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

Infections post-cardiac surgery: new information during challenging times.

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