title: Management practices and major infections after cardiac surgery.
abstract: BACKGROUND
  Infections are the most common noncardiac complication after cardiac surgery, but their incidence across a broad range of operations, as well as the management factors that shape infection risk, remain unknown.
  
  
  OBJECTIVE
  This study sought to prospectively examine the frequency of post-operative infections and associated mortality, and modifiable management practices predictive of infections within 65 days from cardiac surgery.
  
  
  METHODS
  This study enrolled 5,158 patients and analyzed independently adjudicated infections using a competing risk model (with death as the competing event).
  
  
  RESULTS
  Nearly 5% of patients experienced major infections. Baseline characteristics associated with increased infection risk included chronic lung disease (hazard ratio [HR]: 1.66; 95% confidence interval [CI]: 1.21 to 2.26), heart failure (HR: 1.47; 95% CI: 1.11 to 1.95), and longer surgery (HR: 1.31; 95% CI: 1.21 to 1.41). Practices associated with reduced infection risk included prophylaxis with second-generation cephalosporins (HR: 0.70; 95% CI: 0.52 to 0.94), whereas post-operative antibiotic duration >48 h (HR: 1.92; 95% CI: 1.28 to 2.88), stress hyperglycemia (HR: 1.32; 95% CI: 1.01 to 1.73); intubation time of 24 to 48 h (HR: 1.49; 95% CI: 1.04 to 2.14); and ventilation >48 h (HR: 2.45; 95% CI: 1.66 to 3.63) were associated with increased risk. HRs for infection were similar with either <24 h or <48 h of antibiotic prophylaxis. There was a significant but differential effect of transfusion by surgery type (excluding left ventricular assist device procedures/transplant) (HR: 1.13; 95% CI: 1.07 to 1.20). Major infections substantially increased mortality (HR: 10.02; 95% CI: 6.12 to 16.39).
  
  
  CONCLUSIONS
  Major infections dramatically affect survival and readmissions. Second-generation cephalosporins were strongly associated with reduced major infection risk, but optimal duration of antibiotic prophylaxis requires further study. Given practice variations, considerable opportunities exist for improving outcomes and preventing readmissions. (Management Practices and Risk of Infection Following Cardiac Surgery; NCT01089712).
authors: International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York. Electronic address: annetine.gelijns@mssm.edu.
authors: Annetine C
authors: AC
authors: Gelijns
authors: International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York.
authors: Alan J
authors: AJ
authors: Moskowitz
authors: Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
authors: Michael A
authors: MA
authors: Acker
authors: Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York.
authors: Michael
authors: M
authors: Argenziano
authors: Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors: Nancy L
authors: NL
authors: Geller
authors: Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors: John D
authors: JD
authors: Puskas
authors: Montréal Heart Institute, University of Montréal, Montréal, Québec, Canada.
authors: Louis P
authors: LP
authors: Perrault
authors: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
authors: Peter K
authors: PK
authors: Smith
authors: Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Virginia.
authors: Irving L
authors: IL
authors: Kron
authors: Department of Cardiothoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York.
authors: Robert E
authors: RE
authors: Michler
authors: Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors: Marissa A
authors: MA
authors: Miller
authors: Center for Heart & Vascular Health, Christiana Care Health System, Newark, Delaware.
authors: Timothy J
authors: TJ
authors: Gardner
authors: International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York.
authors: Deborah D
authors: DD
authors: Ascheim
authors: Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Virginia.
authors: Gorav
authors: G
authors: Ailawadi
authors: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors: Pamela
authors: P
authors: Lackner
authors: Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York.
authors: Lyn A
authors: LA
authors: Goldsmith
authors: Montréal Heart Institute, University of Montréal, Montréal, Québec, Canada.
authors: Sophie
authors: S
authors: Robichaud
authors: Department of Medicine, Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa.
authors: Rachel A
authors: RA
authors: Miller
authors: International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York.
authors: Eric A
authors: EA
authors: Rose
authors: Department of Cardiovascular Sciences; East Carolina Heart Institute at East Carolina University, Greenville, North Carolina.
authors: T Bruce
authors: TB
authors: Ferguson
authors: NIH Heart Center at Suburban Hospital, Bethesda, Maryland.
authors: Keith A
authors: KA
authors: Horvath
authors: International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York.
authors: Ellen G
authors: EG
authors: Moquete
authors: International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York.
authors: Michael K
authors: MK
authors: Parides
authors: International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York.
authors: Emilia
authors: E
authors: Bagiella
authors: Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.
authors: Patrick T
authors: PT
authors: O'Gara
authors: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors: Eugene H
authors: EH
authors: Blackstone
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis / Q000379:methods*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D016001:Confidence Intervals; D019468:Disease Management; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000517:prevention & control*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents
keywords: cardiac surgery; infection; risk factors