Management practices and major infections after cardiac surgery

Annetine C. Gelijns, Alan J. Moskowitz, Michael A. Acker, Michael Argenziano, Nancy L. Geller, John D. Puskas, Louis P. Perrault, Peter K. Smith, Irving L. Kron, Robert E. Michler, Marissa A. Miller, Timothy J. Gardner, Deborah D. Ascheim, Gorav Ailawadi, Pamela Lackner, Lyn A. Goldsmith, Sophie Robichaud, Rachel A. Miller, Eric A. Rose, T. Bruce Ferguson & 6 others Keith A. Horvath, Ellen G. Moquete, Michael K. Parides, Emilia Bagiella, Patrick T. O'Gara, Eugene H. Blackstone

Research output: Contribution to journalArticle

52 Citations (Scopus)

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 <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).

Original languageEnglish (US)
Pages (from-to)372-381
Number of pages10
JournalJournal of the American College of Cardiology
Volume64
Issue number4
DOIs
StatePublished - Jul 29 2014

Fingerprint

Practice Management
Thoracic Surgery
Confidence Intervals
Infection
Antibiotic Prophylaxis
Cephalosporins
Heart-Assist Devices
Mortality
Risk Management
Ambulatory Surgical Procedures
Intubation
Hyperglycemia
Lung Diseases
Ventilation
Chronic Disease
Heart Failure

Keywords

  • cardiac surgery
  • infection
  • risk factors

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Gelijns, A. C., Moskowitz, A. J., Acker, M. A., Argenziano, M., Geller, N. L., Puskas, J. D., ... Blackstone, E. H. (2014). Management practices and major infections after cardiac surgery. Journal of the American College of Cardiology, 64(4), 372-381. https://doi.org/10.1016/j.jacc.2014.04.052

Management practices and major infections after cardiac surgery. / Gelijns, Annetine C.; Moskowitz, Alan J.; Acker, Michael A.; Argenziano, Michael; Geller, Nancy L.; Puskas, John D.; Perrault, Louis P.; Smith, Peter K.; Kron, Irving L.; Michler, Robert E.; Miller, Marissa A.; Gardner, Timothy J.; Ascheim, Deborah D.; Ailawadi, Gorav; Lackner, Pamela; Goldsmith, Lyn A.; Robichaud, Sophie; Miller, Rachel A.; Rose, Eric A.; Ferguson, T. Bruce; Horvath, Keith A.; Moquete, Ellen G.; Parides, Michael K.; Bagiella, Emilia; O'Gara, Patrick T.; Blackstone, Eugene H.

In: Journal of the American College of Cardiology, Vol. 64, No. 4, 29.07.2014, p. 372-381.

Research output: Contribution to journalArticle

Gelijns, AC, Moskowitz, AJ, Acker, MA, Argenziano, M, Geller, NL, Puskas, JD, Perrault, LP, Smith, PK, Kron, IL, Michler, RE, Miller, MA, Gardner, TJ, Ascheim, DD, Ailawadi, G, Lackner, P, Goldsmith, LA, Robichaud, S, Miller, RA, Rose, EA, Ferguson, TB, Horvath, KA, Moquete, EG, Parides, MK, Bagiella, E, O'Gara, PT & Blackstone, EH 2014, 'Management practices and major infections after cardiac surgery', Journal of the American College of Cardiology, vol. 64, no. 4, pp. 372-381. https://doi.org/10.1016/j.jacc.2014.04.052
Gelijns AC, Moskowitz AJ, Acker MA, Argenziano M, Geller NL, Puskas JD et al. Management practices and major infections after cardiac surgery. Journal of the American College of Cardiology. 2014 Jul 29;64(4):372-381. https://doi.org/10.1016/j.jacc.2014.04.052
Gelijns, Annetine C. ; Moskowitz, Alan J. ; Acker, Michael A. ; Argenziano, Michael ; Geller, Nancy L. ; Puskas, John D. ; Perrault, Louis P. ; Smith, Peter K. ; Kron, Irving L. ; Michler, Robert E. ; Miller, Marissa A. ; Gardner, Timothy J. ; Ascheim, Deborah D. ; Ailawadi, Gorav ; Lackner, Pamela ; Goldsmith, Lyn A. ; Robichaud, Sophie ; Miller, Rachel A. ; Rose, Eric A. ; Ferguson, T. Bruce ; Horvath, Keith A. ; Moquete, Ellen G. ; Parides, Michael K. ; Bagiella, Emilia ; O'Gara, Patrick T. ; Blackstone, Eugene H. / Management practices and major infections after cardiac surgery. In: Journal of the American College of Cardiology. 2014 ; Vol. 64, No. 4. pp. 372-381.
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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 <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).",
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TY - JOUR

T1 - Management practices and major infections after cardiac surgery

AU - Gelijns, Annetine C.

AU - Moskowitz, Alan J.

AU - Acker, Michael A.

AU - Argenziano, Michael

AU - Geller, Nancy L.

AU - Puskas, John D.

AU - Perrault, Louis P.

AU - Smith, Peter K.

AU - Kron, Irving L.

AU - Michler, Robert E.

AU - Miller, Marissa A.

AU - Gardner, Timothy J.

AU - Ascheim, Deborah D.

AU - Ailawadi, Gorav

AU - Lackner, Pamela

AU - Goldsmith, Lyn A.

AU - Robichaud, Sophie

AU - Miller, Rachel A.

AU - Rose, Eric A.

AU - Ferguson, T. Bruce

AU - Horvath, Keith A.

AU - Moquete, Ellen G.

AU - Parides, Michael K.

AU - Bagiella, Emilia

AU - O'Gara, Patrick T.

AU - Blackstone, Eugene H.

PY - 2014/7/29

Y1 - 2014/7/29

N2 - 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 <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).

AB - 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 <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).

KW - cardiac surgery

KW - infection

KW - risk factors

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