Overview and management of sternal wound infection.
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ABSTRACT:
SUBMITTER: Singh K
PROVIDER: S-EPMC3140234 | biostudies-other | 2011 Feb
REPOSITORIES: biostudies-other
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Project description:BackgroundSternal Wound Infection (SWI) is a severe complication after cardiac surgery. Debridement associated with primary closure using Redon drains (RD) is an effective treatment, but data on RD management and antibiotic treatment are scarce.MethodsWe performed a single-center analysis of consecutive patients who were re-operated for SWI between 01/2009 and 12/2012. All patients underwent a closed drainage with RD (CDRD). Patients with endocarditis or those who died within the first 45 days were excluded from management analysis. RD fluid was cultured twice weekly. Variables recorded were clinical and biological data at SWI diagnosis, severity of SWI based on criteria for mediastinitis as defined by the Centers for Disease Control (CDC), antibiotic therapy, RD management and patient's outcome.Results160 patients developed SWI, 102 (64%) fulfilled CDC criteria (CDC+) and 58 (36%) did not (CDC- SWI). Initial antibiotic treatment and surgical management were similar in CDC+ and CDC- SWI. Patients with CDC+ SWI had a longer duration of antibiotic therapy and a mortality rate of 17% as compared to 3% in patients with CDC- SWI (p = 0.025). Rates of superinfection (10% and 9%) and need for second reoperation (12% and 17%) were similar. Failure (death or need for another reoperation) was associated with female gender, higher EuroScore for prediction of operative mortality, and stay in the ICU.ConclusionIn patients with SWI, initial one-stage surgical debridement with CDRD is associated with favorable outcomes. CDC+ and CDC- SWI received essentially the same management, but CDC+ SWI has a more severe outcome.
| S-EPMC4589393 | biostudies-literature
Project description:ObjectivesDeep sternal wound infection is a devastating complication of cardiac surgery. In the current era of increasing patient comorbidity, newer techniques must be evaluated in attempts to reduce the rates of deep sternal wound infection.MethodsA randomized controlled trial comparing sternal closure with traditional sternal wires in figure-8 formation with the Pioneer cabling system® from Medigroup after adult cardiac surgery was performed.ResultsA total of 273 patients were enrolled with 137 and 135 patients randomized to sternal wires and cables group, respectively. Baseline characteristics between the two groups were well balanced. Deep sternal wound infection occurred in 0.7% of patients in the wires group and 3.7% of patients in the cables group (absolute risk difference = -3.0%, 95% confidence interval: -7.7 to 0.9%; P = 0.12). Patients in the cables group were extubated slightly earlier than those in the sternal wires group postoperatively (9.7 vs 12.8 h; P = 0.03). There was, however, no significant difference in hospital and follow-up pain scores or analgesia requirements.ConclusionsThe Pioneer sternal cabling system appears to facilitate early extubation after adult cardiac surgery, but it does not reduce the rate of deep sternal infectionAustralian New Zealand Clinical Trials Registry: ANZCTR-ACTRN12615000973516.
| S-EPMC4892157 | biostudies-literature
Project description:BackgroundManagement of deep sternal wound infection (DSWI) in cardiac surgical patients still remains challenging. A variety of treatment strategies has been described. Aim of this cohort study was to analyse two different treatment strategies for DSWI: titanium sternal plating system (TSFS) and muscle flap coverage (MFC).MethodsBetween January 2007 and December 2011, from 3122 patients undergoing cardiac surgery 42 were identified with DSWI and treated with one of the above mentioned strategies. In-hospital data were collected, follow-up performed by telephone and assessment of Quality of Life (QoL) using the SF-12 Health Survey Questionnaire.Results20 patients with deep sternal wound infection were stabilized with TSFS and 22 patients treated with MFC. Preoperative demographics and risk factors did not reveal any significant differences. Patients treated with TSFS had a significantly shorter operation time (p<0.05) and shorter hospitalization (p<0.05). A tendency towards lower mortality rate (p = n.s.) and less re-interventions were also noted (plating 0.6 vs. flap 1.17 per patient, n.s.). Quality of Life in the TSFS group for the physical-summary-score was significantly elevated compared to the MFC group (p<0.05). Relating to chest stability and cosmetic result the treatment with TSFS showed superior results, but the usage of MFC gave the patients more freedom in breathing and less chest pain.ConclusionOur results demonstrate that the use of TSFS is a feasible and safe alternative in DSWI. However, MFC remains an absolutely essential option for complicated DSWI since the amount of perfused tissue can be the key for infection control.
| S-EPMC5493354 | biostudies-literature
Project description:Introduction. Case reports have emerged with identification of Gordonia bronchialis infections including sternal wound infections and foreign bodies such as central lines and shunts. Case presentation. We present a case that demonstrates the need to consider Gordonia infection as a cause of sternal wound infection and highlights the utility of novel diagnostics to aid in the identification of unusual pathogens that can cause post-operative infections. We report here the first successful use of ceftaroline for treatment of a G. bronchialis sternal wound infection. Conclusion. There are only case reports and in vitro assays to date to guide treatment of this infection, and we now add ceftaroline as a new drug to consider, though adequate surgical debridement is paramount.
| S-EPMC5643002 | biostudies-literature
Project description:The results of current studies are not conclusive on the efficacy of incisional negative-pressure wound therapy (NPWT) for the prevention of sternal wound infection (SWI) after adult cardiac surgery. A systematic review of the literature was performed through PubMed, Scopus and Google to identify studies which investigated the efficacy of NPWT to prevent SWI after adult cardiac surgery. Available data were pooled using RevMan and Meta-analyst with random effect models. Out of 191 studies retrieved from the literature, ten fulfilled the inclusion criteria and were included in this analysis. The quality of these studies was judged fair for three of them and poor for seven studies. Only one study was powered to address the efficacy of NPWT for the prevention of postoperative SWI. Pooled analysis of these studies showed that NPWT was associated with lower risk of any SWI (4.5% vs. 9.0%, RR 0.54, 95% CI 0.34-0.84, I2 48%), superficial SWI (3.8% vs. 4.4%, RR 0.63, 95% CI 0.29-1.36, I2 65%), and deep SWI (1.8% vs. 4.7%, RR 0.46, 95% CI 0.26-0.74, I2 0%), but such a difference was not statistically significant for superficial SWI. When only randomized and alternating allocated studies were included, NPWT was associated with a significantly lower risk of any SWI (3.3% vs. 16.5%, RR 0.22, 95% CI 0.08-0.62, I2 0%), superficial SWI (2.6% vs. 12.4%, RR 0.21, 95% CI 0.06-0.69, I2 0%), and deep SWI (1.2% vs. 4.8%, RR 0.17, 95% CI 0.03-0.95, I2 0%). This pooled analysis showed that NPWT may prevent postoperative SWI after adult cardiac surgery. NPWT is expected to be particularly useful in patients at risk for surgical site infection and may significantly reduce the burden of resources needed to treat such a complication. However, the methodology of the available studies was judged as poor for most of them. Further studies are needed to obtain conclusive results on the potential benefits of this preventative strategy.
| S-EPMC9330054 | biostudies-literature
Project description:We aimed to quantitatively and systematically elucidate the rationality of the examined variables as independent risk factors for sternal wound infection. We searched databases to screen studies, ascertained the variables to be analysed, extracted the data and applied meta-analysis to each qualified variable. Odds ratios and mean differences were considered to be the effect sizes for binary and continuous variables, respectively. A random-effects model was used for these procedures. The source of heterogeneity was evaluated using a meta-regression. Publication bias was tested by funnel plot and Egger's test, the significant results of which were then calculated using trim and fill analysis. We used a sensitivity analysis and bubble chart to describe their robustness. After screening all variables in the eligible literature, we excluded 55 because only one or no research found them significant after multivariate analysis, leaving 33 variables for synthesis. Two binary variables (age over 65 years, NYHA class >2) and a continuous variable (preoperative stay) were not significant after the meta-analysis. The most robust independent risk factors in our study were diabetes mellitus, obesity, use of bilateral internal thoracic arteries, chronic obstructive pulmonary disease, prolonged surgery time, prolonged ventilation and critical preoperative state, followed by congestive heart failure, atrial fibrillation, renal insufficiency, stroke, peripheral vascular disease and use of an intra-aortic balloon pump. Relatively low-risk factors were emergent/urgent surgery, smoking, myocardial infarction, combined surgery and coronary artery bypass grafting. Sternal wound infection after open-heart surgery is a multifactorial disease. The detected risk factors significantly affected the wound healing process, but some were different in strength. Anything that affects wound healing and antibacterial ability, such as lack of oxygen, local haemodynamic disorders, malnutrition condition and compromised immune system will increase the risk, and this reminds us of comprehensive treatment during the perioperative period.
| S-EPMC10898401 | biostudies-literature
Project description:This study aimed to evaluate the impact of delayed flap closure on mortality and resource use for treatment of deep sternal wound infection.The authors analyzed the Truven MarketScan Databases from 2009 to 2013 to identify adult patients who developed deep sternal wound infection after open cardiac surgery and who underwent flap closure for treatment. A multivariable logistic regression model was created to evaluate the relationship between mortality and flap timing. Multivariable Poisson regressions were used to investigate the relationship between flap timing and number of procedures, number of hospitalizations, and length of stay outcomes. A multivariable log-linear regression model was created for cost analysis. All analyses were adjusted for patient risk factors and treatment characteristics.The authors identified 612 patients with deep sternal wound infection who underwent flap closure. The timing of flap closure was delayed more than 7 days after diagnosis in 39 percent of patients. Delayed time to flap closure greater than 3 days after diagnosis of infection was associated with higher mortality odds for delay 4 to 7 days (OR, 2.94) and delay greater than 7 days (OR, 2.75; p < 0.03), greater additional procedures for delay 4 to 7 days (incidence rate ratio, 1.72) and delay greater than 7 days (incidence rate ratio, 1.93; p < 0.001), and up to 43 percent longer hospital length of stay and 37 percent greater costs compared with patients undergoing flap closure 0 to 3 days after diagnosis.Delay in flap closure was associated with greater mortality and resource use. Prompt involvement of reconstructive surgeons may improve quality and efficiency of deep sternal wound infection care.Therapeutic, III.
| S-EPMC5529255 | biostudies-literature
Project description:ObjectivesThe Gatti score is a weighted scoring system based on risk factors for deep sternal wound infection (DSWI) that has been specifically created to predict DSWI risk after routine bilateral internal thoracic artery (BITA) grafting. It has not undergone an external validation. The aim of the present study was to perform this validation.MethodsBITA grafts were used as skeletonized conduits in 304 (90.7%) of 335 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution between January 2014 and July 2015. Baseline characteristics, operative data and immediate outcomes of every patient were prospectively collected in a computerized data registry. A score was assigned to each patient preoperatively. The goodness-of-fit and the discrimination power of both models, preoperative and combined, of the Gatti score were assessed with the Hosmer-Lemeshow test and the calculation of the area under the receiver-operating characteristic curve, respectively.ResultsEighteen (5.9%) patients suffered from DSWI. Major differences were found between the original series whence the Gatti score has been derived and the present prospective series. The Gatti score goodness-of-fit was satisfactory for both the preoperative (P = 0.61) and the combined model (P = 0.81). The area under the receiver-operating characteristic curve was 0.82 (95% confidence interval: 0.72-0.91) for the preoperative model and 0.8 (95% confidence interval: 0.71-0.9) for the combined model.ConclusionsOn the basis of the results of the present prospective study, the Gatti score has proved to be effective in predicting DSWI following BITA grafting despite some differences between the original and the present series of patients. More studies have to be performed in order to strengthen the evidence of this first external validation.
| S-EPMC4892156 | biostudies-literature
Project description:BackgroundBilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database.MethodsPrimary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching.ResultsWe analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P = .129) and 23% (P = .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P = .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories.ConclusionsThe observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization.
| S-EPMC7890569 | biostudies-literature
Project description:BACKGROUND:Sternal wound complications (SWC) are a rare but potentially life-threatening complication after coronary artery bypass grafting (CABG) surgery. Especially the use of bilateral IMA (BIMA) grafts as opposed to single IMA (SIMA) grafts is associated with an increased risk of SWC. Skeletonised harvesting has been proposed to reduce this risk. The purpose of this study was to retrospectively investigate the effect of skeletonisation on SWC after off-pump coronary artery bypass grafting (OPCAB) in a centre with a high volume of off-pump procedures and high frequencies of BIMA. METHODS:From January 2010 to November 2016, 1900 consecutive patients underwent OPCAB surgery at the University Hospitals of Leuven. The first group (n?=?1487) received non-skeletonised IMA grafts, whereas the second group (n?=?413) received skeletonised grafts. Optimal wound management was pursued in all patients. A new four-grade classification for SWC was developed. Incidence and grade of SWC as well as overall survival were assessed. RESULTS:Analysis of diabetic patients showed a lower incidence of SWC in the skeletonised (12/141, 8.5%) compared to the non-skeletonised group (82/414, 19.8%) [odds ratio 0.46, 95% confidence interval (0.23;0.88), p?=?0.019] as well as a lower grade [0.45 (0.24;0.871), p?=?0.018]. There was no significant effect on overall survival [0.67 (0.19;2.32), p?=?0.529]. Subanalysis of this population revealed that the observed effects were most prominent in patients receiving BIMA grafts, with 6/56 (10.7%) SWC in the skeletonised and 62/252 (24.6%) in the non-skeletonised group [0.37 (0.15;0.90), p?=?0.028 for incidence], as well as a lower grade [0.36 (0.15;0.88), p?=?0.025]. These advantages were not significant in diabetic patients receiving SIMA grafts nor in the full study population. CONCLUSIONS:This study, using a more sensitive classification of SWC, shows in a large group of patients that, in combination with optimized wound management, the skeletonisation technique is associated with a clear reduction in the incidence and grade of SWC in diabetic patients receiving BIMA grafts. This encourages the extension of BIMA use in OPCAB to this risk population.
| S-EPMC6734214 | biostudies-literature