HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anne M. Eklund Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Eklund, A. M. Articles by Valtonen, M. Search for Related Content PubMed PubMed Citation Articles by Eklund, A. M. Articles by Valtonen, M. Related Collections Mediastinum Cardiac - other

Ann Thorac Surg 2006;82:1784-1789
© 2006 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Mediastinitis After More Than 10,000 Cardiac Surgical Procedures

^a Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland
^b Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland
^c Department of Infectious Disease Epidemiology, National Public Health Institute, University of Helsinki, Helsinki, Finland

Accepted for publication May 25, 2006.

^_* Address correspondence to Dr Eklund, HUCH, Jorvi Hospital, Department of Surgery, Turuntie 150, FIN-02740 Espoo, Finland (Email: anne.eklund{at}fimnet.fi).

	Abstract

Top Abstract Introduction Material and Methods Results Comment Footnotes Acknowledgments References

 
BACKGROUND: Poststernotomy mediastinitis as a complication is rare but disastrous. We assessed incidence, predisposing factors for, and outcome from, mediastinitis after cardiac surgery.

METHODS: We studied 10,713 consecutive patients who underwent open-heart surgery from 1990 to 1999 in a tertiary care university hospital using data prospectively recorded in the hospital discharge register, operating room log, and the hospital's cardiothoracic surgery unit register. Those cases with possible mediastinitis were identified from the hospital infection register and discharge register. Patients' charts were reviewed and cases of mediastinitis confirmed based on criteria of the Centers for Disease Control and Prevention.

RESULTS: The overall rate of mediastinitis was 1.1% (120 cases), and higher in coronary artery bypass surgery than in valvular surgery (1.2 vs 0.8%). No trend in incidence was detectable, although surgical patients became progressively older (mean age, 59 to 65 years, p < 0.01), and the proportion of women (from 25% to 31%; p < 0.01) and of patients with American Society of Anesthesiologists score over 3 (from 10% to 81%, p < 0.01) both increased. The rate of mediastinitis was almost twice as high in men (1.2% vs 0.7%, p < 0.01). In three body mass index (BMI) categories (<25, 25 to 30, and >30 kg/m²), rates of mediastinitis were 0.5%, 1.0%, and 1.8%. In multivariate analysis adjusted for age, sex, year, operation type, and perfusion time, the only predictor for mediastinitis was BMI.

CONCLUSIONS: Mediastinitis is not diminishing. Larger populations at risk, for example proportions of overweight patients, reinforce the importance of surveillance and pose a challenge in focusing preventive measures.

	Introduction

Top Abstract Introduction Material and Methods Results Comment Footnotes Acknowledgments References

 
Because poststernotomy mediastinitis is a very serious complication causing increased hospital costs, morbidity, and mortality, every effort to understand the epidemiology and to reduce the incidence of surgical site infections (SSI) is justified. Fortunately, mediastinitis is rare, occurring in only 1% to 3 % of patients after cardiac surgery [1–5]. Previous studies have identified risk factors such as obesity, diabetes, reoperation, or use of the bilateral internal thoracic artery, but results are not always consistent over time or may not be applicable to other centers. Many studies are retrospective, study populations are small, wound infection definition varies, and superficial wound infections are included, all of which makes comparison of results difficult.

The aim of this study was to assess incidence, predisposing factors, and outcome for mediastinitis in our patients in order better to understand aspects of this serious complication. We also evaluated whether any changes have occurred during the last decade.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment Footnotes Acknowledgments References

 
Material
The study population comprised all consecutive adult patients undergoing sternotomy or thoracotomy during cardiovascular surgery with cardiopulmonary bypass from January 1990 through December 1999 at the Department of Cardiothoracic Surgery, Helsinki University Central Hospital, which is a tertiary care university hospital serving a population of 1.4 million. For each surgical patient, the following data were prospectively recorded in the hospital discharge register and operating room log: age, gender, operation type, wound class [6], American Society of Anesthesiologists (ASA) score [7], and duration of operation, allowing the National Nosocomial Infections Surveillance (NNIS) risk index [8] to be calculated from the last three. In the hospital's cardiothoracic surgery unit register, data recorded were the following: body mass index (BMI), New York Heart Association (NYHA) class, estimated left ventricular ejection fraction, preoperative hospitalization, type of operation (elective, urgent, emergency), perfusion time, use of internal thoracic artery, length of postoperative stay in the intensive care unit, hospital stay, transmission to other hospitals, and date of death within one year. The Institutional Review Board approved the study and waived the need for informed consent.

No major changes occurred in surgical techniques during this period. Until 1996, antibiotic prophylaxis was two doses of intravenous vancomycin (1 g and 500 mg) in 6 hours. From 1997, the coronary artery bypass grafting surgery (CABG) patients received antibiotic prophylaxis with two doses of intravenous cefuroxime 1.5 g in 6 hours. Patients who underwent valve reconstruction or were hospitalized at least 3 days preoperatively also received intravenous vancomycin 500 mg on two occasions. The staff reported all nosocomial infections to the hospital infection register, and infection control nurses confirmed them and entered them in the database.

Those cases with possible mediastinitis were identified from the hospital discharge register and the hospital infection register, from which were also gathered all cases with sternal wound infection and positive blood cultures. Then patients' charts were reviewed for cases of mediastinitis confirmed with criteria by the Centers for Disease Control and Prevention [9]. According to the CDC, mediastinitis must meet at least one of the following criteria: (1) a positive bacterial culture from the mediastinal space; (2) evidence of mediastinitis during a surgery or in histology; (3) one of the following: fever (>38°C), chest pain, or sternal instability; and at least one of the following: purulent discharge from the mediastinal area, organisms cultured from blood, or from the discharge from the mediastinal area, or mediastinal widening in radiology. Data collected in a retrospective chart review included type and timing of antibiotic prophylaxis, microbiologic cultures, radiologic findings, treatment, and reoperation for mediastinitis.

Statistical Analysis
Univariate analyses for categoric variables were calculated with the ² test or the Fisher exact test, as appropriate and for continuous variables with the Mann-Whitney U test. Potential risk factors with p < 0.20 in univariate analysis and some potential confounding factors were included in multivariate analysis, which was performed as forward step-wise logistic regression. A p value less than 0.05 was considered statistically significant. Data were analyzed by SPSS for Windows version 12.0 (SPSS Inc, Chicago, IL).

	Results

Top Abstract Introduction Material and Methods Results Comment Footnotes Acknowledgments References

 
Study Population and Cases of Mediastinitis
A total of 10,713 cardiovascular operations with cardiopulmonary bypass were performed during the study period with 120 patients (1.1%) identified as having mediastinitis (Table 1). No trend toward an increase in annual incidence of mediastinitis was detected (range, 0.8% to 1.5% in 1990 to 99, p = 0.304) and the average annual incidence did not differ before or after the change in antibiotic prophylaxis in 1997 (1.1% vs 1.1%, p = 0.815) (Fig 1). During the study period, the patient population grew significantly older (mean age, 59.3 to 65.4 years, p < 0.01), and the proportion of women increased significantly (from 25% to 31%, p < 0.01), as did the proportion of patients with ASA greater than 3 (from 10% to 81%, p < 0.01). Men's BMI was slightly higher (26.8 vs 27.0 kg/m², p < 0.01).

View larger version (23K): [in this window] [in a new window]   Fig 1. Number of patients undergoing cardiac procedures and annual incidence of mediastinitis (diamonds).

Microbiology
Microorganisms were isolated from 109 patients (Table 2). For 3 patients, the cultures were negative, for 4, cultures were not taken, and for another 4, information was missing. Superficial or drain cultures accounted for 61% of specimens, and invasive (mediastinal or blood) cultures for 39%. In 66 patients, the mediastinitis was caused by one pathogen, and in 43, more than one. Gram-positives were isolated from 82% cultures (1990 to 1996: 77% vs 1997 to 1999: 93%), and gram-negatives from 16% (1990 to 1996: 20% vs 1997 to 1999: 7%). The most commonly isolated pathogens were Staphylococcus epidermidis (78 patients, 65%) and Staphylococcus aureus (28 patients, 23%). Splitting the data according to the antibiotic regimens used (years 1990 to 1996 vs 1997 to 1999), S. epidermidis was isolated from 61% vs 73% patients and S. aureus from 23% vs 24%. Concomitant bacteremia was diagnosed in 24 cases (20%) and was most often caused by S. aureus (Table 2).

Comparing patients who underwent surgery for mediastinitis (n = 84) with those who did not (n = 36), in the surgery group the proportion of patients from whom S. aureus was isolated was significantly higher than in the nonsurgery group (26% vs 18%, p = 0.025). No difference appeared between these two groups as to time when mediastinitis was diagnosed or existence of concomitant bacteremia.

Risk Factors and Outcome
The operating room log showed the rate of mediastinitis to be zero in patients with ASA score 1-2 (0 of 91) and highest in those with ASA score 5 (2 of 25, 8.0%). It was, however, higher in patients with score 3 (19 of 1,294, 1.5%) than in those with score 4 (88 of 8,644, 1.0%). The mediastinitis rate was not significantly higher in patients with a National Nosocomial Infections Surveillance (NNIS) risk index score 2 or greater than in those with a score less than 2 (1.2% vs 1.0%, p = 0.38).

The rate of mediastinitis was higher in males (1.2% vs 0.7%, p < 0.01), and patients were not older than nonmediastinitis patients but had a higher BMI. Their operation times tended to be longer. In three BMI categories (<25, 25 to 30, and >30 kg/m²), the mediastinitis rate was 0.5%, 1.0%, and 1.8%, respectively. Of the variables entered into a multivariate logistic regression analysis (age, sex, BMI, operation year, perfusion time, type of procedure), only BMI was an independent risk factor (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.05 to 1.15, p < 0.01) (Table 3).

	Comment

Top Abstract Introduction Material and Methods Results Comment Footnotes Acknowledgments References

 
Our study shows that during the 1990s the incidence of mediastinitis after cardiac surgery did not change, although major changes occurred in patients at risk; the population became older and sicker, and the proportion of females increased. The main predictive factor for mediastinitis was obesity.

The rate of mediastinitis we detected (1.1%) is in line with that of other large studies performed since the 1980s. Risk was slightly higher in CABG (1.2%) than in valvular surgery (0.8%). In the retrospective studies dated before 2000, mediastinitis varied between 1.0 and 2.3% [1–3, 10, 11]. Three prospective studies published more recently showed similar rates (0.7% to 1.4%) [5, 12, 13]. Some studies included only CABG procedures, and showed rates of mediastinitis of 0.7% to 2.3% [1, 2, 12, 14, 15]. In those studies that included all cardiac surgery, as did ours, rates of mediastinitis were also higher in CABG surgery than in valvular or other cardiac surgery (1.6% to 3.4% vs 0.7% to 1.7%) [4, 11, 16, 17].

Less than 1% of our patients with mediastinitis died within one month after cardiac surgery, and 9% died within one year. Between patients with and without mediastinitis, mortality did not differ. Increased early mortality has been associated with mediastinitis [1, 3, 5, 18], but a few studies also show increased long-term mortality [2, 12, 19]. Such differences may be related to the causative microbes. In two studies with mortality rates of 30% and 40%, the pathogens involved were mainly S. aureus and Pseudomonas aeruginosa [10, 14], but mediastinitis caused mainly by coagulase-negative staphylococci showed low mortality (2% to 4%) [4, 15, 20]. Among our mediastinitis patients, the most commonly isolated pathogen was S. epidermidis and then S. aureus. Pathogens involved in SSIs after cardiac surgery are usually S. epidermidis and S. aureus [16, 21, 22]. Coagulase-negative staphylococci have recently become the most important pathogen, especially in deep infections [21].

Clearly, treatment of mediastinitis is very expensive [1]. This was also evident in our study, because 70% of the patients had to be reoperated for mediastinitis, 14% underwent more than one operation, and the average hospital stay was more than one month.

Our only predictive factor for mediastinitis was obesity. Obesity has previously been shown to predispose not only to superficial sternal infection but also to mediastinitis [1–3, 15, 16, 18, 20, 23, 24]. Our rate of mediastinitis was also almost three times as high in patients with BMI greater than 30 as in those with BMI less than 25. Similarly, in a French study [16], the rate of mediastinitis was 5.6% with BMI 30 or greater, compared with 2.0% with BMI less than 30. Increased risk for mediastinitis in obese patients may be related to several factors such as technical difficulties during surgery, prolonged operation time, increased bleeding, and ineffective prophylactic antibiotic dose [2]. Overweight may also be associated with type II diabetes mellitus and metabolic syndrome. Several groups have observed an increased risk for mediastinitis among diabetics having cardiac surgery [1, 3, 4, 12, 14, 15, 18, 24, 25]. Of our mediastinitis patients, 21% had diagnosed diabetes. Due to incomplete documentation in postdischarge diagnoses and the cardiothoracic register, we could not, however, evaluate diabetes as a risk factor, nor had we systematic information on perioperative or postoperative glucose levels. More recent studies show that undiagnosed diabetes and postoperative hyperglycemia are also associated with development of SSIs, and that perioperative continuous intravenous insulin infusion can lower the incidence of deep sternal infection in diabetic patients in cardiac surgery [25–27], a finding with important practical implications for prevention. These results were not available during our study period.

Antibiotics used in prophylaxis changed during the study period in 1997 without affecting the incidence of mediastinitis. However, the proportion of isolated gram-negative bacteria fell from 20% to 7%, reflecting the antibiotic regimen change from vancomycin to cefuroxime. Essentially, all our patients with mediastinitis (99%) received antimicrobial prophylaxis, but there is still room for improvement, especially in its timing. Of those who received prophylaxis, 13% did not receive it during the 60 minutes (120 minutes for vancomycin) before incision. Prior studies have demonstrated that timing is critical to the effectiveness of prophylaxis, and current guidelines recommend dosing within 60 minutes before incision [28]. More than half our patients received only vancomycin, most likely to cover methicillin-resistant coagulase-negative staphylococci. We found that vancomycin infusion was often initiated rather close to incision and that the dose might have been insufficient, especially in obese patients [29]. Data available in our operating room log included no information on type and timing of antimicrobial prophylaxis, so these could not be studied as a risk factor.

In our study, risk for mediastinitis did not increase along with ASA and NNIS risk scores. Roy and colleagues [30] also showed that duration of the procedure was the only component of the NNIS index that stratified the patients undergoing cardiothoracic operations by risk for SSI. Their study, however, included all SSIs, not only mediastinitis. The internal thoracic artery as graft material has proven superior to vein grafts, but use of both internal thoracic arteries in the same operation may increase infectious complications [1, 15, 16, 31]. In our patients who developed mediastinitis, we had used both internal thoracic arteries rarely (5%), and between patients with and without mediastinitis proportions did not differ.

Our patient population undergoing cardiac surgery during the last decade changed substantially. This was most likely due to the fact that an increasing number of patients had nonoperative cardiac procedures instead of CABG. Christakis and colleagues [32] found incidence of CABG-associated morbidity and mortality to increase along with the number of elderly patients, patients with previous CABG procedures, and patients undergoing urgent operations. We did not observe similar trends (although our patients got older) with an increasing proportion with ASA score 3 or 4. In addition, the proportion of females increased. This can, in part, explain our findings because risk for mediastinitis was lower in females. Previously, either gender had been one risk factor for SSI after cardiac surgery, depending on site and type of SSI [33]. Our male patients had a slightly higher BMI, but gender was not an independent risk factor in multivariate analysis. Age has been verified as a risk factor for SSIs in many types of surgeries [34, 35]. However, several cardiac surgical studies showed that age does not predispose to sternal infections [1, 4, 10, 11, 15–17], which is consistent also with our findings.

Our study was based on a retrospective chart review and to evaluate the incidence and potential risk factors we utilized data uploaded from four separate in-hospital databases: the hospital discharge register, hospital infection register, operating room log, and a register kept by cardiothoracic surgeons. Linkage of several databases at the patient level was problematic, and only a limited number of variables could be included in our final analysis. For example, in addition to diabetes and blood glucose levels, several other known risk factors for infection, such as tobacco or concurrent corticosteroid use, could not be studied.

Our results indicate that the rate of mediastinitis is not decreasing. Changes in population at risk (for example, an increasing prevalence of overweight patients) reinforce the importance of surveillance and pose a continuous challenge in focusing preventive measures. Planning and selection of data fields entered and compulsory in various hospital information systems requires study of potential infection control interventions for more efficient disease prevention.

	Acknowledgments

Top Abstract Introduction Material and Methods Results Comment Footnotes Acknowledgments References

 
This study was supported financially by Helsinki University Central Hospital and the Jorvi Hospital Scientific Foundation.

	Footnotes

Top Abstract Introduction Material and Methods Results Comment Footnotes Acknowledgments References

 
^_* Dr Valtonen died on Feb 18, 2006.

	References

Top Abstract Introduction Material and Methods Results Comment Footnotes Acknowledgments References

 

1. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care Ann Thorac Surg 1990;49:179-187.[Abstract]
2. Milano CA, Kesler K, Archibald N, Sexton DJ, Jones RH. Mediastinitis after coronary artery bypass graft surgery Circulation 1995;92:2245-2251.[Abstract/Free Full Text]
3. Valla J, Corbineau H, Langanay T, et al. Mediastinitis after cardiac surgeryA 10-year evaluation (1985–1995). Ann Cardiol Angeiol (Paris) 1996;45:369-376.
4. Ståhle E, Tammelin A, Bergström R, Hambreus A, Nyström SO, Hansson HE. Sternal wound complications-- incidence, microbiology and risk factors Eur J Cardiothorac Surg 1997;11:1146-1153.[Abstract]
5. Gårdlund 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]
6. Garner JS. CDC guideline for prevention of surgical wound infections, 1985Supersedes guideline for prevention of surgical wound infections published in 1982. (Originally published in November 1985). Revised Infect Control 1986;7:193-200.[Medline]
7. New classification of physical statusAnonymous. Anesthesiology 1963;24:111.
8. Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk indexNational Nosocomial Infections Surveillance System. Am J Med 1991;91(suppl 3B):152S-157S.[Medline]
9. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori GT. CDC definitions of nosocomial surgical site infections Infect Control Hosp Epidemiol 1992;13:606-608.[Medline]
10. Ottino G, De Paulis R, Pansini S, et al. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures Ann Thorac Surg 1987;44:173-179.[Abstract]
11. Hammermeister KE, Burchfiel C, Johnson R, Grover FL. Identification of patients at greatest risk for developing major complications at cardiac surgery Circulation 1990;82(suppl):IV380-IV389.[Medline]
12. Lu JC, Grayson AD, Jha P, Srinivasan AK, Fabri BM. 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]
13. Lepelletier D, Perron S, Bizouarn P, et al. Surgical-site infection after cardiac surgery: incidence, microbiology, and risk factors Infect Control Hosp Epidemiol 2005;26:466-472.[Medline]
14. Wouters R, Wellens F, Vanermen H, De Geest R, Degrieck I, De Meerleer F. Sternitis and mediastinitis after coronary artery bypass graftingAnalysis of risk factors. Tex Heart Inst J 1994;21:183-188.[Medline]
15. Antunes PE, Bernardo JE, Eugénio L, Ferrão de Oliveira J, Antunes MJ. Mediastinitis after aorto-coronary bypass surgery Eur J Cardiothorac Surg 1997;12:443-449.[Abstract]
16. 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]
17. Muñoz P, Menasalvas A, Bernaldo de Quirós JCL, Desco M, Vallejo JL, Bouza E. Postsurgical mediastinitis: A case-control study Clin Infect Dis 1997;25:1060-1064.[Medline]
18. Fowler Jr VG, O'Brien SM, Muhlbaier LH, Corey GR, Ferguson TB, Peterson ED. Clinical predictors of major infections after cardiac surgery Circulation 2005;112(suppl):I358-I365.
19. Toumpoulis IK, Anagnostopoulos CE, DeRose JJ, Swistel DG. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting Chest 2005;127:464-471.[Abstract/Free Full Text]
20. Bitkover CY, Gårdlund B. Mediastinitis after cardiovascular operations: a case-control study of risk factors Ann Thorac Surg 1998;65:36-40.[Abstract/Free Full Text]
21. Tegnell A, Arén C, Öhman L. Coagulase-negative staphylococci and sternal infections after cardiac operation Ann Thorac Surg 2000;69:1104-1109.[Abstract/Free Full Text]
22. Sharma M, Berriel-Cass D, Baran Jr J. Sternal surgical-site infection following coronary artery bypass graft: prevalence, microbiology, and complications during a 42-month period Infect Control Hosp Epidemiol 2004;25:468-471.[Medline]
23. Abboud CS, Wey SB, Baltar VT. Risk factors for mediastinitis after cardiac surgery Ann Thorac Surg 2004;77:676-683.[Abstract/Free Full Text]
24. Harrington G, Russo P, Spelman D, et al. Surgical-site infection rates and risk factor analysis in coronary artery bypass graft surgery Infect Control Hosp Epidemiol 2004;25:472-476.[Medline]
25. 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]
26. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. 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]
27. Latham R, Lancaster AD, Covington JF, Pirolo JS, Thomas CS. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients Infect Control Hosp Epidemiol 2001;22:607-612.[Medline]
28. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project Clin Infect Dis 2004;38:1706-1715.[Medline]
29. Forse RA, Karam B, MacLean LD, Christou NV. Antibiotic prophylaxis for surgery in morbidly obese patients Surgery 1989;106:750-756.[Medline]
30. Roy MC, Herwaldt LA, Embrey R, Kuhns K, Wenzel RP, Perl TM. Does the Centers for Disease Control's NNIS system risk index stratify patients undergoing cardiothoracic operations by their risk of surgical-site infection? Infect Control Hosp Epidemiol 2000;21:186-190.[Medline]
31. Grover FL, Johnson RR, Marshall G, Hammermeister KE. Impact of mammary grafts on coronary bypass operative mortality and morbidityDepartment of Veterans Affairs Cardiac Surgeons. Ann Thorac Surg 1994;57:559-568.[Abstract]
32. Christakis GT, Ivanov J, Weisel RD, Birnbaum PL, David TE, Salerno TA. The changing pattern of coronary artery bypass surgery Circulation 1989;80:I151-I161.[Medline]
33. Roy MC. Surgical-site infections after coronary artery bypass graft surgery: discriminating site-specific risk factors to improve prevention efforts Infect Control Hosp Epidemiol 1998;19:229-233.[Medline]
34. Scott JD, Forrest A, Feuerstein S, Fitzpatrick P, Schentag JJ. Factors associated with postoperative infection Infect Control Hosp Epidemiol 2001;22:347-351.[Medline]
35. Kaye KS, Schmit K, Pieper C, et al. The effect of increasing age on the risk of surgical site infection J Infect Dis 2005;191:1056-1062.[Medline]

This article has been cited by other articles:

				M. P. Tocco, A. Costantino, M. Ballardini, C. D'Andrea, M. Masala, E. Merico, L. Mosillo, and P. Sordini Improved results of the vacuum assisted closure and Nitinol clips sternal closure after postoperative deep sternal wound infection Eur. J. Cardiothorac. Surg., May 1, 2009; 35(5): 833 - 838. [Abstract] [Full Text] [PDF]

				C. Schimmer, S.-P. Sommer, M. Bensch, T. Bohrer, I. Aleksic, and R. Leyh Sternal closure techniques and postoperative sternal wound complications in elderly patients. Eur. J. Cardiothorac. Surg., July 1, 2008; 34(1): 132 - 138. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anne M. Eklund Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Eklund, A. M. Articles by Valtonen, M. Search for Related Content PubMed PubMed Citation Articles by Eklund, A. M. Articles by Valtonen, M. Related Collections Mediastinum Cardiac - other