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The risk of wound infection after emergency re-sternotomy

Cardiothoracic Surgery Department, University Hospital of Patras, 22500 Rion Patras, Greece

Should additional antibiotics or an iodine washout be given to all patients who suffer an emergency re-sternotomy on the cardiothoracic intensive care unit?

Is the risk of wound infection after emergency re-sternotomy independent of the place of re-opening in patients following cardiac surgery?

Your article has a great interest as it touches on a really debated subject concerning the additional administration of antibiotics in patients who suffer an emergency re-sternotomy on the cardiothoracic ICU [1]. Re-examining your data, it is amazing the fact that only seven papers exist, documenting the incidence of infection after emergency re-sternotomy. In addition, it is also notable that only in five of these papers, the additional intravenous administration of antibiotics, except for the common povodine-iodine washout is mentioned. In our opinion, there is no doubt that for the patients who require an emergency re-sternotomy on ICU, additional antibiotics should be given. Undoubtedly, the need for additional antibiotic administration mainly depends on the place of the re-opening. According to the Practice Guideline from the Society of Thoracic Surgery, prophylactic antibiotics are recommended for every elective cardiac surgery let alone for patients undergoing emergency re-sternotomy on ICU [2]. In fact, the conditions on the ICU impose the administration of antibiotics beyond the common iodine washout. Primarily, on ICU – in contrast to the operating theater – there is a more resistant flora to the usual antibiotics, and therefore, the administration of more effective antibiotics is inevitable. On the other hand, an emergency re-opening means emergency circumstances and further decreased aseptic conditions. Moreover, the patient who must be re-opened on ICU usually is in extremis, and his host-defence will be seriously impaired. The factors mentioned above in combination with the number of people who exist on ICU, increase the possibility of an imminent infection. Indeed, the incidence of sternal wound infection or sepsis after an emergency re-sternotomy ranges between 3% [3] to 9% [4] compared with that of 1.5–1.86% [5] observed in elective patients.

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1. Yap EYL, Levine A, Strang T, Dunning J. Should additional antibiotics or an iodine washout be given to all patients who suffer an emergency re-sternotomy on the cardiothoracic intensive care unit? Interact CardioVasc Thorac Surg 2008;7:464–469.[Abstract/Free Full Text]
2. Engelman R, Shahian D, Shemin R, Guy TS, Bratzler D, Edwards F, Jacobs M, Fernando H, Bridges C, Workforce on Evidence-Based Medicine SoTS. The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part II: antibiotic choice. Ann Thorac Surg 2007;83:1569–1576.[Free Full Text]
3. Charalambous CP, Zipitis CS, Keenan DJ. Chest reexploration in the intensive care unit after cardiac surgery: a safe alternative to returning to the operating theater. Ann Thorac Surg 2006;81:191–194.[Abstract/Free Full Text]
4. El-Banayosy A, Brehm C, Kizner L, Hartmann D, Kortke H, Korner MM, Minami K, Reichelt W, Korfer R. Cardiopulmonary resuscitation after cardiac surgery: a two-year study. J Cardiothorac Vasc Anesth 1998;12:390–392.[CrossRef][Medline]
5. Stahle E, Tammelin A, Bergstrom R, Hambreus A, Nystrom SO, Hansson HE. Sternal wound complications-incidence, microbiology, and risk factors. Eur J Cardiothorac Surg 1997;11:1146–1153.[Abstract]

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