Toward zero: Deep sternal wound infection after 1001 consecutive coronary artery bypass procedures using arterial grafts: Implications for diabetic patients

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Toward zero: Deep sternal wound infection after 1001 consecutive coronary artery bypass procedures using arterial grafts: Implications for diabetic patients Teresa M. Kieser, MD, M. Sarah Rose, PhD, Uthman Aluthman, MD, Marlene Montgomery, RN, Thomas Louie, MD, Israel Belenkie, MD The Journal of Thoracic and Cardiovascular Surgery Volume 148, Issue 5, Pages 1887-1895 (November 2014) DOI: 10.1016/j.jtcvs.2014.02.022 Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Cardiac surgery wound care algorithm. BID, Twice daily; D/C, discontinue; Pt, patient; CT, chest tubes; d/c'd, discontinued; OD, once a day; PRN, pro re nata [as needed]; ASAP, as soon as possible; CV-ICU, cardiovascular intensive care unit. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1887-1895DOI: (10.1016/j.jtcvs.2014.02.022) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Cardiac surgery wound care algorithm. BID, Twice daily; D/C, discontinue; Pt, patient; CT, chest tubes; d/c'd, discontinued; OD, once a day; PRN, pro re nata [as needed]; ASAP, as soon as possible; CV-ICU, cardiovascular intensive care unit. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1887-1895DOI: (10.1016/j.jtcvs.2014.02.022) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, Infection rates per 20 consecutive surgeries (dots). The dashed red arrow indicates when the last deep sternal wound infection was observed. The black arrows indicate when each infection prevention measure (see later discussion) was implemented. *Indicates an institution-wide measure. Infection prevention measures: (1) Skeletonization of internal thoracic arteries with ultrasonic scalpel; (2) vancomycin paste applied to sternal halves; (3) use of iodine-impregnated surgical adhesive drapes; (4) avoidance of use of bilateral internal thoracic arteries in obese diabetic women; (5) preoperative skin preparation with chlorhexidine-alcohol; (6) off-pump coronary artery bypass graft was performed where feasible; (7) wound care was changed to an aseptic technique; (8) cleansing the sternal marrow before applying vancomycin paste. B, Distribution of the interinfection intervals for the first 523 surgeries: the Kaplan-Meier estimate (green line) is the estimated probability of remaining infection-free given the number of surgeries since the last infection. The red line indicates the fitted exponential distribution; ie, the probability of observing 50 surgeries or more between infections is high (about 25%). The probability of observing 100 surgeries or more is about 5% and the probability of observing 200 surgeries or more without infection is low at 0.2%. DSWI, Deep sternal wound infection. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1887-1895DOI: (10.1016/j.jtcvs.2014.02.022) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Comparison of deep sternal wound infection (DSWI) rates in men, women, diabetic and nondiabetic, obese and nonobese patients. Diamonds, DSWI rate in each subgroup before the change point. Lines indicate the confidence intervals (CI). CIs are one-sided (97.5%) when the estimates are zero and 95% when nonzero. There is no significant effect of obesity and diabetes in men (P = .696); the overall rate was 2.4% (1.2-4.4). However, obese diabetic women have a significantly higher risk of DSWI than other women (P < .001). Notably, the only DSWIs in women were observed in obese diabetics. The last 2 columns indicate the number of patients in each subgroup before and after the change point. There was no significant difference within women (P = .547) or men (P = .512). The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1887-1895DOI: (10.1016/j.jtcvs.2014.02.022) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Comparison of the estimated deep sternal wound infection (DSWI) rate in this study (Kieser 2013) before and after the change point with other previously reported studies. The diamonds represent the infection rates and the lines indicate the 95% confidence intervals (CI) of the estimate. Because the number of infections for Kieser 2013 (after) was zero, a one-sided 95% confidence interval is presented. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1887-1895DOI: (10.1016/j.jtcvs.2014.02.022) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions