the driveline tunnel. The purpose of this review is to improve the understanding of VAD-specific infections, from basic "bench" knowledge to clinical "bedside" experience, with a specific focus on the role of biofilms in driveline infections.

Prognostic role of perioperative acid-base disturbances on the risk of Clostridioides difficile infection in patients undergoing cardiac surgery

BACKGROUND

It is unclear whether acid-base balance disturbances during the perioperative period may impact Clostridium difficile infection (CDI), which is the third most common major infection following cardiac surgery. We hypothesized that perioperative acid-base abnormalities including lactate disturbances may predict the probability of incidence of CDI in patients after cardiac procedures.

METHODS

Of the 12,235 analyzed patients following cardiac surgery, 143 (1.2%) developed CDI. The control group included 200 consecutive patients without diarrhea, who underwent cardiac procedure within the same period of observation. Pre-, intra and post-operative levels of blood gases, as well as lactate and glucose concentrations were determined. Postoperatively, arterial blood was drawn four times: immediately after surgery and successively; 4, 8 and 12 h following the procedure.

RESULTS

Baseline pH was lower and PaO2 was higher in CDI patients (p < 0.001 and p = 0.001, respectively). Additionally, these patients had greater base deficiency at each of the analyzed time points (p < 0.001, p = 0.004, p = 0.012, p = 0.001, p = 0.016 and p = 0.001, respectively). Severe hyperlactatemia was also more common in CDI patients; during the cardiac procedure, 4 h and 12 h after surgery (p = 0.027, p = 0.004 and p = 0.001, respectively). Multivariate logistic regression analysis revealed that independent risk factors for CDI following cardiac surgery were as follows: intraoperative severe hyperlactatemia (OR 2.387, 95% CI 1.155-4.933, p = 0.019), decreased lactate clearance between values immediately and 12 h after procedure (OR 0.996, 95% CI 0.994-0.999, p = 0.013), increased age (OR 1.045, 95% CI 1.020-1.070, p < 0.001), emergent surgery (OR 2.755, 95% CI 1.565-4.848, p < 0.001) and use of antibiotics other than periprocedural prophylaxis (OR 2.778, 95% CI 1.690-4.565, p < 0.001).

CONCLUSION

This study is the first to show that perioperative hyperlactatemia and decreased lactate clearance may be predictors for occurrence of CDI after cardiac surgery.

Microbial Contamination after Cardiac Surgery in a Hospital Cardiac Surgery Ward

Surgery site infection is one of the most common postoperative complications which is associated with increased morbidity, mortality and admission costs. It is considered a priority to determine the level of nosocomial infection and its control in reflecting the quality of care. Therefore, this study aimed to evaluate the microbial contamination after cardiac surgery at a hospital cardiac surgery ward of Besat Hospital, Tehran.

In this cross-sectional descriptive-analytic study (2013-2017), 610 patients underwent surgery at the Department of Cardiac Surgery of Besat Hospital. All necessary information such as urine culture, surgical site, histopathologic examination for the diagnosis of microbial contamination and microorganisms were collected from the patient records and inserted in the questionnaire. The data were analyzed using SPSS (version 25).

The incidence of nosocomial infections following cardiac surgery reportedly ranged from 17% to 23%. Accordingly, pneumonia (51.2%) and local infections (22%) were the most common infections in the studied population. The mortality rate in our population was 11.4%. Moreover, 64.3% of the total mortality cases were reported in patients with sepsis. The mean age and duration of admission of patients with catheter infection were significantly higher than other subjects.

Given the relatively high prevalence of the infection and its importance, it is necessary to take more serious measures to prevent and control these infections.

Impact of nosocomial infections on patient mortality following cardiac surgery

STUDY OBJECTIVE

To determine the rate of nosocomial infection among patients undergoing cardiac surgery and to identify risk factors and the impact of these infections on patient mortality.

DESIGN

Prospective observational study.

SETTING

Intensive Care Unit (ICU).

PATIENTS

1097 adult patients who underwent cardiac surgery at Hospital Clínico Universitario de Valladolid between January 2011 and January 2016.

INTERVENTIONS

None.

MEASUREMENTS

Preoperative, intraoperative and postoperative medical, surgical and anaesthetic variables.

MAIN RESULTS

A total of 111 patients (10.1%) acquired a nosocomial infection in the postoperative period. Pneumonia was the most frequent (4.2%) nosocomial infection. Three independent risk factors for the development of a nosocomial infection were identified: cardiopulmonary bypass time, kidney failure and emergency surgery. The stay in the ICU was significantly higher in patients who developed a nosocomial infection (16.6 ± 38.8 vs. 4.4 ± 17.8, P < 0.001). The mortality rate of patients who acquired a nosocomial infection was significantly greater (18%) than that of patients who did not acquire a nosocomial infection (5%) (P < 0.001). The 90-day survival was greater in the group of patients without nosocomial infection (log rank 27.55, P < 0.001). The dynamic modelling of 90-day mortality revealed that in the first week, cardiopulmonary bypass time (HR = 1.00, 95% CI 1.00-1.02, P < 0.001) and emergency surgery (HR = 0.12, 95% CI 0.04-0.37, P < 0.001) were the most important risk factors for mortality, while after the first week, nosocomial infection (HR = 6.23, 95% CI 2.49-15.63, P < 0.001) was the main risk factor, followed by cardiopulmonary bypass time (HR = 1.01, 95% CI 1.00-1.01, P = 0.001) and EuroSCORE (HR = 1.03, 95% CI 1.00-1.06, P = 0.008).

CONCLUSIONS

Nosocomial infections after cardiac surgery constitute the main independent risk factor for mortality after the first week of surgery. These data suggest that its prevention following cardiac surgery must be prioritised to improve patient outcomes.

Clostridioides difficile infection after cardiac surgery: Assessment of prevalence, risk factors and clinical outcomes-retrospective study

Background

Clostridioides difficile infection (CDI) is the most common cause of hospital-acquired diarrhea. There is little available data regarding risk factors of CDI for patients who undergo cardiac surgery. The study evaluated the course of CDI in patients after cardiac surgery.

Methods

Of 6,198 patients studied, 70 (1.1%) developed CDI. The control group consisted of 73 patients in whom CDI was excluded. Perioperative data and clinical outcomes were analyzed.

Results

Patients with CDI were significantly older in comparison to the control group (median age 73.0 vs 67.0, P = 0.005) and more frequently received proton pump inhibitors, statins, β-blockers and acetylsalicylic acid before surgery (P = 0.008, P = 0.012, P = 0.004, and P = 0.001, respectively). In addition, the presence of atherosclerosis, coronary disease and history of malignant neoplasms correlated positively with the development of CDI (P = 0.012, P = 0.036 and P = 0.05, respectively). There were no differences in the type or timing of surgery, aortic cross-clamp and cardiopulmonary bypass time, volume of postoperative drainage and administration of blood products between the studied groups. Relapse was more common among overweight patients with high postoperative plasma glucose or patients with higher C-reactive protein during the first episode of CDI, as well as those with a history of coronary disease or diabetes mellitus (P = 0.005, P = 0.030, P = 0.009, P = 0.049, and P = 0.025, respectively). Fifteen patients died (21.4%) from the CDI group and 7 (9.6%) from the control group (P = 0.050). Emergent procedures, prolonged stay in the intensive care unit, longer mechanical ventilation and high white blood cell count during the diarrhea were associated with higher mortality among patients with CDI (P = 0.05, P = 0.041, P = 0.004 and P = 0.007, respectively).

Conclusions

The study did not reveal any specific cardiac surgery-related risk factors for development of CDI.