Risk factors and impact of pathogen type - SantePub

Epidemiology and outcome
of major postoperative infections
following cardiac surgery :
Risk factors and impact of pathogen type
Luke F. Chen et al.
American Journal of Infection Control,
2012, December
Introduction : contexte
• complications postopératoires majeures (CPOM) :
- bactériémies
- infections du site opératoire (ISO)
• supérieures à 5 % en chirurgie cardiaque
• conséquences :
- morbimortalité
- coûts
1-3
1. Harrington G et al., Surgical site infection rates and risk factor analysis in coronary artery bypass graft surgery. Infect
Control Hosp Epidemiol 2004;25:472-6.
2. Fowler VG Jr, et al., Clinical predictors of major infections after cardiac surgery. Circulation 2005; 112(9 Suppl):I358-65.
3. Eklund AM et al., Mediastinitis after more than 10,000 cardiac surgical procedures. Ann Thorac Surg 2006;82:1784-9.
Introduction : contexte
• peu d’études sur les facteurs prédictifs de CPOM...
• espoir de mieux préparer les patients en
préopératoire en fonction de leurs facteurs prédictifs
(prémédication, antibioprophylaxie, décolonisation...)
Introduction : objectifs
• épidémiologie
• microbiologie
• facteurs prédictifs de CPOM
• mortalité à 30 jours postopératoires
• pronostic des patients en fonction du germe
964
L.F. Chen et al. / American Journal of Infection C
Introduction : objectifs
on the collective burden of SSIs and BSIs after cardiac surgery. In
addition, whether specific pathogens can adversely affect outcome
in patients with MPIs is unknown.8,9 Research examining the
association of pathogen type and outcome of MPIs may inform
future preventive and therapeutic efforts, including the use of
preoperative screening, decolonization of pathogens, selection and
timing of antibiotic prophylaxis, and use of empiric antibiotic
therapy in the management of patients with MPIs.10,11
In the present study, we examined the epidemiology, microbiology, and risk factors for the development of MPIs after cardiac
surgery and mortality within 30 days after surgery. We also evaluated the impact of pathogen type on the outcome of patients who
developed MPIs.
METHODS
This multicenter retrospective cohort study evaluated combined
clinical and microbiology data from 5 US medical centers. These
patient-specific clinical data were prospectively collected for the
Society for Thoracic Surgery (STS) National Cardiac Database.
The STS database was established in 1989 to collect surgical
outcomes after cardiothoracic procedures.12 It currently receives
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Méthode : design
• étude observationnelle de cohorte
• suivi prospectif des sujets
• multicentrique (5 hôpitaux américains)
Méthode : cohorte
• cohorte : Society for Thoracic Surgery National
Cardiac Database
• recueil prospectif des informations
• de plus de la moitié des hôpitaux américains avec
une activité de chirurgie cardiothoracique adulte
• depuis 1989
• envoi des nouvelles données à la base x 2 /an
Méthode :
critères d’inclusion
• âge > 18 ans
• chirurgie cardiaque
• dans 1 des 5 hôpitaux de l’étude
• entre janvier 2000 et décembre 2004
Méthode :
critères d’exclusion
• donnée manquante parmi âge, sexe,
degré d’urgence de la chirurgie
Méthode :
critères pour les CPOM
• contraction d’une CPOM dans les 30 jours postop.
- bactériémie :
- SCN et autres germes cutanés communautaires :
2 hémocultures positives consécutives
- autres germes : au moins une hémoculture positive
-
infection du site opératoire :
- au moins un germe isolé dans un prélèvement
thoracique (superficiel ou profond)
Méthode : division de
l’étude en « 2 parties »
• P1 : lien CPOM - MorbiMortalité (MM)
--> CJ* : - mortalité à 30 jours postopératoires
- durée de séjour postopératoire
• P2 : facteurs prédictifs de CPOM (et donc de MM)
--> CJ* : CPOM dans les 30 jours postop.
* Critères de jugement
Méthode (P2) :
facteurs prédictifs
(recherche des facteurs prédictifs préopératoires de CPOM)
1. détermination des facteurs prédictifs possibles :
analyse univariée sur divers facteurs disponibles
revue de la littérature
•
•
2. régression logistique multivariée sur ces facteurs
prédictifs supposés
Méthode :
analyse statistique
- logiciel statistique SAS 9
- analyse réalisée en excluant les sujets avec
données manquantes
- p < 0,05 considéré comme significatif
Résultats : population
• 10 522 sujets inclus
• 7 460 hommes (71 %)
• 9 208 caucasiens (88 %)
• âge moyen de 65 ans +/- 11,3
• 225 chirurgies en urgence (2,1 %)
• chirurgie : 77,1 % PAC, 12,4 % chirurgie de valve,
10,5 % pour les 2
Résultats : CPOM
CPOM
(bactériémie et/ou ISO)
341 cas
3.2 %
Bactériémie
186 cas
55 % des CPOM
Infection du site
opératoire (ISO)
124 cas
36 % des CPOM
Bactériémie + ISO
31 cas
9 % des CPOM
Population totale : 10 522 sujets inclus
Résultats (P1) :
lien CPOM et MorbiMortalité
965
L.F. Chen et al. / American Journal of Infection Control 40 (2012) 963-8
Table 1
Risk factors and outcomes of MPI
Variable
Risk factors
Caucasian
BMI, kg/m2*
"30 and <40
"40
Emergent surgery
Diabetes
Renal failure
Chronic lung disease
Cerebrovascular accident
Peripheral vascular disease
Immunosuppressive treatment
Previous CABG
Congestive heart failure
NYHA class IV
Outcomes
30-day mortality, n (%)
Postoperative LOS, days, median
Major infection (n ¼ 341)
No major infection (n ¼ 10,181)
Unadjusted OR (95% CI)
278 (81.5)
8,930 (87.7)
0.6 (0.5-0.8)
120
32
15
154
54
(35.2)
(9.4)
(4.4)
(45.2)
(15.8)
3,267
437
210
3,481
550
(32.1)
(4.3)
(2.1)
(34.2)
(5.4)
1.3
2.5
2.2
1.6
3.3
(1.0-1.6)
(1.7-3.7)
(1.3-3.7)
(1.3-2.0)
(2.4-4.5)
.0034
<.0001
<.0001
49
88
22
41
108
121
(14.4)
(25.8)
(6.5)
(12.0)
(31.7)
(35.5)
807
1,640
284
747
2,094
2,702
(7.9)
(16.1)
(2.8)
(7.3)
(20.6)
(26.5)
2.0
1.8
2.4
1.7
1.8
1.5
(1.4-2.7)
(1.4-2.3)
(1.5-3.8)
(1.2-2.4)
(1.4-2.3)
(1.2-1.9)
<.0001
<.0001
<.0001
.0012
<.0001
.0002
29 (8.5)
15.0
227 (2.2)
6.0
P value
.0007
aOR (95% CI)
P value
0.73 (0.54-0.97)
.03
1.31
2.48
1.99
1.25
2.25
0.73
1.57
1.47
1.97
1.72
1.30
1.38
(1.03-1.66)
(1.66-3.71)
(1.13-3.48)
(1.00-1.58)
(1.54-3.28)
(0.55-0.97)
(1.14-2.17)
(1.13-1.92)
(1.23-3.13)
(1.22-2.43)
(1.01-1.67)
(1.09-1.74)
.028
<.0001
.017
.063
<.0001
.029
.006
.004
.005
.002
.043
.007
<.0001
<.0001
CABG, coronary artery bypass graft surgery; NYHA, New York Heart Association.
*Reference group was BMI <30 kg/m2.
Mortalité à 30 jours et durée de séjour significativement
augmentées en cas de CPOM
caused by gram-negative bacilli (GNB), and 79 (23.2%) caused by
other pathogens. Of the 179 staphylococcal MPIs, CoNS was found
in 92 (51.4%) cases, and S aureus as a single species accounted for
the other 87 cases (48.6%). Almost half (48.3%) of the S aureus MPIs
were due to methicillin-resistant S aureus (MRSA).
The most common GNBs associated with MPI were Enter-
Table 2 presents the characteristics of patients with MPI stratified by organism. Patients with MPI due to GNB had a higher rate of
comorbidities, such as cerebrovascular disease, peripheral vascular
disease, renal failure, and immunosuppressive therapy.
Outcomes of patients with MPIs
Résultats (P2) :
facteurs prédictifs
Analyse univariée
965
L.F. Chen et al. / American Journal of Infection Control 40 (2012) 963-8
Table 1
Risk factors and outcomes of MPI
Variable
Risk factors
Caucasian
BMI, kg/m2*
"30 and <40
"40
Emergent surgery
Diabetes
Renal failure
Chronic lung disease
Cerebrovascular accident
Peripheral vascular disease
Immunosuppressive treatment
Previous CABG
Congestive heart failure
NYHA class IV
Outcomes
30-day mortality, n (%)
Postoperative LOS, days, median
Major infection (n ¼ 341)
No major infection (n ¼ 10,181)
Unadjusted OR (95% CI)
278 (81.5)
8,930 (87.7)
0.6 (0.5-0.8)
120
32
15
154
54
(35.2)
(9.4)
(4.4)
(45.2)
(15.8)
3,267
437
210
3,481
550
(32.1)
(4.3)
(2.1)
(34.2)
(5.4)
1.3
2.5
2.2
1.6
3.3
(1.0-1.6)
(1.7-3.7)
(1.3-3.7)
(1.3-2.0)
(2.4-4.5)
.0034
<.0001
<.0001
49
88
22
41
108
121
(14.4)
(25.8)
(6.5)
(12.0)
(31.7)
(35.5)
807
1,640
284
747
2,094
2,702
(7.9)
(16.1)
(2.8)
(7.3)
(20.6)
(26.5)
2.0
1.8
2.4
1.7
1.8
1.5
(1.4-2.7)
(1.4-2.3)
(1.5-3.8)
(1.2-2.4)
(1.4-2.3)
(1.2-1.9)
<.0001
<.0001
<.0001
.0012
<.0001
.0002
29 (8.5)
15.0
227 (2.2)
6.0
P value
.0007
aOR (95% CI)
P value
0.73 (0.54-0.97)
.03
1.31
2.48
1.99
1.25
2.25
0.73
1.57
1.47
1.97
1.72
1.30
1.38
(1.03-1.66)
(1.66-3.71)
(1.13-3.48)
(1.00-1.58)
(1.54-3.28)
(0.55-0.97)
(1.14-2.17)
(1.13-1.92)
(1.23-3.13)
(1.22-2.43)
(1.01-1.67)
(1.09-1.74)
.028
<.0001
.017
.063
<.0001
.029
.006
.004
.005
.002
.043
.007
<.0001
<.0001
CABG, coronary artery bypass graft surgery; NYHA, New York Heart Association.
*Reference group was BMI <30 kg/m2.
caused by gram-negative bacilli (GNB), and 79 (23.2%) caused by
Table 2 presents the characteristics of patients with MPI strati-
Résultats (P2) :
facteurs prédictifs
Analyse multivariée
965
L.F. Chen et al. / American Journal of Infection Control 40 (2012) 963-8
Table 1
Risk factors and outcomes of MPI
Variable
Risk factors
Caucasian
BMI, kg/m2*
"30 and <40
"40
Emergent surgery
Diabetes
Renal failure
Chronic lung disease
Cerebrovascular accident
Peripheral vascular disease
Immunosuppressive treatment
Previous CABG
Congestive heart failure
NYHA class IV
Outcomes
30-day mortality, n (%)
Postoperative LOS, days, median
Major infection (n ¼ 341)
No major infection (n ¼ 10,181)
Unadjusted OR (95% CI)
278 (81.5)
8,930 (87.7)
0.6 (0.5-0.8)
120
32
15
154
54
(35.2)
(9.4)
(4.4)
(45.2)
(15.8)
3,267
437
210
3,481
550
(32.1)
(4.3)
(2.1)
(34.2)
(5.4)
1.3
2.5
2.2
1.6
3.3
(1.0-1.6)
(1.7-3.7)
(1.3-3.7)
(1.3-2.0)
(2.4-4.5)
.0034
<.0001
<.0001
49
88
22
41
108
121
(14.4)
(25.8)
(6.5)
(12.0)
(31.7)
(35.5)
807
1,640
284
747
2,094
2,702
(7.9)
(16.1)
(2.8)
(7.3)
(20.6)
(26.5)
2.0
1.8
2.4
1.7
1.8
1.5
(1.4-2.7)
(1.4-2.3)
(1.5-3.8)
(1.2-2.4)
(1.4-2.3)
(1.2-1.9)
<.0001
<.0001
<.0001
.0012
<.0001
.0002
29 (8.5)
15.0
227 (2.2)
6.0
P value
.0007
aOR (95% CI)
P value
0.73 (0.54-0.97)
.03
1.31
2.48
1.99
1.25
2.25
0.73
1.57
1.47
1.97
1.72
1.30
1.38
(1.03-1.66)
(1.66-3.71)
(1.13-3.48)
(1.00-1.58)
(1.54-3.28)
(0.55-0.97)
(1.14-2.17)
(1.13-1.92)
(1.23-3.13)
(1.22-2.43)
(1.01-1.67)
(1.09-1.74)
.028
<.0001
.017
.063
<.0001
.029
.006
.004
.005
.002
.043
.007
<.0001
<.0001
CABG, coronary artery bypass graft surgery; NYHA, New York Heart Association.
*Reference group was BMI <30 kg/m2.
caused by gram-negative bacilli (GNB), and 79 (23.2%) caused by
Table 2 presents the characteristics of patients with MPI strati-
Résultats (P2) :
facteurs prédictifs
Analyse multivariée
965
L.F. Chen et al. / American Journal of Infection Control 40 (2012) 963-8
Table 1
Risk factors and outcomes of MPI
Variable
Risk factors
Caucasian
BMI, kg/m2*
"30 and <40
"40
Emergent surgery
Diabetes
Renal failure
Chronic lung disease
Cerebrovascular accident
Peripheral vascular disease
Immunosuppressive treatment
Previous CABG
Congestive heart failure
NYHA class IV
Outcomes
30-day mortality, n (%)
Postoperative LOS, days, median
Major infection (n ¼ 341)
No major infection (n ¼ 10,181)
Unadjusted OR (95% CI)
278 (81.5)
8,930 (87.7)
0.6 (0.5-0.8)
120
32
15
154
54
(35.2)
(9.4)
(4.4)
(45.2)
(15.8)
3,267
437
210
3,481
550
(32.1)
(4.3)
(2.1)
(34.2)
(5.4)
1.3
2.5
2.2
1.6
3.3
(1.0-1.6)
(1.7-3.7)
(1.3-3.7)
(1.3-2.0)
(2.4-4.5)
.0034
<.0001
<.0001
49
88
22
41
108
121
(14.4)
(25.8)
(6.5)
(12.0)
(31.7)
(35.5)
807
1,640
284
747
2,094
2,702
(7.9)
(16.1)
(2.8)
(7.3)
(20.6)
(26.5)
2.0
1.8
2.4
1.7
1.8
1.5
(1.4-2.7)
(1.4-2.3)
(1.5-3.8)
(1.2-2.4)
(1.4-2.3)
(1.2-1.9)
<.0001
<.0001
<.0001
.0012
<.0001
.0002
29 (8.5)
15.0
227 (2.2)
6.0
P value
.0007
aOR (95% CI)
P value
0.73 (0.54-0.97)
.03
1.31
2.48
1.99
1.25
2.25
0.73
1.57
1.47
1.97
1.72
1.30
1.38
(1.03-1.66)
(1.66-3.71)
(1.13-3.48)
(1.00-1.58)
(1.54-3.28)
(0.55-0.97)
(1.14-2.17)
(1.13-1.92)
(1.23-3.13)
(1.22-2.43)
(1.01-1.67)
(1.09-1.74)
.028
<.0001
.017
.063
<.0001
.029
.006
.004
.005
.002
.043
.007
<.0001
<.0001
CABG, coronary artery bypass graft surgery; NYHA, New York Heart Association.
*Reference group was BMI <30 kg/m2.
caused by gram-negative bacilli (GNB), and 79 (23.2%) caused by
Table 2 presents the characteristics of patients with MPI strati-
accounting for only 12% of GNB MPIs. Other miscellaneous pathogens associated with MPI included streptococci, enterococci, other
gram-positive cocci, and fungi.
Both categories of staphylococci, S aureus (25.5%) and CoNS
(27.0%), were closely associated with the development of MPIs. In
addition, S aureus was a frequent pathogen in MPIs that simultaneously involved BSIs and sternal SSIs (48.4%). GNB were the most
common pathogens associated with BSIs, found in 59 of 186 cases
(32%). CoNS was the most common pathogen associated with
SSIs (35%).
Mortality varied substantially by the presence of MPI and the type
of causative pathogen. Specific 30-day mortality was 8.5% in
patients with MPI and only 2.2% in those without MPI (P < .0001)
(Table 1). Unadjusted pathogen-specific 30-day mortality was
significantly higher (P < .0001) for patients with MPIs due to GNB
(10 of 83; 12.1%) and patients with MPIs due to S aureus (10 of 87;
11.5%) compared with either CoNS (3 of 92; 3.3%) or other pathogens (6 of 79; 7.6%) (Table 2).
The median LOS for the study patients was 6 days (interquartile
range [IQR], 5-8 days). The presence of an MPI extended the
Résultats (P2) : germes
Table 2
Baseline characteristics and outcomes of MPI by pathogen type
Variable
Any S aureus (n ¼ 87)
Risk factors, n (%)
BMI, kg/m2*
"30 and <40
32 (36.8)
"40
8 (9.2)
Emergent procedure
3 (3.5)
Diabetes
42 (48.3)
Renal failure
13 (14.9)
Cerebrovascular accident
12 (13.9)
Peripheral vascular disease
20 (23.0)
Immunosuppressive treatment
2 (2.3)
Previous CABG
9 (10.3)
Myocardial infarction
47 (54.0)
Congestive heart failure
21 (24.1)
NYHA class IV
28 (32.2)
30-day infection type (infected patients), n (%)
SSI only
36 (41.4)
BSI only
36 (41.4)
SSI and BSI
15 (17.2)
Outcomes
30-day mortality, n (%)
10 (11.5)
Postoperative LOS, days, median
11.0
48,3 % de SAMS
Any gram-negative bacteria
(no S aureus infection) (n ¼ 83)
CABG, coronary artery bypass graft surgery; NYHA, New York Heart Association.
*Reference group was BMI <30 kg/m2.
32
5
5
35
19
14
25
10
16
50
30
34
(38.6)
(6.0)
(6.0)
(42.2)
(22.9)
(16.9)
(30.1)
(12.1)
(19.3)
(60.2)
(36.1)
(41.0)
CoNS only (n ¼ 92)
35
12
7
44
14
13
24
5
12
50
31
31
(38.0)
(13.0)
(7.6)
(47.8)
(15.2)
(14.1)
(26.1)
(5.4)
(13.0)
(54.4)
(33.7)
(33.7)
Other pathogens (n ¼ 79)
21
7
0
33
8
10
19
5
4
41
26
28
(26.6)
(8.9)
(0.0)
(41.8)
(10.1)
(12.7)
(24.1)
(6.3)
(5.1)
(51.9)
(32.9)
(35.4)
P value
<.0001
.0002
.0008
<.0001
.0007
<.0001
<.0001
.0001
<.0001
<.0001
.0040
15 (18.1)
59 (71.1)
9 (10.8)
43 (46.7)
47 (51.1)
2 (2.2)
30 (38.0)
44 (55.7)
5 (6.3)
<.0001
10 (12.1)
22.0
3 (3.3)
14.0
6 (7.6)
13.0
<.0001
<.0001
gram-positive cocci, and fungi.
Both categories of staphylococci, S aureus (25.5%) and CoNS
(27.0%), were closely associated with the development of MPIs. In
addition, S aureus was a frequent pathogen in MPIs that simultaneously involved BSIs and sternal SSIs (48.4%). GNB were the most
common pathogens associated with BSIs, found in 59 of 186 cases
(32%). CoNS was the most common pathogen associated with
SSIs (35%).
patients with MPI and only 2.2% in those without MPI (P < .0001)
(Table 1). Unadjusted pathogen-specific 30-day mortality was
significantly higher (P < .0001) for patients with MPIs due to GNB
(10 of 83; 12.1%) and patients with MPIs due to S aureus (10 of 87;
11.5%) compared with either CoNS (3 of 92; 3.3%) or other pathogens (6 of 79; 7.6%) (Table 2).
The median LOS for the study patients was 6 days (interquartile
range [IQR], 5-8 days). The presence of an MPI extended the
Résultats (P2) : germes
Table 2
Baseline characteristics and outcomes of MPI by pathogen type
Variable
Any S aureus (n ¼ 87)
Risk factors, n (%)
BMI, kg/m2*
"30 and <40
32 (36.8)
"40
8 (9.2)
Emergent procedure
3 (3.5)
Diabetes
42 (48.3)
Renal failure
13 (14.9)
Cerebrovascular accident
12 (13.9)
Peripheral vascular disease
20 (23.0)
Immunosuppressive treatment
2 (2.3)
Previous CABG
9 (10.3)
Myocardial infarction
47 (54.0)
Congestive heart failure
21 (24.1)
NYHA class IV
28 (32.2)
30-day infection type (infected patients), n (%)
SSI only
36 (41.4)
BSI only
36 (41.4)
SSI and BSI
15 (17.2)
Outcomes
30-day mortality, n (%)
10 (11.5)
Postoperative LOS, days, median
11.0
Any gram-negative bacteria
(no S aureus infection) (n ¼ 83)
32
5
5
35
19
14
25
10
16
50
30
34
(38.6)
(6.0)
(6.0)
(42.2)
(22.9)
(16.9)
(30.1)
(12.1)
(19.3)
(60.2)
(36.1)
(41.0)
CoNS only (n ¼ 92)
35
12
7
44
14
13
24
5
12
50
31
31
(38.0)
(13.0)
(7.6)
(47.8)
(15.2)
(14.1)
(26.1)
(5.4)
(13.0)
(54.4)
(33.7)
(33.7)
Other pathogens (n ¼ 79)
21
7
0
33
8
10
19
5
4
41
26
28
(26.6)
(8.9)
(0.0)
(41.8)
(10.1)
(12.7)
(24.1)
(6.3)
(5.1)
(51.9)
(32.9)
(35.4)
P value
<.0001
.0002
.0008
<.0001
.0007
<.0001
<.0001
.0001
<.0001
<.0001
.0040
15 (18.1)
59 (71.1)
9 (10.8)
43 (46.7)
47 (51.1)
2 (2.2)
30 (38.0)
44 (55.7)
5 (6.3)
<.0001
10 (12.1)
22.0
3 (3.3)
14.0
6 (7.6)
13.0
<.0001
<.0001
CABG, coronary artery bypass graft surgery; NYHA, New York Heart Association.
*Reference group was BMI <30 kg/m2.
Une CPOM à S. aureus ou à BGN augmentait significativement le risque de mortalité à
30 jours par rapport à une CPOM à SCN ou à un autre germe
gram-positive cocci, and fungi.
Both categories of staphylococci, S aureus (25.5%) and CoNS
(27.0%), were closely associated with the development of MPIs. In
addition, S aureus was a frequent pathogen in MPIs that simultaneously involved BSIs and sternal SSIs (48.4%). GNB were the most
common pathogens associated with BSIs, found in 59 of 186 cases
(32%). CoNS was the most common pathogen associated with
SSIs (35%).
patients with MPI and only 2.2% in those without MPI (P < .0001)
(Table 1). Unadjusted pathogen-specific 30-day mortality was
significantly higher (P < .0001) for patients with MPIs due to GNB
(10 of 83; 12.1%) and patients with MPIs due to S aureus (10 of 87;
11.5%) compared with either CoNS (3 of 92; 3.3%) or other pathogens (6 of 79; 7.6%) (Table 2).
The median LOS for the study patients was 6 days (interquartile
range [IQR], 5-8 days). The presence of an MPI extended the
Résultats (P2) : germes
Table 2
Baseline characteristics and outcomes of MPI by pathogen type
Variable
Any S aureus (n ¼ 87)
Risk factors, n (%)
BMI, kg/m2*
"30 and <40
32 (36.8)
"40
8 (9.2)
Emergent procedure
3 (3.5)
Diabetes
42 (48.3)
Renal failure
13 (14.9)
Cerebrovascular accident
12 (13.9)
Peripheral vascular disease
20 (23.0)
Immunosuppressive treatment
2 (2.3)
Previous CABG
9 (10.3)
Myocardial infarction
47 (54.0)
Congestive heart failure
21 (24.1)
NYHA class IV
28 (32.2)
30-day infection type (infected patients), n (%)
SSI only
36 (41.4)
BSI only
36 (41.4)
SSI and BSI
15 (17.2)
Outcomes
30-day mortality, n (%)
10 (11.5)
Postoperative LOS, days, median
11.0
Any gram-negative bacteria
(no S aureus infection) (n ¼ 83)
32
5
5
35
19
14
25
10
16
50
30
34
(38.6)
(6.0)
(6.0)
(42.2)
(22.9)
(16.9)
(30.1)
(12.1)
(19.3)
(60.2)
(36.1)
(41.0)
CoNS only (n ¼ 92)
35
12
7
44
14
13
24
5
12
50
31
31
(38.0)
(13.0)
(7.6)
(47.8)
(15.2)
(14.1)
(26.1)
(5.4)
(13.0)
(54.4)
(33.7)
(33.7)
Other pathogens (n ¼ 79)
21
7
0
33
8
10
19
5
4
41
26
28
(26.6)
(8.9)
(0.0)
(41.8)
(10.1)
(12.7)
(24.1)
(6.3)
(5.1)
(51.9)
(32.9)
(35.4)
P value
<.0001
.0002
.0008
<.0001
.0007
<.0001
<.0001
.0001
<.0001
<.0001
.0040
15 (18.1)
59 (71.1)
9 (10.8)
43 (46.7)
47 (51.1)
2 (2.2)
30 (38.0)
44 (55.7)
5 (6.3)
<.0001
10 (12.1)
22.0
3 (3.3)
14.0
6 (7.6)
13.0
<.0001
<.0001
CABG, coronary artery bypass graft surgery; NYHA, New York Heart Association.
*Reference group was BMI <30 kg/m2.
Et donc une CPOM à S. aureus ou à BGN apparaissaient être des facteurs prédictifs
de la mortalité à 30 jours
Résultats : germes
(régression logistique : OR)
966
L.F. Chen et al. / American Journal of In
Table 3
Association between pathogen-specific MPI and 30-day mortality
Odds for 30 day-mortality
aOR
95% CI
Final model 1: includes all enrolled patients
Uninfected individuals
1.00
Reference
MPI due to S aureus
3.67
1.74-7.74
MPI due to any gram-negative bacillus
3.00
1.45-6.24
MPI due to other pathogens
2.51
1.04-6.08
MPI due to CoNSz
0.79
0.24-2.63
Final model 2: includes only enrolled patients with MPI
MPI due to CoNS
1.00
Reference
MPI due to S aureus
4.70
1.19-18.5
MPI due to any gram-negative bacillus
3.12
0.80-12.2
MPI due to other pathogens
2.63
0.62-11.3
P value
<.001
.003
.040
.698
.027
.10
.19
Résultats : germes
(régression logistique : OR)
966
L.F. Chen et al. / American Journal of In
Table 3
Association between pathogen-specific MPI and 30-day mortality
Odds for 30 day-mortality
aOR
95% CI
Final model 1: includes all enrolled patients
Uninfected individuals
1.00
Reference
MPI due to S aureus
3.67
1.74-7.74
MPI due to any gram-negative bacillus
3.00
1.45-6.24
MPI due to other pathogens
2.51
1.04-6.08
MPI due to CoNSz
0.79
0.24-2.63
Final model 2: includes only enrolled patients with MPI
MPI due to CoNS
1.00
Reference
MPI due to S aureus
4.70
1.19-18.5
MPI due to any gram-negative bacillus
3.12
0.80-12.2
MPI due to other pathogens
2.63
0.62-11.3
P value
<.001
.003
.040
.698
.027
.10
.19
Discussion
• taux de CPOM comparable aux autres études
Discussion
• Plus forte morbimortalité avec S. aureus :
-
germe fréquemment en cause dans les infections postop.
-
germe fréquemment associé à d’autres facteurs prédictifs
(obésité, comorbidités...)
difficultés à traiter ce germe efficacement (SAMR +++)
difficultés de couverture de ce germe par
l’antibioprophylaxie préopératoire standard (SAMR +++)
Discussion
• Plus forte morbimortalité en cas d’obésité :
-
facteur prédictif retrouvé dans la littérature
-
relation dose-effet supposé
association à d’autres comorbidités
difficulté d’une antibioprophylaxie préopératoire
suffisante (fonction du poids...)
Discussion
• certains des facteurs prédictifs : difficiles à
corriger en pratique
• éventuellement, renforcer les mesures
préventives préopératoires pour les patients à
haut risque de CPOM (antibioprophylaxie...)
Discussion
• Diminution du taux d’incidence au cours de
l’étude de 5,4 % en 2000 à 2,6 % en 2004
• due à la mise en place de plans préventifs,
notamment pour les CVC
Discussion : limites
• critères de validation des CPOM différents de
ceux de la National Healthcare Safety Network
• pas de prise en compte des sites de chirurgie
secondaires (prélèvement de la saphène pour un
pontage...) pouvant augmenter également la MM
• antibioprophylaxie non connue (présente ou
non, molécule, posologie)
• compliance aux soins non connue
Conclusion (des auteurs)
• La microbiologie influençait la survenue et la
sévérité des CPOM
• La présence de S. aureus était le facteur de
risque prédominant pour la mortalité
postopératoire à 30 jours
• D’autres facteurs, notamment l’obésité, étaient
prédictifs de CPOM
Ouverture
• essais de prévention
• sur l’efficacité de corriger les facteurs
prédictifs identifiés pour réduire les CPOM et
la morbimortalité dans la chirurgie cardiaque