According to the Robert Koch Institute, the anticipated SSI rate varies depending on the type of operation that the patient has undergone, the contamination class of the operation, patient-related risks, operation-specific risks, as well as on other factors.1
Studies suggest that in cardiac surgery, both gender and a history of diabetes mellitus are significant patient-related risk factors for SSI, the latter particularly for coronary artery bypass graft (CABG) procedures2. In addition, surgical conditions such as opening doors1 during surgery and the choice of sternal closure technique4 for median sternotomies, also have an effect on the risk of SSI during cardiac surgery.
Abuzaid AA et al. 20152: Patients with comorbidities (impaired renal function or reduced left ventricular systolic function) are at higher risk of SSI after coronary artery bypass grafting.
Chello C et al. 20204: Deep sternal wound infections (DSWI = deep sternal wound infection) and mediastinitis after median sternotomies are still significant clinical complications after cardiac surgery. Their incidence is between 1% and 5%, and the corresponding mortality is between 20% and 50%. The choice of sternal closure technique plays a crucial role in the prevention of DSWI. Early aggressive surgical debridement, negative pressure therapy, muscle flaps, and newer technologies are transforming the paradigm of DSWI treatment.
Aghdassi SJS et al. 20195: Overall, the SSI rates are higher for male patients. For cardiac and vascular surgery, however, the SSI rates were significantly higher for female patients.
Roth JA et al. 20196: Opening the door in the operating room may be a risk factor for SSI. The frequency of door openings from incision to skin closure was recorded during cardiac surgery. The analysis revealed that more frequent door openings during cardiac surgery were associated with a higher risk of SSI.
Martin ET at al. 20167: A meta-analysis showed that patients who have diabetes mellitus were at a higher risk of SSI than those who do not. The odds ratio [OR] for cardiac surgery was 2.03 (by comparison, the OR for colorectal surgery was 1.16).
Hassoun-Kheir N et al. 20188: The study identified the risk factors for lower extremity wound infections following a CABG procedure that utilises the great saphenous vein, and assessed the implications for the patient: 10.3% of patients developed an SSI at the harvest site. In 69.4% of patients, an SSI was only detected after discharge.
Preventive measures taken pre-, intra- and postoperatively can significantly reduce SSI rates. Al Salmi et al. were able to clearly demonstrate this in CABG patients. Using appropriate preventive measures, the SSI rate was successfully reduced from 10.25% to 3.36%. As an example, implementation of preoperative chlorhexidine gluconate (CHG) showers reduced the SSI rate from 13.56% in the control group to just 1.69%.9
The WHO recommends, among other things: Cardiac surgery patients with known Staphylococcus aureus colonization should receive 2% mupirocin ointment intranasally perioperatively, with or without combination with chlorhexidine body washes (strong recommendation, moderate quality of evidence).10
When we hear the term cardiac surgery, we immediately think of major procedures such as bypass operations or heart transplants, and prolonged hospital stays. However, there are also numerous cardiac procedures that can be performed on an outpatient basis12:
According to the recommendations by the Robert Koch Institute for the prevention of SSI, it is irrelevant whether an operation is performed on an outpatient or inpatient basis (i.e. involving a 24-hour stay or not) when assessing the risk of SSI1.
An American study came to a similar conclusion in certain aspects, showing that the SSI rates for outpatient procedures were comparable to or higher than the rates observed in hospitalised patients. For pacemakers, the rate was 0.4% in each case.13
1) Prävention postoperativer Wundinfektionen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl. 2018;61:448–473.
2) Abuzaid AA et al. Potential Risk Factors for Surgical Site Infection after Isolated Coronary Artery Bypass Grafting in a Bahrain Cardiac Centre: A Retrospective, Case-Controlled Study. Heart Views. 2015;16(3):79–84.
3) Gesundheitsberichterstattung des Bundes – gemeinsam getragen von RKI und DESTATIS. Operationen und Prozeduren der vollstationären Patientinnen und Patienten in Krankenhäusern. http://www.gbe-bund.de/oowa921-install/servlet/oowa/aw92/WS0100/_XWD_PROC?_XWD_2/1/XWD_CUBE.DRILL/_XWD_30/D.390/43135 (Last Access: December 2024).
4) Chello C et al. Deep Sternal Wound Infection (DSWI) and Mediastinitis After Cardiac Surgery: Current Approaches and Future Trends in Prevention and Management. Surg Technol Int. 2020;36:212–216.
5) Aghdassi SJS et al. Gender-related risk factors for surgical site infections. Results from 10 years of surveillance in Germany. Antimicrob Resist Infect Control. 2019;8:95.
6) Roth JA et al. Frequent Door Openings During Cardiac Surgery Are Associated With Increased Risk for Surgical Site Infection: A Prospective Observational Study. Clin Infect Dis. 2019;69(2):290–294.
7) Martin ET at al. Diabetes and Risk of Surgical Site Infection: A systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2016;37(1):88–99.
8) Hassoun-Kheir N et al. Risk factors for limb surgical site infection following coronary artery bypass graft using open great saphenous vein harvesting: a retrospective cohort study. Interact Cardiovasc Thorac Surg. 2018;27(4):530–535.
9) Al Salmi H et al. Implementation of an evidencebased practice to decrease surgical site infection after coronary artery bypass grafting. J Int Med Res. 2019;47(8):3491–3501.
10) World Health Organization (WHO) (2018). Global guidelines on the prevention of surgical site infection. Geneva, WHO Document Production Services. https://www.who.int/publications/i/ item/9789241550475 (Last Access: December 2024).
12) Bundesverband ambulantes Operieren e. V. https://www.operieren.de/e3224/e10/e6846/. (Last Access: December 2024).
13) Rhee C et al. Surgical Site Infection Surveillance Following Ambulatory Surgery. Infect Control Hosp Epidemiol. 2015;36(2):225–228.
