title: Toward zero: deep sternal wound infection after 1001 consecutive coronary artery bypass procedures using arterial grafts: implications for diabetic patients.
abstract: OBJECTIVE
  Coronary artery bypass graft (CABG) surgery with arterial conduits is considered optimal. A deterrent to bilateral internal thoracic artery (BITA) grafting is the risk of deep sternal wound infection (DSWI). We introduced infection prevention measures sequentially, attempting to reduce DSWIs. The aim was to determine (1) if the absence of DSWIs in the last 469 of 1001 consecutive operations was significant; (2) which measures explained the change; and (3) the impact of diabetes.
  
  
  METHODS
  The measures included internal thoracic artery (ITA) skeletonization, no bone wax, wound irrigation, 1 observer per case, harmonic scalpel harvest of ITAs, vancomycin paste on sternal marrow, iodine-impregnated skin drapes, chlorhexidine-alcohol skin preparation, no BITA grafts in obese, diabetic women, more off-pump procedures, aseptic wound care, and marrow irrigation before sternal approximation.
  
  
  RESULTS
  Mean age was 65±10.4 years, 78% were male, 34% had diabetes, and 34% were obese. The first 532 patients had 16 DSWIs (3%) and the subsequent 469 had none (P<.001). Analysis of the data suggested that the first 11 measures likely contributed to the absence of DSWI and less likely, the twelfth. Key measures were likely chlorhexidine-alcohol use and avoidance of BITAs in obese diabetic women who had a 10-fold higher DSWI rate than the other patients (21.4% vs 2.0%). Other diabetics, including obese men, had no increased risk of DSWI.
  
  
  CONCLUSIONS
  The measures applied caused a substantial reduction in DSWIs. Key measures included the use of chlorhexidine-alcohol and avoidance of BITA grafting in obese diabetic females. These measures reduced DSWIs after BITA grafting in most diabetics.
authors.affiliation: Departments of Cardiac Sciences and Surgery, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada. Electronic address: t.kieserprieur@ucalgary.ca.
authors.forename: Teresa M
authors.initials: TM
authors.lastname: Kieser
authors.affiliation: Rho Sigma Scientific Consultants, Calgary, Alberta, Canada.
authors.forename: M Sarah
authors.initials: MS
authors.lastname: Rose
authors.affiliation: Departments of Cardiac Sciences and Surgery, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada.
authors.forename: Uthman
authors.initials: U
authors.lastname: Aluthman
authors.affiliation: Infection Control and Prevention, Alberta Health Services, Calgary, Alberta, Canada.
authors.forename: Marlene
authors.initials: M
authors.lastname: Montgomery
authors.affiliation: Department of Internal Medicine, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Thomas
authors.initials: T
authors.lastname: Louie
authors.affiliation: Departments of Cardiac Sciences and Internal Medicine, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada.
authors.forename: Israel
authors.initials: I
authors.lastname: Belenkie
mesh_terms: D000368:Aged; D000891:Anti-Infective Agents, Local / Q000627:therapeutic use; D003661:Decision Support Techniques; D048909:Diabetes Complications / Q000209:etiology / Q000517:prevention & control*; D005260:Female; D006801:Humans; D017053:Infection Control / Q000379:methods; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000009:adverse effects*; D008297:Male; D008323:Mammary Arteries / Q000601:surgery*; D008875:Middle Aged; D009765:Obesity / Q000150:complications; D018579:Patient Selection; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D013530:Surgical Wound Infection / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors; D020858:Tissue and Organ Harvesting / Q000009:adverse effects*; D016896:Treatment Outcome
chemical_list: D000891:Anti-Infective Agents, Local