Comparison of 48 h and 72 h of prophylactic antibiotic therapy in adult cardiac surgery: a randomized double blind controlled trial

Interventions to prevent surgical site infection in adults undergoing cardiac surgery

BACKGROUND

Surgical site infection (SSI) is a common type of hospital-acquired infection and affects up to a third of patients following surgical procedures. It is associated with significant mortality and morbidity. In the United Kingdom alone, it is estimated to add another £30 million to the cost of adult cardiac surgery. Although generic guidance for SSI prevention exists, this is not specific to adult cardiac surgery. Furthermore, many of the risk factors for SSI are prevalent within the cardiac surgery population. Despite this, there is currently no standard of care for SSI prevention in adults undergoing cardiac surgery throughout the preoperative, intraoperative and postoperative periods of care, with variations in practice existing throughout from risk stratification, decontamination strategies and surveillance.

OBJECTIVES

Primary objective: to assess the clinical effectiveness of pre-, intra-, and postoperative interventions in the prevention of cardiac SSI.

SECONDARY OBJECTIVES

(i) to evaluate the effects of SSI prevention interventions on morbidity, mortality, and resource use; (ii) to evaluate the effects of SSI prevention care bundles on morbidity, mortality, and resource use.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid, from inception) and Embase (Ovid, from inception) on 31 May 2021.

CLINICALTRIALS

gov and the WHO International Clinical Trials Registry Platform (ICTRP) were also searched for ongoing or unpublished trials on 21 May 2021. No language restrictions were imposed.

SELECTION CRITERIA

We included RCTs evaluating interventions to reduce SSI in adults (≥ 18 years of age) who have undergone any cardiac surgery.

DATA COLLECTION AND ANALYSIS

We followed the methods as per our published Cochrane protocol. Our primary outcome was surgical site infection. Our secondary outcomes were all-cause mortality, reoperation for SSI, hospital length of stay, hospital readmissions for SSI, healthcare costs and cost-effectiveness, quality of life (QoL), and adverse effects. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

A total of 118 studies involving 51,854 participants were included. Twenty-two interventions to reduce SSI in adults undergoing cardiac surgery were identified. The risk of bias was judged to be high in the majority of studies. There was heterogeneity in the study populations and interventions; consequently, meta-analysis was not appropriate for many of the comparisons and these are presented as narrative summaries. We focused our reporting of findings on four comparisons deemed to be of great clinical relevance by all review authors. Decolonisation versus no decolonisation Pooled data from three studies (n = 1564) using preoperative topical oral/nasal decontamination in all patients demonstrated an uncertain direction of treatment effect in relation to total SSI (RR 0.98, 95% CI 0.70 to 1.36; I2 = 0%; very low-certainty evidence). A single study reported that decolonisation likely results in little to no difference in superficial SSI (RR 1.35, 95% CI 0.84 to 2.15; moderate-certainty evidence) and a reduction in deep SSI (RR 0.36, 95% CI 0.17 to 0.77; high-certainty evidence). The evidence on all-cause mortality from three studies (n = 1564) is very uncertain (RR 0.66, 95% CI 0.24 to 1.84; I2 = 49%; very low-certainty evidence). A single study (n = 954) demonstrated that decolonisation may result in little to no difference in hospital readmission for SSI (RR 0.80, 95% CI 0.44 to 1.45; low-certainty evidence). A single study (n = 954) reported one case of temporary discolouration of teeth in the decolonisation arm (low-certainty-evidence. Reoperation for SSI was not reported. Tight glucose control versus standard glucose control Pooled data from seven studies (n = 880) showed that tight glucose control may reduce total SSI, but the evidence is very uncertain (RR 0.41, 95% CI 0.19 to 0.85; I2 = 29%; numbers need to treat to benefit (NNTB) = 13; very-low certainty evidence). Pooled data from seven studies (n = 3334) showed tight glucose control may reduce all-cause mortality, but the evidence is very uncertain (RR 0.61, 95% CI 0.41 to 0.91; I2 = 0%; very low-certainty evidence). Based on four studies (n = 2793), there may be little to no difference in episodes of hypoglycaemia between tight control vs. standard control, but the evidence is very uncertain (RR 2.12, 95% CI 0.51 to 8.76; I2 = 72%; very low-certainty evidence). No studies reported superficial/deep SSI, reoperation for SSI, or hospital readmission for SSI. Negative pressure wound therapy (NPWT) versus standard dressings NPWT was assessed in two studies (n = 144) and it may reduce total SSI, but the evidence is very uncertain (RR 0.17, 95% CI 0.03 to 0.97; I2 = 0%; NNTB = 10; very low-certainty evidence). A single study (n = 80) reported reoperation for SSI. The relative effect could not be estimated. The certainty of evidence was judged to be very low. No studies reported superficial/deep SSI, all-cause mortality, hospital readmission for SSI, or adverse effects. Topical antimicrobials versus no topical antimicrobials Five studies (n = 5382) evaluated topical gentamicin sponge, which may reduce total SSI (RR 0.62, 95% CI 0.46 to 0.84; I2 = 48%; NNTB = 32), superficial SSI (RR 0.60, 95% CI 0.37 to 0.98; I2 = 69%), and deep SSI (RR 0.67, 95% CI 0.47 to 0.96; I2 = 5%; low-certainty evidence. Four studies (n = 4662) demonstrated that topical gentamicin sponge may result in little to no difference in all-cause mortality, but the evidence is very uncertain (RR 0.96, 95% CI 0.65 to 1.42; I2 = 0%; very low-certainty evidence). Reoperation for SSI, hospital readmission for SSI, and adverse effects were not reported in any included studies.

AUTHORS' CONCLUSIONS

This review provides the broadest and most recent review of the current evidence base for interventions to reduce SSI in adults undergoing cardiac surgery. Twenty-one interventions were identified across the perioperative period. Evidence is of low to very low certainty primarily due to significant heterogeneity in how interventions were implemented and the definitions of SSI used. Knowledge gaps have been identified across a number of practices that should represent key areas for future research. Efforts to standardise SSI outcome reporting are warranted.

Prophylactic 24 versus 48 h cephalosporins in cardiac surgery: A randomized trial

BACKGROUND

Recommendations for cardiac surgery advocate for antibiotic prophylaxis for up to 48 hour after surgery. However, recent reports found a significant reduction in surgical site infection with extended duration. We evaluated the effect of the type of prophylactic antibiotics and administration durations on the postoperative surgical site infection rate following cardiac surgery in adults.

METHODS

An investigator-initiated randomized controlled trial was conducted from 2018 to 2022 on adult patients undergoing cardiac surgery. Patients were randomized into four groups based on antibiotic treatment type and duration: 24 h cefazolin, 24 h cefuroxime, 48 h cefazolin, and 48 h cefuroxime. The primary outcome was the rate of surgical site infections within 90 days of surgery.

RESULTS

A total of 568 patients were included in this study. The four groups had similar baseline characteristics, including age, sex, EuroSCORE II, and baseline HbA1c. A total of 75 patients developed infection within 90 days postoperative. The overall infection rate was not statistically different across the four groups (p = 0.193). The efficacy of cefazolin and cefuroxime in reducing infection was comparable (p = 0.901). Extended prophylaxis was associated with a significantly reduced overall infection rate within 90 days postoperatively compared to 24-h prophylaxis (10.2% vs. 16.3%; risk ratio = 0.62, 95% confidence interval: 0.40-0.96, p = 0.032).

CONCLUSION

Using cefazolin or cefuroxime for 48 h instead of 24 h was more effective in reducing the overall surgical site infections rate up to 90 days after surgery.

Antimicrobial prophylaxis in adult cardiac surgery in the United Kingdom and Republic of Ireland

BACKGROUND

Deep sternal wound infections are a financially costly complication of cardiac surgery with serious implications for patient morbidity and mortality. Prophylactic antimicrobials have been shown to reduce the incidence of infection significantly. In 2018, the European Association for CardioThoracic Surgery (EACTS) provided clear guidance advising that third-generation cephalosporins are the first-line prophylactic antimicrobial of choice for cardiac surgery via median sternotomy as a result of their broad spectrum of activity and association with reduced postoperative mortality. Despite this guidance, it was believed that UK practice differed from this as a consequence of national concerns surrounding cephalosporins use and Clostridioides difficile infection.

METHODS

A survey was developed and distributed to all UK and Republic of Ireland (ROI) cardiac surgery centres in January 2019 to quantify this variation.

RESULTS

Of the 38 centres, 34 responded. Variation existed between the antimicrobial agent used, as well as the dosage, frequency and duration of suggested regimens even among centres using the same antimicrobial agent. The most common antimicrobial prophylaxis prescribed was a combination of flucloxacillin and gentamicin (16, 47%). Followed by cefuroxime (6, 17.6%) and cefuroxime combined with a glycopeptide (4, 11.7%). In patients colonised with methicillin-resistant Staphylococcus aureus or those with penicillin allergy gentamicin combined with teicoplanin was most common (42% and 50%, respectively).

DISCUSSION

This variation in antimicrobial agents and regimens may well contribute to the varying incidence of surgical site infection seen across the UK and ROI.

Prevention of Infections in Cardiac Surgery study (PICS): study protocol for a pragmatic cluster-randomized factorial crossover pilot trial

Background

A wide range of prophylactic antibiotic regimens are used for patients undergoing open-heart cardiac surgery. This reflects clinical equipoise in choice and duration of antibiotic agents. Although individual-level randomized control trials (RCT) are considered the gold standard when evaluating the efficacy of an intervention, this approach is highly resource intensive and a cluster RCT can be more appropriate for testing clinical effectiveness in a real-world setting.

Methods/design

We are conducting a factorial cluster-randomized crossover pilot trial in cardiac surgery patients to evaluate the feasibility of this design for a definite trial to evaluate the optimal duration and choice of perioperative antibiotic prophylaxis. Specifically, we will evaluate: (a) the non-inferiority of a single preoperative dose compared to prolonged prophylaxis and (b) the potential superiority of adding vancomycin to routine cefazolin in terms of preventing deep and organ/space sternal surgical site infections (s-SSIs). There are four strategies: (i) short-term cefazolin, (ii) long-term cefazolin, (iii) short-term cefazolin + vancomycin, and (iv) long-term cefazolin + vancomycin. These strategies are delivered in a different order in each health-care center participating in the trial. The centers are randomized to an order, and the current strategy becomes the standard operating procedure in that center during the study.

The three feasibility outcomes include: (1) the proportion of patients receiving preoperative, intra-operative, and postoperative antibiotics according to the study protocol, (2) the proportion of completed follow-up assessments, and (3) a full and final assessment of the incidence of s-SSIs by the outcome adjudication committee.

Discussion

We believe that a cluster-randomized factorial crossover trial is an effective and feasible design for these research questions, allowing an evaluation of the clinical effectiveness in a real-world setting. A waiver of individual informed consent was considered appropriate by the research ethics boards in each participating site in Canada as long as an information letter with an opt-out option was provided. However, a waiver of consent was not approved at two sites in Germany and Switzerland, respectively.

Trial registration

Clinicaltrials.gov, NCT02285140. Registered on 15 October 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3080-y) contains supplementary material, which is available to authorized users.

Prevention of deep sternal wound infection in cardiac surgery: a literature review

BACKGROUND

Deep sternal wound infection (DSWI) is a dreaded complication of cardiac surgery with considerable consequences in terms of mortality, morbidity and treatment costs. In addition to standard surgical site infection prevention guidelines, multiple specific measures in the prevention of DSWI have been developed and evaluated in the past decades. This review focuses on these specific measures to prevent DSWI.

METHODS

An extensive literature search was performed to assess interventions in the prevention of DSWI. Articles describing results of a randomized controlled trial were categorized by type of intervention. Results were yielded and, if possible, pooled.

RESULTS

From a total of 743 articles found, 48 randomized controlled trials were selected. Studies were divided into 12 categories, containing pre-, peri- and postoperative preventive measures. Specific measures shown to be effective were: antibiotic prophylaxis with a first-generation cephalosporin for at least 24 h, application of local gentamicin before chest closure, sternal closure with figure-of-eight steel wires, and postoperative chest support using a corset or vest.

CONCLUSION

This study identified several measures that prevent DSWI after cardiac surgery that are not frequently applied in current practice. It is recommended that the guidelines on prevention of surgical site infection in cardiac surgery should be updated.

New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective

Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.

Routine Surveillance Versus Independent Assessment by an Outcome Adjudication Committee in Assessing Patients for Sternal Surgical Site Infections After Cardiac Surgery

Based on a cohort of 966 patients, routine surveillance data were not sufficiently accurate for use in clinical trials investigating surgical site infections. Surveillance data can only be used if adequate 90-day follow-up is provided and if cases identified by surveillance are independently reviewed by a blinded outcome adjudication committee.

Different duration strategies of perioperative antibiotic prophylaxis in adult patients undergoing cardiac surgery: an observational study

Background

All international guidelines recommend perioperative antibiotic prophylaxis (PAB) should be routinely administered to patients undergoing cardiac surgery. However, the duration of PAB is heterogeneous and controversial.

Methods

Between 01.01.2011 and 31.12.2011, 1096 consecutive cardiac surgery patients were assigned to one of two groups receiving PAB with a second-generation cephalosporin for either 56 h (group I) or 32 h (group II). Patients’ characteristics, intraoperative data, and the in-hospital follow-up were analysed. Primary endpoint was the incidence of surgical site infection (deep and superficial sternal wound-, and vein harvesting site infection; DSWI/SSWI/VHSI). Secondary endpoints were the incidence of respiratory-, and urinary tract infection, as well as the mortality rate.

Results

615/1096 patients (56,1%) were enrolled (group I: n = 283 versus group II: n = 332). There were no significant differences with regard to patient characteristics, comorbidities, and procedure-related variables. No statistically significant differences were demonstrated concerning primary and secondary endpoints. The incidence of DSWI/SSWI/VHSI were 4/283 (1,4%), 5/283 (1,7%), and 1/283 (0,3%) in group I versus 6/332 (1,8%), 9/332 (2,7%), and 3/332 (0,9%) in group II (p = 0,76/0,59/0,63). In univariate analyses female gender, age, peripheral arterial obstructive disease, operating-time, ICU-duration, transfusion, and respiratory insufficiency were determinants for nosocomial infections (all ≤ 0,05). Subgroup analyses of these high-risk patients did not show any differences between the two regimes (all ≥ 0,05).

Conclusions

Reducing the duration of PAB from 56 h to 32 h in adult cardiac surgery patients was not associated with an increase of nosocomial infection rate, but contributes to reduce antibiotic resistance and health care costs.

Cardiac surgery antibiotic prophylaxis and calculated empiric antibiotic therapy

BACKGROUND

Ongoing debate exists concerning the optimal choice and duration of antibiotic prophylaxis as well as the reasonable calculated empiric antibiotic therapy for hospital-acquired infections in critically ill cardiac surgery patients.

METHODS

A nationwide questionnaire was distributed to all German heart surgery centers concerning antibiotic prophylaxis and the calculated empiric antibiotic therapy.

RESULTS

The response to the questionnaire was 87.3%. All clinics that responded use antibiotic prophylaxis, 79% perform it not longer than 24 h (single-shot: 23%; 2 doses: 29%; 3 doses: 27%; 4 doses: 13%; and >5 doses: 8%). Cephalosporin was used in 89% of clinics (46% second-generation, 43% first-generation cephalosporin). If sepsis is suspected, the following diagnostics are performed routinely: wound inspection 100%; white blood cell count 100%; radiography 99%; C-reactive protein 97%; microbiological testing of urine 91%, blood 81%, and bronchial secretion 81%; procalcitonin 74%; and echocardiography 75%. The calculated empiric antibiotic therapy (depending on the suspected focus) consists of a multidrug combination with broad-spectrum agents.

CONCLUSION

This survey shows that existing national guidelines and recommendations concerning perioperative antibiotic prophylaxis and calculated empiric antibiotic therapy are well applied in almost all German heart centers.

Surgical site infections and their prevention

PURPOSE OF REVIEW

Recent studies have assessed interventions and bundles of interventions to prevent surgical site infections (SSIs). We reviewed numerous studies to identify those with the strongest evidence supporting interventions for preventing SSIs.

RECENT FINDINGS

Bundles that included more than one intervention to decrease the risk of Staphylococcus aureus wound contamination, such as chlorhexidine bathing and nasal application of mupirocin, had the strongest supporting evidence. However, bundles should be tested to ensure that their components are not antagonistic. Vancomycin prophylaxis and extended antimicrobial prophylaxis should not be used routinely, but should be reserved for high-risk populations such as patients who carry methicillin-resistant S. aureus (MRSA). Novel interventions to prevent SSIs (e.g., topical or oral antimicrobial agents, skin sealant, and antimicrobial sutures) need further evaluation before surgeons implement them routinely.

SUMMARY

There is some evidence that bundled interventions can reduce SSIs. However, more research should be done evaluating the effectiveness of these interventions. Future studies of bundles should use robust methodologies, such as randomized controlled trials, cluster randomized trials, or quasi-experimental studies analyzed by time series analysis.

Prophylactic Antibiotic Therapy in Contaminated Traumatic Wounds: Two Days versus Five Days Treatment

INTRODUCTION

Emergency department manages several kinds of wounds including simple, non-bite traumatic wounds and lacerations. Prophylactic antibiotic therapy is one of pre-scribed treatment in these conditions. We aimed to compare the clinical efficacy of the two day regimen of prophylactic antimicrobial agents with the five day regimen in simple traumatic but highly contaminated wounds.

METHODS

Between January 2010 and May 2010, patients presenting with simple traumatic wounds or lacerations in different parts of the body, highly contaminated with soil, debris or feces in emergency department of a referral educational hospital in Tehran (Rasul-Akram hospital), Iran, went for primary closure. All of the patients were provided prophylactic antibiotic, however, prescribed for one group (A) of patients for 2 days and other group (B) received for 5 days, according to the physician concerned. As these treatments were routine, we selected 70 patients from each group using table of random numbers. The patients were warned about the signs of infection including long-lasting erythema, purulent discharge and inflammation and were supposed to inform the concerned physician in any of such alarming situations. Oral Cephalexin 500 mg qid was prescribed for all patients enrolled for prophylaxis treatment.

RESULTS

On follow-up 11 (8.2%) patients were found to develop sutured site infection (6 out of 70 (8.57%) in group A, and five out of 70 (7.14%) in group B (P=0.31)). There was no statistical difference between infection rates between men (8.6%) in comparison to women (6.25%) (P>0.05; CI=95%).

CONCLUSION

Our study showed that 2-day prophylactic antibiotic therapy using Cephalexin is at least as effective as a 5-day regimen in relation to development of surgical site infection in patients with simple traumatic contaminated wounds or lacerations.