JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 64, NO. 4, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2014.04.052
Management Practices and Major Infections After Cardiac Surgery Annetine C. Gelijns, PHD,* Alan J. Moskowitz, MD,* Michael A. Acker, MD,y Michael Argenziano, MD,z Nancy L. Geller, PHD,x John D. Puskas, MD,k Louis P. Perrault, MD, PHD,{ Peter K. Smith, MD,# Irving L. Kron, MD,** Robert E. Michler, MD,yy Marissa A. Miller, DVM, MPH,zz Timothy J. Gardner, MD,xx Deborah D. Ascheim, MD,* Gorav Ailawadi, MD,** Pamela Lackner, BA,kk Lyn A. Goldsmith, MA, RN, BSN,z Sophie Robichaud, RT,{ Rachel A. Miller, MD,{{ Eric A. Rose, MD,* T. Bruce Ferguson, Jr, MD,## Keith A. Horvath, MD,*** Ellen G. Moquete, RN, BSN,* Michael K. Parides, PHD,* Emilia Bagiella, PHD,* Patrick T. O’Gara, MD,yyy Eugene H. Blackstone, MD,kk for the Cardiothoracic Surgical Trials Network (CTSN)
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. OBJECTIVES 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
VOL. 64, NO. 4, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2014.04.052
Management Practices and Major Infections After Cardiac Surgery Annetine C. Gelijns, PHD,* Alan J. Moskowitz, MD,* Michael A. Acker, MD,y Michael Argenziano, MD,z Nancy L. Geller, PHD,x John D. Puskas, MD,k Louis P. Perrault, MD, PHD,{ Peter K. Smith, MD,# Irving L. Kron, MD,** Robert E. Michler, MD,yy Marissa A. Miller, DVM, MPH,zz Timothy J. Gardner, MD,xx Deborah D. Ascheim, MD,* Gorav Ailawadi, MD,** Pamela Lackner, BA,kk Lyn A. Goldsmith, MA, RN, BSN,z Sophie Robichaud, RT,{ Rachel A. Miller, MD,{{ Eric A. Rose, MD,* T. Bruce Ferguson, Jr, MD,## Keith A. Horvath, MD,*** Ellen G. Moquete, RN, BSN,* Michael K. Parides, PHD,* Emilia Bagiella, PHD,* Patrick T. O’Gara, MD,yyy Eugene H. Blackstone, MD,kk for the Cardiothoracic Surgical Trials Network (CTSN)
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. OBJECTIVES 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
