Impact of hospital infections on patients outcomes
               undergoing cardiac surgery at Santa Casa de Misericórdia de Marília

Conterno, Lucieni Oliveira; Toni, Silvana Martins Dias; Konkiewitz, Rubiana Gonçalves; Guedes, Elaine Salla; Barros, Rubens Tofano de; Tiveron, Marcos Gradim

doi:10.5935/1678-9741.20140037

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Brazilian Journal of Cardiovascular Surgery

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ORIGINAL ARTICLES • Rev Bras Cir Cardiovasc 29 (2) • Apr-Jun 2014 • https://doi.org/10.5935/1678-9741.20140037 copy

Impact of hospital infections on patients outcomes undergoing cardiac surgery at Santa Casa de Misericórdia de Marília

Impacto das infecções hospitalares na evolução de pacientes submetidos à cirurgia cardíaca na Santa Casa de Misericórdia de Marília

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

this study aimed to determine the incidence of nosocomial infections, the risk factors and the impact of these infections on mortality among patients undergoing to cardiac surgery.

Methods:

Retrospective cohort study of 2060 consecutive patients from 2006 to 2012 at the Santa Casa de Misericórdia de Marília.

Results:

351 nosocomial infections were diagnosed (17%), 227 non-surgical infections and 124 surgical wound infections. Major infections were mediastinitis (2.0%), urinary tract infection (2.8%), pneumonia (2.3%), and bloodstream infection (1.7%). The in-hospital mortality was 6.4%. Independent variables associated with non-surgical infections were age > 60 years (OR 1.59, 95% CI 1.09 to 2.31), ICU stay > 2 days (OR 5, 49, 95% CI 2.98 to 10, 09), mechanical ventilation > 2 days (OR11, 93, 95% CI 6.1 to 23.08), use of urinary catheter > 3 days (OR 4.85 95% CI 2.95 -7.99). Non-surgical nosocomial infections were more frequent in patients with surgical wound infection (32.3% versus 7.2%, OR 6.1, 95% CI 4.03 to 9.24). Independent variables associated with mortality were age greater than 60 years (OR 2.0; 95% CI 1.4 to3.0), use of vasoactive drugs (OR 3.4, 95% CI 1.9 to 6, 0), insulin use (OR 1.8; 95% CI 1.2 to 2.8), surgical reintervention (OR 4.4; 95% CI 2.1 to 9.0) pneumonia (OR 4.3; 95% CI 2.1 to 8.9) and bloodstream infection (OR = 4.7, 95% CI 2.0 to 11.2).

Conclusion:

Non-surgical hospital infections are common in patients undergoing cardiac surgery; they increase the chance of surgical wound infection and mortality.

Cross Infection; Risk Factors; Mortality; Thoracic Surgery; Surgical Wound Infection

	No.	%
Nº. of Patients	2060	100
Age > =60 years	1082	52.4
BMI > = 30kg/m²	423	20.5
Acute myocardial infarction	322	15.6
Hypertension	1314	63.8
Dyslipidemia	659	32.0
Diabetes mellitus	484	23.5
Smoking	406	19.7
Preoperative hospitalization in days ± SD	4.0 ± 4.0
Mean surgical time in minutes± SD	206+ 80.8
Time of cardiopulmonary bypass in minutes+ SD	81.6 ± 32.0
Insulin use in the postoperative	693	33.6
Vasoactive drug use of postoperative	1229	59.6
Patients using CVC in the postoperative	1769	85.8
Average time in days of UC use ±SD	4.5 + 5.1
Patients using UC in the postoperative	1799	87.3
Average time in days of CVD + SD	4.3 ±6.4
Patients under MV in the postoperative	873	42.3
Average time in days under MV ± SD	2.0 + 4.4
Average ICU days ± SD	4.0 ±7.4
Average days of hospital stay± SD	13.3 ± 12.3
Death	132	6.4

	No of HI	incidence	% of total HI
Total of hospital infection	351	17
Total of patients with hospital infection	265	12.9
Surgical site infection	124	6	35.3
Urinary tract infection	57	2.8	16.2
Pneumonia associated ventilation	52	2.5	14.7
Tracheobronchitis	39	1.9	11.1
Primary bloodstream infection	35	1.7	9.9
Vascular Catheter Infection	18	0.8	5.1

	With HI	%	Without HI	%	P
Nº. of Patients	180	8.7	1880	91.3
Age <60 years	55	5.6	927	94.4
=> 60 years	125	11.6	953	88.4	<0.0001
Preoperative hospitalization in days ± SD	5.3 +5.0	5.3 +5.0	3.8 ± 3.8	3.8 ± 3.8	0.001
Postoperative insulin
Yes	75	10.8	618	89.2
No	105	7.7	1262	92.3
Postoperative vasoactive drug
Yes	154	12.5	1075	87.5	0.01
No	26	3.1	804	96.9
Use of urinary catheter ≥ 3days	144	27.1	388	72.9	<0.0001
<3 days	36	2.4	1492	97.6
Use of vascular catheter ≥ 3days	132	20.1	526	79.9	<0.0001
<3 days	48	3.4	1354	93.7
Respirator ≥ 2 days	170	13.0	1 139	87.0	<0.0001
< 2 days	10	1.3	741	98.7
Mean ICU stay in days ± SD	15.8 ± 6.7	15.8 ± 6.7	2.9 ± 4.4	2.9 ± 4.4	<0.0001
Mean hospital stay in days + SD	33 ± 7.4	33 ± 7.4	11.5 ± 7.5	11.5 ± 7.5	<0.0001
Death	35	19.4	97	5.2
Survival	145	83.0	1 708	92.5	<0.0001

	Surgical site infection
	Yes		No		P
	No.	%	No.	%
Nº. patients	124	6	1936	94
Age < 60 years	46	4.7	936	95.3
> = 60 years	78	7.2	1000	92.8	0.01
Body mass index ≥ 30kg/m²	38	9.0	385	91.0
< 30 Kg/m²	71	5.3	1274	94.7	0.008
Preoperative hospitalization					0.002
in days± SD	5.4±4.9		3.9±4.0
Mean surgical time in minutes ±SD	231±81.0		204±80.5		< 0.0001
Average time of cardiopulmonary bypass in minutes ± SD	91±35.0		81± 31.7		0.005

Surgical reintervention
Yes	18	30.0	42	70.0
No	106	5.3	1894	94.7	<0.0001

Postoperative insulin use
Yes	60	8.7	633	91.3
No	64	4.7	1303	95.3	0.001

Postoperative vasoactive drug use
Yes	102	8.3	1127	91.7
No	22	2.7	808	97.3	<0.0001

Urinary tract infection
Yes	8	14.0	49	86.0
No	116	5.8	1887	94.2	0.01

Ventilation associated pneumonia
Yes	10	19.2	42	80.8
No	114	5.7	1894	94.3	0.001

Vascular catheter infection
Yes	7	38.9	11	61.1
No	117	5.7	1925	94.3	<0.0001

Bloodstream infection
Yes	102	8.6	25	7 1.4
No	114	5.6	1911	94.4	<0.0001

Mean of ICU stay in days ± SD	12.6 +17.1		3.5 +5.9		< 0.0001
Mean of hospital stay in days ± SD	32.5 +29.1		12.1 + 9.1		< 0.0001
Death	45	17	87	4.8
Survival	220	83.0	1 707	92.5	< 0.0001

	Death		Survival
	N	%	N	%	P
Age <60 years	34	3.5	948	96.5
= >60	98	9.1	980	90.0	<0.0001
Body mass index> = 30Kg/m²	35	8.5	378	91.5
< 30Kg/m²	75	5.6	1270	94.4	0.03
Mean of preoperative hospital stay in days± SD	5.7 ± 9		3.9+3.9		0.001
Mean time of cardiopulmonary bypass in minutes ± SD	105 ± 59.4		80 ± 28.5		<0.0001

Surgical reintervention
Yes	10	43.5	13	56.5
No	122	6	1915	94.0	<0.0001

Postoperative use of insulin
Yes	63	9.1	630	90.9
No	69	5.0	1298	95.0	<0.0001

Postoperative use of vasoactive drug
Yes	111	9.0	1118	91.0
No	21	2.5	809	97.5	<0.0001

Mediastinitis
Yes	10	24.4	31	75.6
No	122	6.0	1897	94.0	<0.0001

Pneumonia
Yes	13	25. 0	39	75.0
No	119	5.9	1889	94.1	<0.0001

Tracheobronchitis
Yes	6	15.4	33	84.6
No	126	6.2	1895	93.8	0.03

Primary Bloodstream infection
Yes	11	31.4	24	68.6
No	121	6.0	1904	94.0	<0.0001

Secondary sepsis
Yes	12	37.5	20	62.5
No	120	5.9	1908	94.1	0.001

	B Coefficient	Odds Ratio	95% CI
Age > = 60 years	0.46	1.59	1.09-.31
ICU stay > 2days	1.70	5.49	2.98-10.09
Use of urinary catheter > 3days	1.58	4.85	2.95-7.99
Mechanical ventilation > 2days	2.47	11.93	6.1-23.08
Constant	-3.346

	B Coefficient	Odds Ratio	95% CI
Postoperative use of vasoactive drugs	0.91	2.9	1.5 - 4.1
Postoperative use of insulin	0.55	1.7	1.2 - 2.6
Primary bloodstream infection	1.28	3.6	1.6-8.3
Vascular catheter infection	1.9	6.8	2.3-19.8
Pneumonia	0.99	2.7	1.2-5.9
Surgical reintervention	1.92	6.8	3.6 - 12.7
Constant	-3.840

	B Coefficient	Odds Ratio	95% CI
Age≥60 years	0.72	2.0	1.4-3.0
Postoperative use of vasoactive drugs	1.11	3.4	1.9-6.0
Postoperative use of insulin	0.54	1.8	1.2-2.8
Pneumonia	1.4	4.3	2.1-8.9
Primary infection of the bloodstream	1.55	4.7	2.0-11.2
Surgical reintervention	1.52	4.4	2.1-9.0
Constant	-4.34

Sociedade Brasileira de Cirurgia Cardiovascular Rua Afonso Celso, 1178 Vila Mariana, CEP: 04119-061 - São Paulo/SP Brazil, Tel +55 (11) 3849-0341, Tel +55 (11) 5096-0079 - São Paulo - SP - Brazil
E-mail: bjcvs@sbccv.org.br

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[1] Correspondence address: Lucieni Oliveira Conterno, Santa Casa de Misericórdia de Marília, Avenida Vicente Ferreira 828, Cascata, Marília, SP, Brazil Zip code: 17515-900. E-mail: lucieni@famema.br