Ann Thorac Surg 2009;88:1909. doi:10.1016/j.athoracsur.2009.08.073
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Alfred T. Culliford, MD
Cardiothoracic Surgery, NYU Medical Center, 530 First Ave, Suite 9-V, New York, NY 10016
(Email: alfred.culliford{at}med.nyu.edu).
Modrau and colleagues [1] have added important and sobering information about postoperative fungal mediastinitis. In the past, this may have been regarded as an uncommon pathogen in mediastinitis or perhaps just an incidental contaminant of no special significance. This retrospective study of 4,222 cardiac procedures carried out for a 7-year duration revealed 83 (2%) deep sternal wound infections. Candida was the responsible organism in 17 patients (20.5%) and bacterial infection occurred in 66 patients (79.5%). In the first group, Candida was the primary pathogen in 11, and Candida was a supra-infection in 6 patients. Because of this unexpected frequency of fungal infection a detailed analysis was carried out. Predisposing factors included patients on mechanical ventilators prior to the operation who were colonized with Candida, positive sputum, or urine cultures revealing Candida and an additional cardiac procedure after the primary repair.
The diagnosis of Candida deep infection was made 5 to 519 days after surgery, with a median time of 18 days. The treatment consisted of intravenous fluconazole with amphotericin B in selected patients for 1 month, and radical surgical debridement and vacuum-assisted closure, followed by possible secondary wound closure. In-hospital and all-cause mortality at 1 year was 35% and 41% for Candida infections and 15% and 23% for bacterial infections, respectively. Not surprisingly Candida-infected patients required 23.5 days of mechanical ventilation and 26 days of intensive care unit days compared with 2.0 days and 5.0 days for non-Candida infected patients.
This retrospective study is not without limitation, but is important because: (1) the authors found Candida to be the causative organism in one of five deep sternal wound infections, (2) they have identified three important preoperative risk factors, and (3) Candida infections are associated with the doubling of the mortality and a five-fold increase in the intensive care unit stay. The reader is left to speculate as to preventative modification of risk factors and optimal management of this devastating infection. It is likely that healthcare economists will also be keenly interested in these findings, because postoperative mediastinitis is currently not a reimbursable complication by CMS.
The serious economic impact of this complication was recently studied by Spier and colleagues [2] in a survey of more than 14,000 patients who had bypass surgery in Virginia. The additive cost of mediastinitis increased the baseline cost in an astonishing 240% (mean cost increase, $88,000) when compared with patients who had uneventful courses. Thus, it becomes the most costly postoperative occurrence of nine studied complications.
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- Modrau IS, Ejlertsen T, Rasmussen BS. Emerging role of Candida in deep sternal wound infection Ann Thoracic Surg 2009;88:1905-1909.[Abstract/Free Full Text]
- Spier A, Kasirajan V, Barnett S, Fronner E. Additive costs of postoperative complications for isolated coronary artery bypass grafting patients in Virginia Ann Thoracic Surg 2009;88:40-46.[Abstract/Free Full Text]
Related Article
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Emerging Role of Candida in Deep Sternal Wound Infection
- Ivy S. Modrau, Tove Ejlertsen, and Bodil S. Rasmussen
Ann. Thorac. Surg. 2009 88: 1905-1909.
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