Perioperative Management
Association of adherence to individual components of Society of Thoracic Surgeons cardiac surgery antibiotic guidelines and postoperative infections

https://doi.org/10.1016/j.jtcvs.2023.03.031Get rights and content

Abstract

Objectives

The study objectives were to measure the association among the 4 components of Society of Thoracic Surgeons antibiotic guidelines and postoperative complications in a cohort of patients undergoing valve or coronary artery bypass grafting requiring cardiopulmonary bypass.

Methods

In this retrospective observational study, adult patients undergoing coronary revascularization or valvular surgery who received a Surgical Care Improvement Project–compliant antibiotic from January 1, 2016, to April 1, 2021, at a single, tertiary care hospital were included. The primary exposures were adherence to the 4 individual components of Society of Thoracic Surgeons antibiotic best practice guidelines. The association of each component and a combined metric was tested in its association with the primary outcome of postoperative infection as determined by Society of Thoracic Surgeons data abstractors, controlling for several known confounders.

Results

Of the 2829 included patients, 1084 (38.3%) received care that was nonadherent to at least 1 aspect of Society of Thoracic Surgeons antibiotic guidelines. The incidence of nonadherence to the 4 individual components was 223 (7.9%) for timing of first dose, 639 (22.6%) for antibiotic choice, 164 (5.8%) for weight-based dose adjustment, and 192 (6.8%) for intraoperative redosing. In adjusted analyses, failure to adhere to first dose timing guidelines was directly associated with Society of Thoracic Surgeons–adjudicated postoperative infection (odds ratio, 1.9; 95% confidence interval, 1.1-3.3; P = .02). Failure of weight-adjusted dosing was associated with both postoperative sepsis (odds ratio, 6.9; 95% confidence interval, 2.5-8.5; P < .01) and 30-day mortality (odds ratio, 4.3; 95% confidence interval, 1.7-11.4; P < .01). No other significant associations among the 4 Society of Thoracic Surgeons metrics individually or as a combination were observed with postoperative infection, sepsis, or 30-day mortality.

Conclusions

Nonadherence to Society of Thoracic Surgeons antibiotic best practices is common. Failure of antibiotic timing and weight-adjusted dosing is associated with odds of postoperative infection, sepsis, and mortality after cardiac surgery.

Section snippets

Data Source and Study Population

In this retrospective single-center observational study, after Institutional Review Board approval (protocol #2000030764. Date of approval: September 2, 2021), patients who underwent cardiopulmonary bypass for CABG or valve repair or replacement at the Yale-New Haven Health System from January 1, 2016, to April 1, 2021, were included for analysis. The protocol was deemed exempt from the requirement of informed consent. Given the key hypothesis was to assess whether the components of a more

Baseline Characteristics

The study cohort comprised 2829 patients, with a mean (SD) age of 66.1 (11.5) years, and 881 (31.1%) were female. A total of 1085 patients (38.3%) received STS nonadherent antibiotics. In univariate analyses, men received significantly higher STS concordant antibiotic prophylaxis than women (1289 [66.2%] vs 455 [51.6%], (P < .01)). The mean age (± SD) was similar in the 2 groups: 66.2 (10.7) and 65.9 (12.7) years, respectively. Patients who received STS nonadherent antibiotic care had a higher

Discussion

Our results demonstrate that both STS guideline nonadherence and postoperative infections/sepsis after cardiac surgeries are common, with the latter complicating approximately 7.5% of cardiac surgeries in our dataset. Noncompliance with the 4 aspects of STS antibiotic guidelines appeared to have differential associations with our outcomes of interest, with antibiotic timing nonadherence associated with postoperative infection, and weight-adjusted dosing nonadherence associated with sepsis and

Conclusions

The findings of our study suggest that adherence to STS metrics of timing and weight-adjusted dosing may have incremental benefits in reducing infections, postoperative sepsis, and 30-day mortality after cardiac surgery. However, our observational findings are hypothesis generating and do not confer causation. In this context, our results point to the need of future larger studies to understand barriers to guideline adherence and to better understand which aspects of antibiotic administration

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    The work on this study was supported in part by grant T32GM086287 from the National Institute of General Medical Sciences (NIGMS) and by grant R01HS029172 from the Agency for Healthcare Research and Quality (AHRQ). The opinions expressed are those of the authors and do not necessarily represent the thoughts or opinions of NIGMS, National Institutes of Health, AHRQ, or the United States government.

    Institutional Review Board Approval: This work was performed with prior approval of the Yale Human Investigations Committee; protocol #2000030764. Date of approval: September 2, 2021. The protocol was deemed exempt from the requirement of informed consent.

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