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(Chest. 2005;127:464-471.)
© 2005 American College of Chest Physicians

The Impact of Deep Sternal Wound Infection on Long-term Survival After Coronary Artery Bypass Grafting*

Ioannis K. Toumpoulis, MD; Constantine E. Anagnostopoulos, MD; Joseph J. DeRose, Jr, MD and Daniel G. Swistel, MD

* From the College of Physicians and Surgeons of Columbia University (Drs. Toumpoulis, DeRose, and Swistel), Department of Cardiac Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY; and Department of Cardiac Surgery (Dr. Anagnostopoulos), University of Athens School of Medicine, Attikon Hospital Center, Athens, Greece.

Correspondence to: Constantine E. Anagnostopoulos, MD, St. Luke’s-Roosevelt Hospital Center at Columbia University, 45 East Eighty-Ninth St, New York, NY 10128; e-mail: cea8{at}columbia.edu


   Abstract
TOP
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 Conclusions
 References
 
Objectives: To identify the impact of deep sternal wound infection (DSWI) on long-term survival after coronary artery bypass grafting (CABG).

Background: DSWI following CABG is an infrequent, yet devastating complication with increased morbidity and mortality. However, little has been published regarding the impact of DSWI on long-term mortality.

Methods: We studied 3,760 consecutive patients who underwent isolated CABG between 1992 and 2002. Patients with CABG and no DSWI were compared with those in whom DSWI developed. Long-term survival data (mean follow-up, 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for DSWI was determined by logistic regression analysis, and each patient with DSWI was then matched to 10 patients without DSWI.

Results: DSWI developed in 40 of 3,760 patients (1.1%). Independent predictors for DSWI were diabetes (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.7 to 11.6; p < 0.001), hemodynamic instability preoperatively (OR, 4.0; 95% CI, 1.2 to 13.9; p = 0.026), preoperative renal failure on dialysis (OR, 3.4; 95% CI, 1.0 to 13.6; p = 0.049), use of bilateral internal thoracic arteries (OR, 2.6; 95% CI, 1.3 to 5.3; p = 0.010), and sepsis and/or endocarditis after CABG (OR, 29.9; 95% CI, 11.7 to 76.4; p < 0.001). Patients with DSWI had prolonged length of stay (35.0 days vs 16.4 days; p < 0.001); however, there was no difference in early mortality between matched groups. After adjustment for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 2.44 (95% CI, 1.51 to 3.92; p < 0.001). Patients without DSWI had a better 5-year survival rate (72.8 ± 2.4% vs 50.8.6 ± 8.5% [mean ± SE]; p = 0.0007 between matched groups).

Conclusions: We found that DSWI following CABG was associated with increased long-term mortality during a 10-year follow-up study.

Key Words: coronary artery bypass grafting • deep sternal wound infection • long-term mortality • risk factors


   Introduction
TOP
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 Conclusions
 References
 
Deep sternal wound infection (DSWI) is an infrequent, yet potentially devastating complication following coronary artery bypass grafting (CABG). This complication is associated with increased cost of care, prolonged hospitalization, and increased morbidity and mortality.12 The reported incidence of DSWI ranges between 1% and 3%,345 and the reported in-hospital mortality can be as high as 20%.678 The exact mechanism by which DSWI develops is not fully understood and is thought to be multifactorial. However, many risk factors have been identified as independent predictors for DSWI following CABG, which include preoperative (eg, obesity, diabetes mellitus, COPD, reoperation, connective tissue disease, steroids use, smoking, peripheral vascular disease [PVD], renal insufficiency, male sex), intraoperative (eg, use of bilateral internal thoracic arteries [BITA], antibiotic prophylaxis, operation time), and postoperative variables (eg, prolonged mechanical ventilation, reexploration for bleeding, postoperative transfusions, and nephrologic and pulmonary complications).12391011121314

The impact of DSWI on long-term survival has been poorly investigated, and little has been published in the literature. The primary purpose of this study was to determine the impact of DSWI on long-term survival after CABG even after successful treatment and discharge from the hospital. We utilized long-term follow-up data of 3,760 consecutive patients with isolated CABG from 1992 through 2002. We also reported early outcome after the development of DSWI, and we examined the patient and disease characteristics associated with DSWI following CABG.


   Patients and Methods
TOP
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 Conclusions
 References
 
Patient Population and Data Collection
A total of 3,760 consecutive patients who underwent isolated CABG at St. Luke’s-Roosevelt Hospital Center, a university hospital of Columbia University, from January 1992 to March 2002 were included in these analyses. Data were prospectively collected during hospital admission as part of routine clinical practice and entered into the New York State adult cardiac surgery report for the following variables: age, sex, ethnicity, race, body mass index (BMI), number of arteries diseased, urgency of operation, prior cardiac surgery, Canadian Cardiovascular Society angina class, history of myocardial infarction, smoking, diabetes mellitus, hypertension, PVD, COPD, neurologic dysfunction, renal dysfunction, previous percutaneous coronary intervention, current or past congestive heart failure, preoperative intra-aortic balloon pump support, and left ventricular ejection fraction. Procedural data were also collected on the use of cardiopulmonary bypass, use of the microscope for construction of the distal anastomoses, the number and type of grafts used, as well as the number of distal anastomoses. Postoperative data collected included 30-day mortality, in-hospital mortality, postoperative length of stay (LOS), and major complications after surgery: stroke, transmural myocardial infarction, DSWI, reexploration for bleeding, endocarditis and/or sepsis, GI complications, renal failure, and respiratory failure. Risk stratification was performed according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE).15

DSWI was defined according to the guidelines of the Centers for Disease Control and Prevention,16 and its diagnosis required at least one of the following criteria: (1) an organism isolated from culture of mediastinal tissue or fluid; (2) evidence of mediastinitis seen during operation; or (3) presence of either chest pain, sternal instability, or fever (> 38°C), and either purulent discharge from the mediastinum isolation of an organism isolated from blood culture or culture of drainage of the mediastinal area. All patients received postoperative follow-up care during hospitalization and were routinely seen 4 weeks after discharge from the hospital. Therefore, all wounds were subject to postdischarge surveillance with a minimum of 30 days of follow-up.

Data Analysis
Long-term patient mortality data were obtained from the US Social Security Death Index database (http://ssdi.genealogy.rootsweb.com). The sensitivity of the death index to identify deaths is between 92% and 99%, depending on which identifiers are available.17 The social security number alone has the best accuracy of any combination of other identifiers (first initial, last name, day of birth, month of birth, year of birth, etc.) with a sensitivity of 97% and a specificity of 99%.17 In this study, we used only social security numbers, which were available in most patients (99.1%), and this allowed avoiding utilization of patients’ names. In addition, patients without a social security number (n = 34, none in the DSWI group) were censored at the time of discharge from the hospital. The death index was queried in September 2002, and patients not found there were assumed to be alive at that date.

Statistical Methods
Numerical variables were presented as the mean ± SD, while discrete variables were summarized by percentages. Patient characteristics, 30-day mortality, in-hospital mortality, and the use of BITA grafting were compared using the Fisher Exact Test or the x2 test where appropriate. The LOS before discharge, the Canadian Cardiovascular Society angina class, and the total number of distal anastomoses were compared using the nonparametric Mann-Whitney U test. The Kaplan-Meier survival curves were compared with the log-rank test.18

The propensity for DSWI developing after CABG was determined using logistic regression analysis.19 All 48 preoperative, intraoperative, and postoperative variables were entered into the model. Variables were evaluated first univariately, then multivariately. The model selection was done with backward stepwise method starting from all variables with a p value < 0.05 in univariate analyses. This model was then used to calculate a propensity score. This propensity score represented the probability that DSWI would develop. The C statistic (equivalent to the area under the receiver operating characteristic curve) and the Lemeshow-Hosmer goodness-of-fit statistic were calculated to assess the performance and the calibration of the model, respectively.1920 A C statistic of > 0.70 indicates reasonable ability to discriminate between patients in whom DSWI developed and those in whom it did not. For the Lemeshow-Hosmer goodness-of-fit statistic, a p value > 0.05 indicates acceptable calibration of the model. Each patient with DSWI was then matched to 10 patients without DSWI using propensity scores identical to within 1%. All 40 patients with DSWI were matched with 400 CABG patients without DSWI and compared for early outcome as well as for long-term survival with the Kaplan-Meier method.

Finally, the impact of DSWI on long-term mortality after CABG was analyzed by Cox regression analysis.21 Cox proportional hazard models were applied separately to the following (1) all patients (n = 3,760), (2) only those patients who were discharged from the hospital (n = 3,657), (3) only those patients surviving at least 6 months (n = 3,583), and (4) only those patients surviving at least 1 year (n = 3,522). In either case, the model selection was done with backward stepwise method starting from all variables with a p value < 0.05 in univariate analyses. The model was then confirmed using forward stepwise selection. The DSWI parameter was forced to remain in each multivariate model, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. All analyses were performed using software (SPSS 11.0; SPSS; Chicago, IL), and all p values are two-tailed.


   Results
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 Conclusions
 References
 
Patient and Disease Characteristics, Early and Late Outcome
The mean age within the study sample (n = 3,760) was 64.1 ± 10.4 years (mean ± SD); 30.9% (n = 1,162) were women, and 34.0% (n = 1,277) were diabetics. During the 19,335 person-years of follow-up (mean follow-up, 5.2 ± 3.2 years), 764 deaths (20.3%) were recorded. DSWI developed in 40 of 3,760 patients (1.1%). The surgical treatment of DSWI included debridement of necrotic tissue or sternectomy, topical treatment with antiseptic solution, systemic antibiotics, and reconstruction with rotated muscle flaps or greater omentum flap. The comparison of patients with DSWI to patients without DSWI is shown in Table 1 . Patients with DSWI after CABG had more comorbid conditions (PVD, calcified aorta, diabetes mellitus, preoperative dialysis) than did patients without DSWI and were less likely to have elective operations and more than one myocardial infarction. Patients with DSWI also received more BITA grafts (72.5% vs 55.0%, p = 0.036) and had more GI complications (7.5% vs 1.3%, p = 0.015), sepsis and/or endocarditis (20.0% vs 0.8%, p < 0.001), and respiratory failure (25.0% vs 4.1%, p < 0.001) postoperatively. There was no difference between the two groups in 30-day mortality, although patients with DSWI had longer LOS (35.0 days vs 10.7 days, p < 0.001) and higher in-hospital mortality (15.0% vs 2.6%, p = 0.001) in comparison to patients without DSWI. Freedom from all-cause mortality in patients with DSWI at 1 year, 5 years, and 10 years after surgery was 66.2 ± 7.7%, 50.8 ± 8.5%, and 40.6 ± 9.4%, respectively, compared with 93.6 ± 0.4%, 83.2 ± 0.7%, and 67.3 ± 1.3% for patients without DSWI (p < 0.0001; Fig 1 ).


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  		Table 1. Patient and Preoperative, Intraoperative, and Postoperative Characteristics in Patients With CABG Without DSWI and With DSWI*

 


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  		Figure 1. Kaplan-Meier survival plots of patients with DSWI after CABG were compared with patients without DSWI.

 
Multivariate Logistic Regression Analysis and Matched Groups
Multivariate logistic regression analysis found that the independent predictors of DSWI were diabetes mellitus (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.7 to 11.6; p < 0.001), hemodynamic instability prior to operation (OR, 4.0; 95% CI, 1.2 to 13.9; p = 0.026), preoperative renal failure requiring dialysis (OR, 3.4; 95% CI, 1.0 to 13.6; p = 0.049), use of BITA grafting (OR, 2.6; 95% CI, 1.3 to 5.3; p = 0.010), and sepsis and/or endocarditis following CABG (OR, 29.9; 95% CI, 11.7 to 76.4; p < 0.001). The discriminatory ability of the logistic model as measured by C statistic was 0.77, and the Lemesow-Hosmer goodness-of-fit test was not statistically significant (p = 0.540), indicating very good discriminative power and calibration of the model, respectively.

Regarding the increased risk for DSWI in the subgroup of patients who received BITA grafting, our group has previously published that the BITA grafting increased the risk of DSWI only in emergent cases and in older patients, while the excess risk was negligible among 1,206 patients who did not have emergent revascularization and were ≤ 70 years old.22 This finding was also confirmed in the present study among 2,492 patients (BITA grafting; OR, 0.77; p = 0.540).

All 40 patients with DSWI were appropriately matched with 400 patients without DSWI for all preoperative, intraoperative, and postoperative variables. The matched groups had similar mean EuroSCORE (5.77 vs 6.05 in DSWI group, p = 0.331) and no difference in 30-day mortality (4.3% vs 2.5% in DSWI group, p = 0.999) and in-hospital mortality (7.0% vs 15.0% in DSWI group, p = 0.109). However, patients with DSWI had still significant prolonged LOS (35.0 days vs 16.4 days, p < 0.001). The Kaplan-Meier curves of the matched groups are shown in Figure 2 . Freedom from all-cause mortality in patients in whom DSWI developed at 1 year, 5 years, and 10 years after the operation was 66.2 ± 7.7%, 50.8 ± 8.5%, and 40.6 ± 9.4% respectively, compared with 87.2 ± 1.7%, 72.8 ± 2.4%, and 54.3 ± 2.8% in patients without DSWI (p = 0.0007).



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  		Figure 2. Kaplan-Meier survival plots of matched groups for all preoperative, intraoperative, and postoperative risk factors. Patients with DSWI after CABG were compared with patients without DSWI.

 
Cox Proportional Hazard Models and Risk Stratification According to EuroSCORE
The crude HR of long-term mortality for patients with DSWI was 3.90 (95% CI, 2.50 to 6.08, p < 0.001). After adjustment for preoperative, intraoperative, and postoperative factors, the adjusted HR was 2.44 (95% CI, 1.51 to 3.92; p < 0.001). The adjusted HR of long-term mortality for patients with DSWI discharged from the hospital (n = 34) and apparently successfully treated was 2.96 (95% CI, 1.73 to 5.07; p < 0.001). The HR for patients who survived the first 6 months postoperatively (n = 27) was 2.71 (95% CI, 1.44 to 5.13; p = 0.002), and the HR for patients who survived the first year postoperatively (n = 24) was 2.04 (95% CI, 0.95 to 4.35; p = 0.067). Interestingly, when the patients who acquired DSWI after CABG were categorized according to the three traditional risk groups of standard EuroSCORE, there was a significant trend toward increasing risk for DSWI with increased predicted mortality (p < 0.001, x2 test for trend; Fig 3 ).



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  		Figure 3. Percentage of patients with DSWI according to preoperative predicted mortality as estimated by the standard EuroSCORE. We utilized the traditional groups of EuroSCORE: 0 to 2, 3 to 5 and ≥ 6. The percentage of patients with DSWI was determined within each category of predicted mortality.

 

   Discussion
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
Conclusions
 References
 
DSWI and Long-term Mortality
Many studies12345678 have reported the in-hospital or early mortality associated with DSWI as well as the risk factors that predispose to this devastating complication after cardiac surgery with median sternotomy. However, little has been published regarding the impact of DSWI on long-term mortality after CABG, and this was the primary purpose of the present study. We showed that DSWI had a detrimental effect on patient survival at least through the first 6 months after surgery in a series of CABG patients with a mean follow-up of 5.2 years. After multivariate adjustment for all preoperative, intraoperative, and postoperative differences in patient characteristics, disease characteristics, intraoperative variables, and major postoperative complications, DSWI is associated overall with an approximately 2.5-fold increase in mortality, and with an approximately threefold increase in mortality in patients apparently successfully treated and discharged from the hospital or survived for at least 6 months during a 10-year follow-up period.

These findings confirm the suggestion by Loop et al,2 who mentioned for the first time that DSWI has a long-term negative influence on survival after CABG, and indeed are consistent with four published studies23242526 evaluating the impact of DSWI on long-term mortality. Milano et al23 evaluated for the first time the impact of DSWI on long-term mortality (DSWI developed in 83 patients [1.3%] in a series of 6,459 patients with CABG) using a Cox proportional hazards model, and concluded that the adjusted mortality rate was higher for the DSWI group throughout the 2-year postoperative follow-up study, but they did not calculate the adjusted HR for DSWI. Stahle et al,24 in a series of patients with cardiac surgery (DSWI developed in 203 patients [1.5%] in a series of 13,285 patients), calculated the adjusted HRs for DSWI in 8,393 patients: 1.9 in the CABG subgroup and 2.1 in the valve or combined valve and CABG subgroup (maximum follow-up, 10 years). Braxton et al,25 in a larger series of patients with CABG (DSWI developed in 193 patients [1.25%] in a series of 15,406 patients), calculated the adjusted HR for DSWI: 3.09 (maximum follow-up, 4 years).

In our study, the adjusted HR of long-term mortality for DSWI was 2.44 (mean follow-up, 5.2 years). In the studies of Milano et al,23 Stahle et al,24 and Braxton et al,25 the investigators excluded postoperative variables, arguing that these are complications and hence may not be true independent predictors of DSWI. We, along with others,10121426 contend that identifying postoperative complications that increase the likelihood of DSWI developing is important; therefore, we report a multivariate analysis that includes postoperative variables. In the fourth published study by Lu et al,26 in a series of CABG patients (DSWI or superficial sternal wound infection developed in 109 patients [2.6%] in a series of 4228 patients), the adjusted HR for sternal infection was 1.64 (mean follow-up, 3.2 years). Ridderstolpe et al12 and Lu et al26 performed adjustment for all preoperative, intraoperative, and postoperative factors; however, they included in their analysis both deep and superficial sternal infections, and we can speculate that this is the reason for the lower reported HR in comparison to our study, because superficial sternal infections have shown lower long-term mortality rates than DSWI.

Independent Predictors for DSWI
We also identified the independent predictors for DSWI, and these included three preoperative factors (diabetes mellitus, hemodynamic instability prior to operation, renal failure patients on dialysis), one intraoperative factor (BITA grafting), and one postoperative complication (sepsis and/or endocarditis). The model developed based on these factors had very good discrimination ability and calibration in this series of patients with CABG. All of these factors were previously identified as independent predictors for DSWI,123111213142426 except for sepsis and/or endocarditis following CABG. However, the association between DSWI and postoperative sepsis and/or endocarditis is not surprising because patients with sepsis and/or endocarditis were considered to be all patients with two or more positive blood culture findings. In addition, Olsen et al4 found that sepsis was a common factor in patients with DSWI (five of eight patients [62.5%] who died within a year of their operation), and this observation was confirmed in the present study (eight of nine patients [88.9%]). The identification of the bacterial pathogens was not the aim of the present study. Previous studies have focused on microbiology of DSWI; in most series,36824 Staphylococcus aureus and Staphylococcus epidermidis account for 50 to 75% of all bacterial isolates.

Strategies to Reduce the Incidence of DSWI
The prevention of DSWI is of great importance, and the preventing process starts with the identification of patients at high risk and risk factor modification when possible. We showed in this study that patients with a high EuroSCORE are at higher risk for DSWI; however, most risk factors for DSWI are not amenable to modification.27 Many studies, 7911142223 including the present study, have identified the use of BITA grafting as an independent risk factor for DSWI. Because each hemisternum loses > 90% of its blood supply on mobilization of the corresponding internal thoracic artery, it is not surprising that wound healing can be compromised in patients with BITA harvesting for surgery.7 However, skeletonized BITA grafting carries an acceptable risk of DSWI except for repeat CABG or patients with COPD.11 We also support the use of BITA grafting among patients who do not have emergent operation and are ≤ 70 years old.22

The risk of DSWI in patients with diabetes mellitus should be taken into account when surgeons choose BITA grafting.28 In the subgroup of diabetic patients, it has been found that tight control of glucose with perioperative continuous IV insulin infusion significantly reduced DSWI.29 Skeletonized BITA grafting lowers the risk of DSWI in diabetic patients,30 while the use of radial artery as second arterial graft can further lower the incidence of DSWI with no difference in perioperative and midterm outcome.31

Other strategies for the reduction of DSWI include the prophylactic use of intranasal mupirocin because of the correlation of nasal carriage of S aureus with DSWI.3233 These studies3233 found that the routine use of mupirocin was safe, inexpensive, and very effective in reducing significantly the DSWI both in diabetic and nondiabetic subjects. Also, the optimal time of antimicrobial prophylaxis has been found to be critical for the prevention of DSWI.5 However, the incidence of DSWI can be reduced to a minimum by following a simple protocol based on the strict adherence to preoperative aseptic technique, attention to hemostasis, and precise sternal closure.27 Finally, early diagnosis may also improve short-term results in cases of DSWI by controlling of sepsis and preventing multiorgan failure, although no single study has demonstrated the need for in-hospital, 6-week antibiotic therapy.

Limitations of the Study
First, this is a retrospective study. Nevertheless, the collected information on preoperative, intraoperative, and postoperative factors has been collected with highly standardized methods for the New York State database. Second, this study refers to a single-center regional database, and it is likely that selection of patients, choice of procedures, as well as management of the perioperative period may be important determinants of DSWI, and these parameters vary widely among cardiac surgical units. Third, the cause of death in these patients is not documented and is not necessarily related to infection. However, for practical purposes, estimation of overall mortality is probably more important than estimation of infectious deaths alone after a long-term follow-up period. Fourth, the number of DSWIs, as in most previous studies,45101314 was small, and this precluded us from subanalyzing the long-term mortality according to the treatment followed in each case. Overcoming this limitation as well as the limitation of a single-center regional database will likely require a multi-institutional approach.


   Conclusions
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 Conclusions
References
 
The present study clearly demonstrates that DSWI is a continuing detrimental risk factor for long-term survival following CABG, and its effect on patient survival extends far beyond the 30-day mortality and in-hospital mortality time periods. Thus, these data suggest the need for a more extended hospitalization and frequent follow-up, at least during the first 6 months postoperatively, among patients with DSWI.


   Footnotes
 
Abbreviations: BITA = bilateral internal thoracic arteries; BMI = body mass index; CABG = coronary artery bypass grafting; CI = confidence interval; DSWI = deep sternal wound infection; EuroSCORE = European System for Cardiac Operative Risk Evaluation; HR = hazard ratio; LOS = length of stay; OR = odds ratio; PVD = peripheral vascular disease

Received for publication May 12, 2004. Accepted for publication August 9, 2004.


   References
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 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 Conclusions
 References
 

  1. Hollenbeak, CS, Murphy, DM, Koenig, S, et al (2000) The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest 118,397-402[Abstract/Free Full Text]
  2. Loop, FD, Lytle, BW, Cosgrove, DM, et al J. Maxwell Chamberlain memorial paper: sternal wound complications after isolated coronary artery bypass grafting; early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49,179-186[Abstract]
  3. Borger, MA, Rao, V, Weisel, RD, et al Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg 1998;65,1050-1056[Abstract/Free Full Text]
  4. Olsen, MA, Lock-Buckley, P, Hopkins, D, et al The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different. J Thorac Cardiovasc Surg 2002;124,136-145[Abstract/Free Full Text]
  5. Trick, WE, Scheckler, WE, Tokars, JI, et al Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000;119,108-114[Abstract/Free Full Text]
  6. De Feo, M, Renzulli, A, Ismeno, G, et al Variables predicting adverse outcome in patients with deep sternal wound infection. Ann Thorac Surg 2001;71,324-331[Abstract/Free Full Text]
  7. El Oakley, RM, Wright, JE Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996;61,1030-1036[Abstract/Free Full Text]
  8. Gardlund, B, Bitkover, CY, Vaage, J Postoperative mediastinitis in cardiac surgery: microbiology and pathogenesis. Eur J Cardiothorac Surg 2002;21,825-830[Abstract/Free Full Text]
  9. The Parisian Mediastinitis Study Group.. Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg 1996;111,1200-1207[Abstract/Free Full Text]
  10. Noyez, L, van Druten, JA, Mulder, J, et al Sternal wound complications after primary isolated myocardial revascularization: the importance of the post-operative variables. Eur J Cardiothorac Surg 2001;19,471-476[Abstract/Free Full Text]
  11. Pevni, D, Mohr, R, Lev-Run, O, et al Influence of bilateral skeletonized harvesting on occurrence of deep sternal wound infection in 1,000 consecutive patients undergoing bilateral internal thoracic artery grafting. Ann Surg 2003;237,277-280[CrossRef][ISI][Medline]
  12. Ridderstolpe, L, Gill, H, Granfeldt, H, et al Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg 2001;20,1168-1175[Abstract/Free Full Text]
  13. Slaughter, MS, Olson, MM, Lee, JT, Jr, et al A fifteen-year wound surveillance study after coronary artery bypass. Ann Thorac Surg 1993;56,1063-1068[Abstract]
  14. Zacharias, A, Habib, RH Factors predisposing to median sternotomy complications: deep vs superficial infection. Chest 1996;110,1173-1178[Abstract/Free Full Text]
  15. Nashef, SA, Roques, F, Hammill, BG, et al Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery. Eur J Cardiothorac Surg 2002;22,101-105[Abstract/Free Full Text]
  16. Garner, JS, Jarvis, WR, Emori, TG, et al CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16,128-140[CrossRef][ISI][Medline]
  17. Williams, BC, Demitrack, LB, Fries, BE The accuracy of the National Death Index when personal identifiers other than Social Security number are used. Am J Public Health 1992;82,1145-1147[Abstract/Free Full Text]
  18. Kaplan, EL, Meier, P Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53,547-581
  19. Hosmer, DW, Taber, S, Lemeshow, S The importance of assessing the fit of logistic regression models: a case study. Am J Public Health 1991;81,1630-1635[Abstract/Free Full Text]
  20. Hanley, JA, McNeil, BJ The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982;143,29-36[Abstract/Free Full Text]
  21. Cox, DR Regression models and life-tables. J R Stat Soc 1972;34,187-220
  22. Ioannidis, JP, Galanos, O, Katritsis, D, et al Early mortality and morbidity of bilateral versus single internal thoracic artery revascularization: propensity and risk modeling. J Am Coll Cardiol 2001;37,521-528[Abstract/Free Full Text]
  23. Milano, CA, Kesler, K, Archibald, N, et al Mediastinitis after coronary artery bypass graft surgery: risk factors and long-term survival. Circulation 1995;92,2245-2251[Abstract/Free Full Text]
  24. Stahle, E, Tammelin, A, Bergstrom, R, et al Sternal wound complications: incidence, microbiology and risk factors. Eur J Cardiothorac Surg 1997;11,1146-1153[Abstract]
  25. Braxton, JH, Marrin, CA, McGrath, PD, et al Mediastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg 2000;70,2004-2007[Abstract/Free Full Text]
  26. Lu, JC, Grayson, AD, Jha, P, et al Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery. Eur J Cardiothorac Surg 2003;23,943-949[Abstract/Free Full Text]
  27. Baskett, RJ, MacDougall, CE, Ross, DB Is mediastinitis a preventable complication? A 10-year review. Ann Thorac Surg 1999;67,462-465[Abstract/Free Full Text]
  28. Tavolacci, MP, Merle, V, Josset, V, et al Mediastinitis after coronary artery bypass graft surgery: influence of the mammary grafting for diabetic patients. J Hosp Infect 2003;55,21-25[CrossRef][ISI][Medline]
  29. Furnary, AP, Zerr, KJ, Grunkemeier, GL, et al Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 1999;67,352-360[Abstract/Free Full Text]
  30. Peterson, MD, Borger, MA, Rao, V, et al Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes. J Thorac Cardiovasc Surg 2003;126,1314-1319[Abstract/Free Full Text]
  31. Borger, MA, Cohen, G, Buth, KJ, et al Multiple arterial grafts: radial versus right internal thoracic arteries. Circulation 1998;98,II7-II13
  32. Cimochowski, GE, Harostock, MD, Brown, R, et al Intranasal mupirocin reduces sternal wound infection after open heart surgery in diabetics and nondiabetics. Ann Thorac Surg 2001;71,1572-1578[Abstract/Free Full Text]
  33. Usry, GH, Johnson, L, Weems, JJ, Jr, et al Process improvement plan for the reduction of sternal surgical site infections among patients undergoing coronary artery bypass graft surgery. Am J Infect Control 2002;30,434-436[CrossRef][ISI][Medline]



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