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• W2124579381 abstract "I. OverviewProphylactic intravenous antibiotics should be routinely administered to patients undergoing cardiac surgery. Although this is a well-accepted tenet of contemporary practice, the duration during which the antibiotics should be given is far from settled. As one may see from the studies discussed as follows, in the field of cardiac surgery there is wide variation in prophylactic antibiotic duration (PAD) across the United States as well as other countries.In other surgical specialties, there seems to be little debate regarding PAD. However, in cardiac surgery there are several factors that contribute to the divergence of practice patterns: (1) The question of optimum duration has not been adequately explored with identical antibiotic regimens administered to groups differing only in the duration of prophylaxis; (2) surgical-site infections have been low during the years, implying that present practice is effective and need not be changed; and (3) there has been only a vaguely perceived downside to aggressive, prolonged prophylaxis.However today there is mounting evidence of important disadvantages to prolonged prophylaxis. Emerging antibiotic resistance was once regarded as an ill-defined notion that received only passing notice [1Giblin T.B. Sinkowitz-Cochran R.L. Harris P.L. et al.Clinicians’ perceptions of the problem of antimicrobial resistance in health care facilities.Arch Intern Med. 2004; 164: 1662-1668Crossref PubMed Scopus (107) Google Scholar, 2Burke J.P. Antibiotic resistance squeezing the balloon?.JAMA. 1998; 280: 1270-1271Crossref PubMed Scopus (201) Google Scholar]. There is now considerable evidence that this problem is: (1) real, (2) clinically important, and (3) directly linked to the duration of prophylactic antibiotic administration. This fact alone is enough to prompt a reassessment of our practice, but in addition we now face the introduction of quality metrics linked to third party pay for performance initiatives [3Harris J.A. Cebuhar B. … the next step for quality measurement paying for it!.Bulletin Am Coll Surg. 2004; 89: 8-11Google Scholar]. In virtually all of these pay for performance programs, the duration of prophylactic antibiotics will be used as a quality metric. For example, one of the quality measures used in a demonstration project sponsored by the Center for Medicare and Medicaid Services specifies that prophylactic antibiotics in cardiac surgery should be administered for no more than 24 hours.Organization and Scope of the Practice GuidelinesThe principles of antibiotic prophylaxis are based on (1) the choice of the antimicrobial agent; (2) the timing of the first administered dose, and (3) the duration of the prophylactic regimen.The Society of Thoracic Surgeons’ guideline for antibiotic prophylaxis in cardiac surgery will consist of two parts. Because duration is the most controversial of the three principles previously listed, it will be addressed in the first guideline. Part 2 will focus on the choice of antibiotic agent and the timing of the first dose to be used in cardiac surgery.Both guidelines will address the adult cardiac surgery population. In order to concentrate on the most appropriate and reasonably homogeneous population, the following patients are excluded from the analysis: patients with active preoperative infections, those undergoing cardiac transplantation, patients on immunosuppressive therapy, and those having aortic replacement surgery. Because of the paucity of published information regarding prophylaxis in off-pump cardiac surgery, this population will not be included.The guidelines will cover the use of perioperative intravenous antibiotics used in prophylaxis. The use of topical agents such as nasal antimicrobial applications will not be considered. The writing committee fully recognizes the potential impact of mechanical aspects and medical management other than antibiotics, but factors such as glycemic control, use of internal mammary arteries, use of bone wax, and patient preparation techniques are beyond the scope of this guideline.The spectrum of cardiac surgery has changed considerably in the past 2 decades. There is ample evidence that cardiac surgery patients of today are older and generally have higher risk factors with more pronounced comorbid conditions. Because of this well-recognized fact, only very few reports published more than 20 years ago will be used in the analysis.The guidelines will consider surgical-site infections (SSI) as the primary outcome to be examined. Postoperative infectious complications not involving the surgical site, such as pneumonia, bacteremia, or urinary tract infection are not addressed. As seen as described as follows, many reports group both soft-tissue sternal infections and suppurative mediastinitis together as surgical-site infections. The writing committee has made a concerted effort to separate superficial soft-tissue infections from mediastinitis whenever possible.Unique Aspects of Cardiac SurgeryThere is general consensus that postoperative prophylactic antibiotics should be stopped within 24 hours of most major surgical procedures [4American Society of Health-System Pharmacists Commission on TherapeuticsASHP therapeutic guidelines on antimicrobial prophylaxis in surgery.Am J Health Syst Pharm. 1999; 56: 1839-1888PubMed Google Scholar, 5Bratzler D.W. Houck P.M. Antimicrobial prophylaxis for surgery an advisory statement from the National Surgical Infection Prevention Project.Clin Infect Dis. 2004; 38: 1706-1715Crossref PubMed Scopus (768) Google Scholar, 6Gilbert D.N. Moellering R.C. Sande M.A. The Sanford guide to antimicrobial therapy. 33 ed. Antimicrobial Therapy, Inc, Hyde Park, VT2003Google Scholar, 7Mangram A.J. Horan T.C. Pearson M.L. Silver L.C. Jarvis W.R. Hospital Infection Control Practices Advisory CommitteeGuideline for prevention of surgical site infection, 1999.Infect Control Hosp Epidemiol. 1999; 20: 247-280Crossref Scopus (1754) Google Scholar, 8Page C.P. Bohnen J.M.A. Fletcher J.R. McManus A.T. Solomkin J.S. Wittman D.H. Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care.Arch Surg. 1993; 128: 79-88Crossref PubMed Scopus (436) Google Scholar, 9Lafreniere R. Berguer R. Seifert P.C. et al.Preparation of the operating room.in: Wilmore D.W. ACS Surgery principles and practice 2004. WebMD, New York, NY2004: 12-13Google Scholar].However, results of studies on the general surgical population do not directly apply to cardiac surgery. The most obvious reason is the fact that cardiopulmonary bypass is used in cardiac surgery. The pump itself is associated with a broad array of adverse physiologic sequelae that predispose cardiac surgery patients to infectious complications. Cardiopulmonary bypass is known to compromise humoral immunologic defenses, reduce phagocytosis, and activate white blood cells, all of which impair the ability to neutralize infectious organisms. The often-used systemic hypothermia is associated with increased SSI [7Mangram A.J. Horan T.C. Pearson M.L. Silver L.C. Jarvis W.R. Hospital Infection Control Practices Advisory CommitteeGuideline for prevention of surgical site infection, 1999.Infect Control Hosp Epidemiol. 1999; 20: 247-280Crossref Scopus (1754) Google Scholar, 9Lafreniere R. Berguer R. Seifert P.C. et al.Preparation of the operating room.in: Wilmore D.W. ACS Surgery principles and practice 2004. WebMD, New York, NY2004: 12-13Google Scholar, 10Kurz A. Sessler D.I. Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization.N Engl J Med. 1996; 334: 1209-1215Crossref PubMed Scopus (2128) Google Scholar] and the degradation of clotting factors predisposes postoperative bleeding, which is also recognized as a risk factor for postoperative infection [11Meakins J.L. Masterson B.L. Prevention of postoperative infection.in: Wilmore D.W. ACS Surgery principles and practice 2004. WebMD, New York NY2004: 26-35Google Scholar].The length of a surgical procedure is also generally correlated with the risk of postoperative infection [7Mangram A.J. Horan T.C. Pearson M.L. Silver L.C. Jarvis W.R. Hospital Infection Control Practices Advisory CommitteeGuideline for prevention of surgical site infection, 1999.Infect Control Hosp Epidemiol. 1999; 20: 247-280Crossref Scopus (1754) Google Scholar, 12Ariano R. Zhanel G.G. Antimicrobial prophylaxis in coronary bypass surgery a critical appraisal.DICP Ann Pharmacother. 1991; 25: 478-484PubMed Google Scholar]. Cardiac surgical procedures routinely require 3 to 4 hours for completion, thereby placing patients at increased infectious risk. In addition, cardiac surgery patients invariably leave the operating room with indwelling chest catheters that have the potential to serve as external routes for bacterial entry.Probably the most compelling, unique aspect of cardiac surgery is the specter of suppurative mediastinitis. Postoperative mediastinitis carries a very high hospital mortality [13Braxton J.H. Marrin C.A.S. McGrath P.D. et al.10-year follow-up of patients with and without mediastinitis.Sem Thorac Cardiovasc Surg. 2004; 16: 70-76Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar, 14Demmy T.L. Park S.B. Liebler G.A. et al.Recent experience with major sternal wound complications.Ann Thorac Surg. 1990; 49: 458-462Abstract Full Text PDF PubMed Scopus (137) Google Scholar, 15Tang G.H.L. Maganti M. Weisel R.D. Borger M.A. Prevention and management of deep sternal wound infection.Sem Thorac Cardiovasc Surg. 2004; 16: 62-69Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar] and is also associated with reduced long-term survival [13Braxton J.H. Marrin C.A.S. McGrath P.D. et al.10-year follow-up of patients with and without mediastinitis.Sem Thorac Cardiovasc Surg. 2004; 16: 70-76Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar]. This complication invariably involves an additional operation, a prolonged hospitalization, a significant toll in clinical resources, and dramatically increased costs. Anyone who has provided care for a patient with mediastinitis also knows well the emotional cost not only for the patient but also for the family, the nursing staff, and the surgeons. Truly one of the most devastating infections in all of surgery, this dreaded complication influences the perioperative management strategy of virtually all cardiothoracic surgeons.The Central IssueAll surgeons, regardless of specialty, want to minimize the possibility of postoperative infection. Because of the adverse sequelae of the pump and the high cost of mediastinitis, cardiac surgeons rightly consider their patients to be at particularly high risk. It is therefore logical and appropriate to be exceptionally aggressive in minimizing this risk.One approach has been to adopt a policy in which the duration of antibiotic prophylaxis lasts several postoperative days. A common approach involves the use of antibiotics until all chest tubes and central intravenous lines are removed [6Gilbert D.N. Moellering R.C. Sande M.A. The Sanford guide to antimicrobial therapy. 33 ed. Antimicrobial Therapy, Inc, Hyde Park, VT2003Google Scholar, 16Harbarth S. Samore M.H. Lichtenberg D. Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effects on surgical site infections and antimicrobial resistance.Circulation. 2000; 101: 2916-2921Crossref PubMed Scopus (418) Google Scholar, 17Baskett R.J. MacDougall C.E. Ross D.B. Is mediastinitis a preventable complication? A 10-year review.Ann Thorac Surg. 1999; 67: 462-465Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar].The downside to this approach is the fact that prolonged administration of antibiotics carries the certainty of increased cost, the prospect of drug toxicity, and the distinct possibility of creating an environment favorable to the development of resistant bacterial strains. Superinfection, particularly with Clostridium difficile, is associated with prolonged cephalosporin administration [18Scher K.S. Studies on the duration of antibiotic administration for surgical prophylaxis.Am Surg. 1997; 63: 59-62PubMed Google Scholar, 19Kreisel D. Savel T.G. Silver A.L. Cunningham J.D. Surgical antibiotic prophylaxis and Clostridium difficile toxin positivity.Arch Surg. 1995; 130: 989-993Crossref PubMed Scopus (55) Google Scholar] and must also be taken into account. Of these, the issue of bacterial resistance is the most compelling consideration.The central issue then involves the balance between the risk of SSI and the risk of developing resistant bacterial organisms. Several questions must be addressed in order to objectively analyze this central issue: 1Does the duration of antibiotic prophylaxis influence the probability of developing antibiotic-resistant bacteria?2If so, at what postoperative time does this become clinically significant?3Does the duration of antibiotic prophylaxis influence the incidence of SSI?4If so, at what postoperative time does this become clinically significant?II. Antimicrobial ResistanceIn the context of cardiac surgery, antimicrobial resistance essentially refers to the development of cephalosporin-resistant enterobacteriaceae and vancomycin-resistant enterococci [16Harbarth S. Samore M.H. Lichtenberg D. Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effects on surgical site infections and antimicrobial resistance.Circulation. 2000; 101: 2916-2921Crossref PubMed Scopus (418) Google Scholar, 20Harbarth S. Cosgrove S. Carmeli Y. Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci.Antimicrob Agents Chemother. 2002; 46: 1619-1628Crossref PubMed Scopus (138) Google Scholar]. The threat of resistant staphylococci is related to vancomycin-resistant enterococci and may be associated with significant infectious complications [20Harbarth S. Cosgrove S. Carmeli Y. Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci.Antimicrob Agents Chemother. 2002; 46: 1619-1628Crossref PubMed Scopus (138) Google Scholar].In the last 2 decades, the incidence of antimicrobial-resistant organisms has increased considerably [20Harbarth S. Cosgrove S. Carmeli Y. Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci.Antimicrob Agents Chemother. 2002; 46: 1619-1628Crossref PubMed Scopus (138) Google Scholar, 21Kollef M.H. Fraser V.J. Antibiotic resistance in the intensive care unit.Ann Int Med. 2001; 134: 298-314Crossref PubMed Scopus (379) Google Scholar]. The Centers for Disease Control and Prevention reports that intensive care unit vancomycin-resistant enterococci has increased in the United States from 0.3% in 1989 to greater than 25% in 1999 [2Burke J.P. Antibiotic resistance squeezing the balloon?.JAMA. 1998; 280: 1270-1271Crossref PubMed Scopus (201) Google Scholar, 22Centers for Disease Control and PreventionNational nosocomial infection surveillance (NNIS) system report, data summary from January 1992-April 2000.Am J Infect Control. 2000; 28: 429-448Abstract Full Text Full Text PDF PubMed Scopus (244) Google Scholar]. Although several factors, including patient age [20Harbarth S. Cosgrove S. Carmeli Y. Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci.Antimicrob Agents Chemother. 2002; 46: 1619-1628Crossref PubMed Scopus (138) Google Scholar], may play a role in the development of antimicrobial resistance, there is universal agreement that excessive antibiotic usage is one of the most important causes [8Page C.P. Bohnen J.M.A. Fletcher J.R. McManus A.T. Solomkin J.S. Wittman D.H. Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care.Arch Surg. 1993; 128: 79-88Crossref PubMed Scopus (436) Google Scholar, 16Harbarth S. Samore M.H. Lichtenberg D. Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effects on surgical site infections and antimicrobial resistance.Circulation. 2000; 101: 2916-2921Crossref PubMed Scopus (418) Google Scholar, 20Harbarth S. Cosgrove S. Carmeli Y. Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci.Antimicrob Agents Chemother. 2002; 46: 1619-1628Crossref PubMed Scopus (138) Google Scholar, 21Kollef M.H. Fraser V.J. Antibiotic resistance in the intensive care unit.Ann Int Med. 2001; 134: 298-314Crossref PubMed Scopus (379) Google Scholar, 23Carrier M. Marchand R. Auger P. et al.Methicillin-resistant Staphylococcus aureus infection in a cardiac surgical unit.J Thorac Cardiovasc Surg. 2002; 123: 40-44Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 24Ehrenkranz N.J. Antimicrobial prophylaxis in surgery mechanisms, misconceptions, and mischief.Infect Control Hosp Epidemiol. 1993; 14: 99-106Crossref PubMed Scopus (45) Google Scholar, 25Murray B.E. Vancomycin-resistant enterococcal infections.N Engl J Med. 2000; 342: 710-721Crossref PubMed Scopus (725) Google Scholar, 26Terpstra S. Noordhoek G.T. Voesten H.G. et al.Rapid emergence of resistant coagulase-negative staphylococci in the skin after antibiotic prophylaxis.J Hosp Infect. 1999; 43: 195-202Abstract Full Text PDF PubMed Scopus (64) Google Scholar].The clinical sequelae of resistant organisms are quite serious. Patients infected with antibiotic-resistant bacteria experience higher mortality, prolonged hospitalization, and increased health care costs compared with those infected with nonresistant organisms [21Kollef M.H. Fraser V.J. Antibiotic resistance in the intensive care unit.Ann Int Med. 2001; 134: 298-314Crossref PubMed Scopus (379) Google Scholar, 27Goldmann D.A. Weinstein R.A. Wenzel R.P. et al.Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals. A challenge to hospital leadership.JAMA. 1996; 275: 234-240Crossref PubMed Google Scholar]. In spite of the documented increase in antibiotic resistance and the recognition of clinical consequences, there is a distinct tendency to consider the problem to be only a minor inconvenience [1Giblin T.B. Sinkowitz-Cochran R.L. Harris P.L. et al.Clinicians’ perceptions of the problem of antimicrobial resistance in health care facilities.Arch Intern Med. 2004; 164: 1662-1668Crossref PubMed Scopus (107) Google Scholar, 2Burke J.P. Antibiotic resistance squeezing the balloon?.JAMA. 1998; 280: 1270-1271Crossref PubMed Scopus (201) Google Scholar]. Further evidence for this lies in the fact that a literature search of the two major United States cardiothoracic surgery journals failed to find any articles addressing antibiotic resistance in the last 2 decades.It is clear that antibiotic resistance is a progressive problem with serious clinical implications. It is less clear that the problem is directly linked to prolonged use of prophylactic antibiotics in cardiac surgery. Harbarth and colleagues [16Harbarth S. Samore M.H. Lichtenberg D. Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effects on surgical site infections and antimicrobial resistance.Circulation. 2000; 101: 2916-2921Crossref PubMed Scopus (418) Google Scholar] specifically explored this relationship in an observational study of 2,641 patients undergoing coronary artery bypass grafting (CABG). His group found that antibiotic prophylaxis for more than 48 hours increased antimicrobial resistance. Specifically, patients receiving greater than 48 hours of antibiotics had a 1.6 times higher probability of harboring resistant organisms compared with those having a regimen of less than 48 hours. The criteria for selecting which patients to undergo culture were not mentioned. Only 41% of patients were cultured, and the site from which the culture was taken was not specified.Several general studies have suggested some correlation between the prolonged use of postoperative antimicrobial prophylaxis and the development of resistance [24Ehrenkranz N.J. Antimicrobial prophylaxis in surgery mechanisms, misconceptions, and mischief.Infect Control Hosp Epidemiol. 1993; 14: 99-106Crossref PubMed Scopus (45) Google Scholar, 26Terpstra S. Noordhoek G.T. Voesten H.G. et al.Rapid emergence of resistant coagulase-negative staphylococci in the skin after antibiotic prophylaxis.J Hosp Infect. 1999; 43: 195-202Abstract Full Text PDF PubMed Scopus (64) Google Scholar, 28Archer G.L. Armstrong B.C. Alteration of staphloccal flora in cardiac surgery patients receiving antibiotic prophylaxis.J Infect Dis. 1983; 147: 642-649Crossref PubMed Scopus (116) Google Scholar]. Unfortunately these reports are not controlled for specific postoperative time and there is a wide variation in the antibiotics used. Nevertheless there is universal agreement that the longer the duration of an antibiotic regimen, the greater the probability of developing resistant microorganisms [2Burke J.P. Antibiotic resistance squeezing the balloon?.JAMA. 1998; 280: 1270-1271Crossref PubMed Scopus (201) Google Scholar, 9Lafreniere R. Berguer R. Seifert P.C. et al.Preparation of the operating room.in: Wilmore D.W. ACS Surgery principles and practice 2004. WebMD, New York, NY2004: 12-13Google Scholar, 11Meakins J.L. Masterson B.L. Prevention of postoperative infection.in: Wilmore D.W. ACS Surgery principles and practice 2004. WebMD, New York NY2004: 26-35Google Scholar, 12Ariano R. Zhanel G.G. Antimicrobial prophylaxis in coronary bypass surgery a critical appraisal.DICP Ann Pharmacother. 1991; 25: 478-484PubMed Google Scholar, 16Harbarth S. Samore M.H. Lichtenberg D. Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effects on surgical site infections and antimicrobial resistance.Circulation. 2000; 101: 2916-2921Crossref PubMed Scopus (418) Google Scholar, 20Harbarth S. Cosgrove S. Carmeli Y. Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci.Antimicrob Agents Chemother. 2002; 46: 1619-1628Crossref PubMed Scopus (138) Google Scholar, 23Carrier M. Marchand R. Auger P. et al.Methicillin-resistant Staphylococcus aureus infection in a cardiac surgical unit.J Thorac Cardiovasc Surg. 2002; 123: 40-44Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 24Ehrenkranz N.J. Antimicrobial prophylaxis in surgery mechanisms, misconceptions, and mischief.Infect Control Hosp Epidemiol. 1993; 14: 99-106Crossref PubMed Scopus (45) Google Scholar, 25Murray B.E. Vancomycin-resistant enterococcal infections.N Engl J Med. 2000; 342: 710-721Crossref PubMed Scopus (725) Google Scholar, 26Terpstra S. Noordhoek G.T. Voesten H.G. et al.Rapid emergence of resistant coagulase-negative staphylococci in the skin after antibiotic prophylaxis.J Hosp Infect. 1999; 43: 195-202Abstract Full Text PDF PubMed Scopus (64) Google Scholar, 28Archer G.L. Armstrong B.C. Alteration of staphloccal flora in cardiac surgery patients receiving antibiotic prophylaxis.J Infect Dis. 1983; 147: 642-649Crossref PubMed Scopus (116) Google Scholar].The implications for cardiac surgery are not straightforward. Other than the Harbarth and colleagues study [16Harbarth S. Samore M.H. Lichtenberg D. Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effects on surgical site infections and antimicrobial resistance.Circulation. 2000; 101: 2916-2921Crossref PubMed Scopus (418) Google Scholar], there is no evidence directly linking duration of prophylactic antibiotics in cardiac surgery to antibiotic resistance. There is no scientific evidence that prophylactic antibiotics used for less than 48 hours after cardiac surgery are associated with the development of antibiotic resistance. We believe that there are no studies specifically addressing the issue of resistance in the first 24 hours after cardiac surgery.However, the fact that the issue has not been specifically studied is not a license to disregard the problem. The position of cardiac surgeons seems to be precisely stated in a well-respected surgical text endorsed by the American College of Surgeons [11Meakins J.L. Masterson B.L. Prevention of postoperative infection.in: Wilmore D.W. ACS Surgery principles and practice 2004. WebMD, New York NY2004: 26-35Google Scholar]: “Complications of antibiotic prophylaxis are few. Although data linking prophylaxis to the development of resistant organisms are meager, resistant microbes have been developed in every other situation in which antibiotics are utilized, and it is reasonable to expect that prophylaxis in any ecosystem will have the same result, particularly if selection of patients is poor, if prophylaxis lasts too long, or if too many late-generation agents are used.”ConclusionThe duration of a prophylactic antibiotic regimen is directly related to the probability of developing resistant microorganisms.Optimal practiceThe duration of a prophylactic antibiotic regimen is limited to the shortest amount of time required to effectively minimize the probability of postoperative infection (class IIa, level B).III. Surgical Site InfectionRecent studies show that the incidence of deep sternal infections associated with cardiac surgery ranges between 0.25% and 4% [13Braxton J.H. Marrin C.A.S. McGrath P.D. et al.10-year follow-up of patients with and without mediastinitis.Sem Thorac Cardiovasc Surg. 2004; 16: 70-76Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar, 17Baskett R.J. MacDougall C.E. Ross D.B. Is mediastinitis a preventable complication? A 10-year review.Ann Thorac Surg. 1999; 67: 462-465Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 29Abboud S.C. Wey S.B. Baltar V.T. Risk factors for mediastinitis after cardiac surgery.Ann Thorac Surg. 2002; 77: 676-683Abstract Full Text Full Text PDF Scopus (158) Google Scholar, 30Crabtree T.D. Codd J.E. Fraser V.J. Bailey M.S. Olsen M.A. Damiano R.J. Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center.Sem Thorac Cardiovasc Surg. 2004; 16: 53-61Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 31Society of Thoracic SurgeonsSTS NCD Executive Summary.Spring. 2003Google Scholar]. The Society of Thoracic Surgeons National Cardiac Surgery Database reported an incidence of 0.4% in 2002 [31Society of Thoracic SurgeonsSTS NCD Executive Summary.Spring. 2003Google Scholar]. Superficial sternal wound infections are seen in approximately 2% to 6% of patients after cardiac surgery [30Crabtree T.D. Codd J.E. Fraser V.J. Bailey M.S. Olsen M.A. Damiano R.J. Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center.Sem Thorac Cardiovasc Surg. 2004; 16: 53-61Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 31Society of Thoracic SurgeonsSTS NCD Executive Summary.Spring. 2003Google Scholar, 32Olsen M.A. Lock-Buckley P. Hopkins D. Polish L.B. Sundt T.M. Fraser V.J. The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different.J Thorac Cardiovasc Surg. 2002; 124: 136-145Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 33Ridderstolpe L. Gill H. Granfeldt H. et al.Superficial and deep sternal wound complications incidence, risk factors, and mortality.Eur J Cardiothorac Surg. 2001; 20: 1168-1175Crossref PubMed Scopus (349) Google Scholar]. It should be emphasized that even superficial infections are associated with prolonged patient care, increased costs, and reduced patient satisfaction [30Crabtree T.D. Codd J.E. Fraser V.J. Bailey M.S. Olsen M.A. Damiano R.J. Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center.Sem Thorac Cardiovasc Surg. 2004; 16: 53-61Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar].The devastating sequelae of mediastinitis are well recognized by all cardiothoracic surgeons. The in-hospital mortality associated with mediastinitis ranges from 7% to 20% [5Bratzler D.W. Houck P.M. Antimicrobial prophylaxis for surgery an advisory statement from the National Surgical Infection Prevention Project.Clin Infect Dis. 2004; 38: 1706-1715Crossref PubMed Scopus (768) Google Scholar, 14Demmy T.L. Park S.B. Liebler G.A. et al.Recent experience with major sternal wound complications.Ann Thorac Surg. 1990; 49: 458-462Abstract Full Text PDF PubMed Scopus (137) Google Scholar, 15Tang G.H.L. Maganti M. Weisel R.D. Borger M.A. Prevention and management of deep sternal wound infection.Sem Thorac Cardiovasc Surg. 2004; 16: 62-69Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar], and the mortality in patients with superficial sternotomy infections may be in excess of 5% [30Crabtree T.D. Codd J.E. Fraser V.J. Bailey M.S. Olsen M.A. Damiano R.J. Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center.Sem Thorac Cardiovasc Surg. 2004; 16: 53-61Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. In addition to the high hospital mortality from mediastinitis, there is a residual increase in long-term mortality in those having had mediastinitis [5Bratzler D.W. Houck P.M. Antimicrobial prophylaxis for surgery an advisory statement from the National Surgical Infection Prevention Project.Clin Infect Dis. 2004; 38: 1706-1715Crossref PubMed Scopus (768) Google Scholar, 32Olsen M.A. Lock-Buckley P. Hopkins D. Polish L.B. Sundt T.M. Fraser V.J. The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different.J Thorac Cardiovasc Surg. 2002; 124: 136-145Abstract Full Text Full Text PDF PubMed Sco" @default.
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• W2124579381 title "The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part I: Duration" @default.
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