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J Am Coll Cardiol. 2014 Jul 29;64(4):372-81. doi: 10.1016/j.jacc.2014.04.052.

Management practices and major infections after cardiac surgery.

Author information

  • 1International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York. Electronic address: annetine.gelijns@mssm.edu.
  • 2International Center for Health Outcomes and Innovation Research (InCHOIR) in the Department of Health Evidence and Policy, Ichan School of Medicine at Mount Sinai, New York, New York.
  • 3Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
  • 4Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York.
  • 5Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
  • 6Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
  • 7Montréal Heart Institute, University of Montréal, Montréal, Québec, Canada.
  • 8Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
  • 9Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Virginia.
  • 10Department of Cardiothoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York.
  • 11Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
  • 12Center for Heart & Vascular Health, Christiana Care Health System, Newark, Delaware.
  • 13Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
  • 14Department of Medicine, Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa.
  • 15Department of Cardiovascular Sciences; East Carolina Heart Institute at East Carolina University, Greenville, North Carolina.
  • 16NIH Heart Center at Suburban Hospital, Bethesda, Maryland.
  • 17Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.



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.


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.


This study enrolled 5,158 patients and analyzed independently adjudicated infections using a competing risk model (with death as the competing event).


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).


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).

Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.


cardiac surgery; infection; risk factors

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