Pneumonia after cardiac surgery: Experience of the National Institutes of Health/Canadian Institutes of Health Research Cardiothoracic Surgical Trials Network.
Pneumonia remains the most common major infection after cardiac surgery despite numerous preventive measures.



To prospectively examine the timing, pathogens, and risk factors, including modifiable management practices, for postoperative pneumonia and estimate its impact on clinical outcomes.



A total of 5158 adult cardiac surgery patients were enrolled prospectively in a cohort study across 10 centers. All infections were adjudicated by an independent committee. Competing risk models were used to assess the association of patient characteristics and management practices with pneumonia within 65 days of surgery. Mortality was assessed by Cox proportional hazards model and length of stay by a multistate model.



The cumulative incidence of pneumonia was 2.4%, 33% of which occurred after discharge. Older age, lower hemoglobin level, chronic obstructive pulmonary disease, steroid use, operative time, and left ventricular assist device/heart transplant were risk factors. Ventilation time (24-48 vs ≤24 hours; hazard ratio [HR], 2.83; 95% confidence interval [95% CI], 1.72-4.66; >48 hours HR, 4.67; 95% CI, 2.70-8.08), nasogastric tubes (HR, 1.80; 95% CI, 1.10-2.94), and each unit of blood cells transfused (HR, 1.16; 95% CI, 1.08-1.26) increased the risk of pneumonia. Prophylactic use of second-generation cephalosporins (HR, 0.66; 95% CI, 0.45-0.97) and platelet transfusions (HR, 0.49, 95% CI, 0.30-0.79) were protective. Pneumonia was associated with a marked increase in mortality (HR, 8.89; 95% CI, 5.02-15.75) and longer length of stay of 13.55 ± 1.95 days (bootstrap 95% CI, 10.31-16.58).



Pneumonia continues to impose a major impact on the health of patients after cardiac surgery. After we adjusted for baseline risk, several specific management practices were associated with pneumonia, which offer targets for quality improvement and further research.
Cardiothoracic Surgery, University of Virginia, Charlottesville, Va.
Gorav
G
Ailawadi
Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
Helena L
HL
Chang
Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Mass.
Patrick T
PT
O'Gara
Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
Karen
K
O'Sullivan
Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.
Y Joseph
YJ
Woo
Cardiovascular and Thoracic Surgery, Montefiore-Einstein Heart Center, Bronx, NY.
Joseph J
JJ
DeRose
Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
Michael K
MK
Parides
Cardiothoracic Surgery, Emory University Hospital Midtown, Atlanta, Ga.
Vinod H
VH
Thourani
Montreal Heart Institute, Montreal, Canada.
Sophie
S
Robichaud
Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
A Marc
AM
Gillinov
Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Md.
Wendy C
WC
Taddei-Peters
Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Md.
Marissa A
MA
Miller
Montreal Heart Institute, Montreal, Canada.
Louis P
LP
Perrault
Cardiac Surgery, The Heart Hospital Baylor Plano, Plano, Tex.
Robert L
RL
Smith
Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY.
Lyn
L
Goldsmith
NIH Heart Center at Suburban Hospital, Bethesda, Md.
Keith A
KA
Horvath
Cardiothoracic Research, Cleveland Clinic, Cleveland, Ohio.
Kristen
K
Doud
Cardiothoracic Surgery, Emory University Hospital Midtown, Atlanta, Ga.
Kim
K
Baio
Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address: Annetine.gelijns@mssm.edu.
Annetine C
AC
Gelijns
Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
Alan J
AJ
Moskowitz
Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
Emilia
E
Bagiella
Division of Cardiology and Duke Clinical Research Institute, Duke Medicine, Durham, NC.
John H
JH
Alexander
Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Alexander
A
Iribarne
D000368:Aged; D002170:Canada / Q000453:epidemiology; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000401:mortality; D002986:Clinical Trials as Topic; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009316:National Institutes of Health (U.S.); D011014:Pneumonia / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality; D011446:Prospective Studies; D019984:Quality Indicators, Health Care; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
cardiac surgery; infections; outcomes; pneumonia; quality improvement