Deep sternal wound infection after cardiac surgery: Evidences and controversies

Abstract

Despite many advances in prevention and perioperative care, deep sternal wound infection (DSWI) remains a pressing concern in cardiac surgery, with a still relevant incidence and with a considerable impact on in-hospital mortality and also on mid-and long-term survival. The permanent high impact of this complication is partially related to the increasing proportion of patients at highrisk for infection, as well as to the many patient and surgical risk factors involved in the pathogenesis of DSWI. The prophylactic antibiotic therapy is one of the most important tools in the prevention of DSWI. However, the choice of antibiotic, the dose, the duration, the adequate levels in serum and tissue, and the timing of antimicrobial prophylaxis are still controversial. The treatment of DSWI ranges from surgical revision with primary closure to surgical revision with open dressings or closed irrigation, from reconstruction with soft tissue flaps to negative pressure wound therapy (NPWT). However, to date, there have been no accepted recommendations regarding the best management of DSWI. Emerging evidence in the literature has validated the efficacy and safety of NPWT either as a single-line therapy, or as a "bridge" prior to final surgical closure. In conclusion, the careful control of patient and surgical risk factors -when possible, the proper antimicrobial prophylaxis, and the choice of validated techniques of treatment could contribute to keep DSWIs at a minimal rate. Core tip: Intensivists and cardiothoracic surgeons are commonly worried about surgical site infections due to increasing length of stay, costs, and mortality. In particular, deep sternal wound infection (DSWI) is a worrying complication after cardiac surgery, with a still relevant incidence. Unfortunately, DWSI appearance is related to a wide number of both patient and surgical factors. This review may be useful for guiding physicians to the knowledge of main risk factors and the choice of the appropriate management of DWSIs with the aim of reducing the rate of this potentially devastating complication in cardiac surgery patients.Cotogni P, Barbero C, Rinaldi M. Deep sternal wound infection after cardiac surgery: Evidences and controversies. World J Crit Care Med 2015; 4(4): 265-273 Available from: URL: http:// www.wjgnet.com/2220-3141/full/v4/i4/265.htm DOI: http:// dx.doi.org/10.5492/wjccm.v4.i4.265 INTRODUCTIONDeep sternal wound infection (DSWI) is one of the most complex and potentially devastating complications following median sternotomy in cardiac surgery with a significant impact on both patient prognosis and hospital budgets [1][2][3][4][5] . Despite many advances in prevention, it still remains significant and ranges between 0.5% and 6.8% [6][7][8][9][10] , with in-hospital mortality rates between 7% and 35% [2,3,7,9,[11][12][13] . Moreover, mid-and long-term survival is significantly reduced in patients that have experienced DSWI. By the end of the first year, Filsoufi et al [6] found a 15% absolute survival difference between patients ...

Ten‐year analyses of the German DRG data about negative pressure wound therapy

“…The mechanism by which NPWT is thought to promote wound healing is through increasing local perfusion, eliminating tissue oedema, drawing wound edges together, removing exudates and proinflammatory cytokines, inhibiting bacterial growth and promoting cell hyperplasia. NPWT systems have been widely adopted for a broad range of indications in acute and chronic wounds .…”

Impact of an Institutional Antimicrobial Stewardship Program on Bacteriology of Surgical Site Infections in Cardiac Surgery

“…1,2,4,5 Microbial cultures of SSIs in our study predominantly grew Staphylococcus aureus, 60% of which were methicillin-resistant. Despite changes in antibiotic prophylaxis duration and postoperative skin treatment, our data demonstrate a stable incidence and composition of wound infections during the study period.…”

“…6,7 Mitigation of individual patients factors such as tight glycemic control, use of particular skin preparation agents, and wound dressings have met variable success in reducing SSIs. 5,8,9 Recent studies also indicate that daily chlorhexidine baths significantly reduce hospital-acquired infections; however, neither the Center for Disease Control and Prevention (CDC) nor the World Health Organization (WHO) have reported an optimum unified recommendation of skin antiseptic practices or antibiotic prophylaxis strategies. 5,8,9 Recent studies also indicate that daily chlorhexidine baths significantly reduce hospital-acquired infections; however, neither the Center for Disease Control and Prevention (CDC) nor the World Health Organization (WHO) have reported an optimum unified recommendation of skin antiseptic practices or antibiotic prophylaxis strategies.…”

Randomized Study of a New Noninvasive Skin Closure Device for Use After Congenital Heart Operations

“…(Ann Thorac Surg 2016;-:---) Ó 2016 by The Society of Thoracic Surgeons S urgical site infections and hypertrophic scars are the major postsurgical wound complications, and these sometimes can occur after cardiovascular operations [1][2][3]. The use of several skin closure devices, such as cyanoacrylate glue and surgical staples, has been reported [4][5][6], and these devices have been demonstrated to have good potential in reducing skin closure time, improving cosmetic appearance, and decreasing infection rate.…”