JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 64, NO. 4, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2014.04.050
EDITORIAL COMMENT
Infections Post-Cardiac Surgery New Information During Challenging Times* Olaf Wendler, MD, PHD, Max Baghai, PHD
S
urgical site infections (SSIs) are one of the most
create benchmarks and to identify areas of care,
challenging complications of surgery, for pa-
which could benefit from further improvements.
tients and surgeons alike. For that reason, it
In numerous countries, including the United States
is interesting to note that in this recent experience, re-
and United Kingdom, we are entering an interesting
ported by Gelijns et al. (1) in this issue of the Journal,
next phase in that, outcomes after cardiac surgery—
of more than 5,000 patients who underwent various
which include immediate and mid-term follow-up—
cardiac surgeries including cardiac transplantation,
will be directly correlated to reimbursement. In the
SSIs played only a minor role (1). The majority of
United Kingdom, this is known as “Payment by Results” (PbR). In the United States, the Centers of
SEE PAGE 372
Medicare and Medicaid Services (CMS) decided to withhold reimbursement for care relating to post-
infections observed were pneumonia, bloodstream in-
operative complications including SSIs, mediastinitis
fections, and C. difficile colitis, which accounted for
after coronary artery bypass grafting, urinary tract
79% of all major post-operative infections. Although
infections, and intravenous catheter-associated in-
we should not underestimate the importance of SSIs,
fections. For this reason alone, it is vital to know
the continued improvements in care delivery in
more about the incidence and associated risk factors
recent years have had a significant impact on patients
for certain complications in a normal cohort of pa-
undergoing cardiac surgery.
tients undergoing cardiac surgery today. The findings
Historically, institutions and surgeons assessed
by Gelijns et al. (1) will hopefully influence healthcare
and reported only on their individual outcomes to
providers when building new policies. Previous
improve their practice, as well as to reassure them-
reports generally focused more on specific types of
selves and their patients about their quality of care.
surgical procedures and reported on in-hospital or
Over the last 20 years, cardiothoracic societies have
30-day results. Gelijns et al. (1) provide vital infor-
been on the forefront to collect national data on car-
mation on a diverse cohort of patients undergoing
diac surgery and its outcomes. Now, these data are
cardiac surgery and include not only early but also
available in the public domain. For that purpose,
mid-term outcomes up to 65 days after surgery. This
national societies such as the Society of Thoracic
astute approach has led to the finding that 45% of all
Surgeons and the Society for Cardiothoracic Surgery
post-operative infections occur after discharge. While
have developed databases in which surgical outcomes
this is important for the patients’ recovery, it also has
of their members are collected in standardized
significant economic implications as it leads to read-
fashion, with the aim of covering the national activity
missions and delayed rehabilitation of patients.
for their specialty. These data have been used to
When it comes to reimbursement and penalties of complications, it is of tremendous importance to distinguish between post-operative complications as
* Editorials published in the Journal of the American College of Cardiology
a result of individual patient or surgical characteris-
reflect the views of the authors and do not necessarily represent the
tics and those due to quality of care. In this in-
views of JACC or the American College of Cardiology. From the Department of Cardiothoracic Surgery, King’s College Hospital/ King’s Health Partners, London, England. Both authors have reported
vestigation, the authors identify baseline patient demographics such as chronic lung disease, heart
that they have no relationships relevant to the contents of this paper to
failure, and elevated creatinine as predictors of
disclose.
post-operative infections, while previously known
Wendler and Baghai
JACC VOL. 64, NO. 4, 2014 JULY 29, 2014:382–4
Infections Post-Cardiac Surgery
characteristics such as obesity, diabetes, and urgent
What is not documented in this paper are data on
surgery did not play a role. Given that surgeons and
how patients were screened for their infectious status
institutions cannot influence the risk profile of indi-
prior to admission. This is of even more importance as
vidual patients, healthcare providers should not
the number of patients colonized with multiresistant
scrutinize treatment of these individuals by the same
microorganisms, such as MRSA, is steadily increasing.
financial penalties introduced for patients without a
Therefore, pre-admission nasal and skin swabs
high-risk profile for cardiac surgery.
should be a routine, standardized screening protocol
Alternatively, healthcare providers can expect a
for urgent or in-hospital patients. In this respect, it
high standard of care, which is known to reduce
may be interesting that nasal decontamination in this
complications such as infections. The authors provide
investigation did not have a positive effect on the
important information on which medical practices
incidence of infections, in contrast to a previously
reduce infectious complications after cardiac surgery.
published randomized trial (3). It does, however, raise
Perioperative prophylaxis using second-generation
the question of whether this is only due to the fact
cephalosporins proved to be of prophylactic value in
that most patients treated did not present with
North America, but it should not be given for more
pathological nasal contamination and these results
than 48 h after surgery. In addition, post-operative
may have been different if treatment was selected
hyperglycemia is identified as a significant risk fac-
only for patients with pathological colonization.
tor for infections. While it is well known that post-
There are 2 findings in this investigation, which
operative normoglycemia improves patient outcome
should further encourage us to review current stan-
(2), it raises the question why diabetes mellitus was
dards of care. While the duration of mechanical
not a risk factor. It would be interesting to see if the
ventilation is well known to have a negative effect on
subgroup of diabetic mellitus patients who are insulin
post-operative infections, blood transfusions have
dependent were found to be at higher risk for post-
been more recently identified as independent pre-
operative infections. However, these findings may
dictors of negative outcome after surgery (4). Given
support the CMS decision to introduce performance
that an intubation time of 24 to 48 h and mechanical
measures such as choice and timing of antibiotics,
ventilation of more than 48 h increases the risk of
control of early post-operative blood glucose level,
infections, it is of even more importance to have
and appropriate surgical site hair removal into their
treatment protocols and close collaboration between
reimbursement scheme.
surgeons and anesthesiologists in place, which enable
When it comes to quality of care and surgery
early extubation post-surgery. In our own institution,
itself, it is important to notice that “prolonged sur-
post-operative ventilation time for all comers of car-
gery” in this report predicted infective complica-
diac surgery has been continuously reduced over
tions, which aligns with previous studies. While
recent years to a mean of 12 h, with 85% of patients
surgery can be unavoidably prolonged due to the
extubated