Deep Sternal Wound Infections after Coronary Artery Bypass Grafting: Analysis of 29 Cases from Iraq

Background: Deep sternal wound infection (DSWI), or mediastinitis, is a devastating complication of coronary artery bypass grafting (CABG). This prospective study aimed to assess our management of DSWI in view of the published literature. Methods: Over 2-years (ending in January 2016), 29 patients (20 males) developed DSWI amongst 520 patients who underwent standard CABG surgeries (5.6%). Pre-, intra- and postoperative variables were documented. Whenever possible, the infections were culture-verified. Besides antibiotics, patients received one or more of the following therapies: drainage, debridement, closed irrigation, sternal re-wiring, vacuum-assisted closure (VAC), and bone resection. Results: the male to female ratio was 2.2:1. Mean age was 58.1 ± 7.3 years. The mean body mass index (BMI) was 27.9 ± 3.4 kg/m2. There were 18, 16 and 11 patients with diabetes mellitus (DM), hypertension and chronic obstructive pulmonary disease (COPD) respectively. Cardiopulmonary bypass (CPB) was utilized in 26 (89.7%) patients with a mean time of 117.5 ± 23.3 minutes. Most surgeries (n = 21, 72.4%) lasted 5 - 6 hrs. According to Pairolero classification, there were 3 (10.3%) Type I, 22 (75.9%) Type II and 4 (13.8%) Type III infections. Four (13.8%) cases were culture-verified. Twenty-three (79.3%) DSWIs were surgically managed. Sternal re-wiring was performed in 14 (48.3%) cases while VAC was added to other therapies in 2 (6.9%) patients. DSWIs completely resolved in 18 (62.0%) patients within 3 - 24 weeks while two (6.9%) patients died within 30 days. Conclusion: We have identified six independent risk factors for DSWI (male gender, obesity, DM, hypertension, COPD and CPB), five of them are modifiable.

Intraoperative vs 24-Hour Administration of Cefamandole to Prevent Deep Sternal Wound Infection and Endocarditis after Adult Cardiac Surgery

Background and Objectives: Duration of antibiotic prophylaxis for cardiac surgery is still debated and controversial. International guidelines are vague: French guidelines recommend an intraoperative administration, while the Society of Thoracic Surgeons’ guidelines suggest that optimal postoperative prophylactic antibiotics be given for 48 hours or less. Very few studies have compared the same antibiotic with 2 different administration durations. The study was designed to compare the efficacy of 24-hour administration of cefamandole vs intraoperative cefamandole to prevent deep sternal wound infection and endocarditis after cardiac surgery. Methods: This retrospective and observational study compared the rates of severe surgical site infections (deep sternal wound infection, endocarditis) after cardiac surgery between period 1, 01/01/2008-31/08/2008, with 24-hour administration of cefamandole, and period 2, 01/09/2008-30/04/2009 with intraoperative cefamandole. Results: Among 933 patients, 14 patients (1.5%) developed surgical site infection during the 16-month study: 1.3% during the first period and 1.7% during the second (ns). The populations (470 patients in period 1 and 463 in period 2) were homogeneous and comparable for pre-, intra- and postoperative characteristics. Surgical site infection characteristics (pathogens involved, time to diagnosis) and consequences (longer hospital stay, outcomes) were comparable in the 2 groups. Conclusions: Intraoperative cefamandole was as safe as its 24-hour administration to prevent deep sternal wound infection and endocarditis after adult cardiac surgery.

Clinical analysis of patients with deep sternal wound infection-induced sepsis:a retrospective cohort study

Background:This study aimed to summarize the clinical characteristics of patients with deep sternal wound infection-induced sepsis after median sternotomy and improve the treatment outcomes of infection-related sepsis.Methods:A retrospective cohort study was conducted on 21 patients with deep sternal wound infection-induced sepsis after median sternotomy who were admitted to the Department of Critical Care.The clinical manifestations,laboratory test results,infection control,and organ and nutritional support of the patients were summarized,and the follow-up data were obtained.Results:The primary symptoms of deep sternal wound infection-induced sepsis included dyspnea,high fever,chills,and altered state of consciousness.Laboratory test results revealed increased inflammatory markers and decreased oxygenation index.Renal and liver function injury were observed in 8 and 4 patients,respectively;18 and 12 patients demonstrated elevated D-dimer and N-terminal Pro B type natriuretic peptide levels,respectively.Of the 8 patients whose wound secretions tested positive for bacteria,Acinetobacter baumannii and Staphylococcus aureus infections were present in 6 and 2 patients,respectively.One of the 6 patients whose blood cultures tested positive for bacteria demonstrated Candida albicans infection.Fifteen patients received ventilator-assisted ventilation and 2 patients received renal replacement therapy.Of all the 21 patients,17 were cured,2 died,and 2 were discharged.Conclusion:Postmedian sternotomy sepsis attributed to a deep sternal wound infection usually results from a preexisting condition.The most prominent clinical manifestation is dyspnea,which is sometimes accompanied by the impairment of organ function.Infection prevention,proper nutrition support,and maintenance of healthy organ function are the cornerstones for successful treatment outcomes.

Surgical treatment for deep sternal wound infection after cardiac surgery

Background Deep sterna wound infection （DSWI） after median sternotomy for cardiac surgery is one of the most complex and potentially life-threatening complications. It＇s very difficult to treat DSWI, and there is lack of agreement regarding the best therapy strategy. Thus, we aimed to summarize our experiences of surgical treatment for DSWI, in which satisfactory clinical results were obtained. Methods We retrospectively analyzed 17 cases who suffered from DSWI after cardiac surgery in our department from January 2010 to June 2015. There were 8 male and 9 female patients with their average age of 62.7 ___ 9.5 years （range 42 ~ 75 years）. All patients re- ceived reservation of part of sternum combined with vacuum-assisted suction drainage and bilateral pectoralis ma- jor myocutaneous advancement flaps. Results The average interval between cardiac surgery and diagnosed DSWI was 10.9 ± 6.5 days （range 5 - 21 days）. Time of vacuum-assisted suction drainage was 11.6±4.8 days （range 5 - 15 days） and wound healing time was 27.3 ± 7.2 days （range 23 - 35 days）. All patients had an uneventful postoperative recovery and good wound healing. Follow-up time was 33.7 _ 13.3 months （range 8 74 months）. No recurrent infection was observed. Conclusions Reservation of part of sternum combined with vacuum-assisted suction drainage and bilateral pectoralis major myocutaneous advancement flaps is a simple and effective surgical strategy for the treatment of DSWI after cardiac surgery.