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The epidemiology and consequences of wound infections caused by coagulase negative staphylococci after thoracic surgery
Linköping University, Department of Molecular and Clinical Medicine, Infectious Diseases. Linköping University, Faculty of Health Sciences.
2002 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

Nosocomial infections in general and postoperative infections in pmticular are important aspects of modern health care. They are important factors to be taken into account when planning and organizing any kind of surgery. Thoracic surgery has become a common and important form of surgery involving significant amounts of patients and resources. Different kinds of infectious complications are not uncommon and cause considerable problems. Many microbes have been implicated in post-operative infections, but one of the most important ones in activities such as thoracic surgety is Coagulase Negative Staphylococci (CoNS). They exist in our environment and produce infections that are difficult to diagnose and complicated to treat. The source of the infections and the transmission routes remain to a great extent unclear.

Aims

To describe the basic epidemiology of sterna! infections after cardiac surgery and to find early indications of infections.To investigate the epidemiology of Coagulase Negative Staphylococci causing sternal infections and to describe the development of antibiotic resistance.

Methods and results

To describe and evaluate the impact of infections after thoracic surgety in our hospital we followed different patient populations. When examining the patients being infected we could show that risk factors mostly involved surgery and hospital related variables. The diagnosis of the infections was often late and the treatment is difficult and consuming major resomces. The late diagnosis could be explained by the discrete symptoms and that a marker for infection like CRP are difficult to evaluate in the post-operative patient. With increased surveillance of the wounds an earlier diagnosis would be possible. Following the development of the management of the infections in our hospital during the 90's we could also show that the time to diagnosis and the treatment periods became shorter.

CoNS caused the majority of the infections in our patients with little change during the 10-year petiod. Preliminary results indicate that the source of the CoNS is the hospital environment in a majority of the serious infections. The place and route of transmission is unclear but the operating theatre remains a possible place of transmissions. Even if the resistance patterns of the CoNS are quite diverse they are often multi resistant and to a substantial degree vancomycin remains the only antibiotic that can be used for the treatment.

Conclusions

Wound infections after cardiac surgery are an important cause of morbidity and mortality, and CoNS play a major role in these infections. Risk factors that contribute to the infections are often associated with complicated surgery. Symptoms of the infections are often discrete and the diagnosis and treatment of the infections often stmt late. Intensified surveillance of the wounds could improve management of infections. We found a clone of CoNS causing a majority of the infections indicating that the source of the bacteria is often the hospital environment. CoNS as a major pathogen makes antibiotic treatment difficult, and there is a high risk of extensive antibiotic resistance.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2002. , 35 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 742
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-26672Local ID: 11239ISBN: 91-7373-186-2 (print)OAI: oai:DiVA.org:liu-26672DiVA: diva2:247221
Public defence
2002-09-27, Elsa Brändsströmsalen, Universitetssjukhuset, Linköping, 13:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-19Bibliographically approved
List of papers
1. Coagulase-negative staphylococci and sternal infections after cardiac operation
Open this publication in new window or tab >>Coagulase-negative staphylococci and sternal infections after cardiac operation
2000 (English)In: Annals of Thoracic Surgery, ISSN 0003-4975, E-ISSN 1552-6259, Vol. 69, no 4, 1104-1119 p.Article in journal (Refereed) Published
Abstract [en]

Background. Coagulase negative staphylococci (CoNS) have been recognized as important pathogens in nosocomial infections, especially in connection with implanted foreign materials. In cardiac operation they are among the most common pathogens isolated from infected sternal wounds. The definition of the infection is very important. In this study we focus on deep postoperative chest infections.

Methods. By studying 33 infected patients retrospectively and comparing them to 33 matched uninfected controls, we studied the characteristics and costs of the infections.

Results. Typical for these infections is the late and insidious onset, and that the infections initially give only minor symptoms such as pain, redness, and serous secretion. We found the following risk factors for infection: number of preoperative days in a hospital, the total length of the operation, and if the patient had undergone an early reoperation due to causes other than infection. This kind of infection more than doubled the hospital costs for the patients affected.

Conclusions. Coagulase negative staphylococci are the most important pathogens in deep postoperative infections in this material. They cause infections that are difficult to recognize since they give only discrete symptoms and start well after the patients leave the hospital. The risk factors for patients with CoNS infections are mostly associated with a long exposure to the hospital environment. The treatment is often difficult and costly because of multiresistant bacteria and frequent need for repeated surgical revisions.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26120 (URN)10.1016/S0003-4975(99)01563-5 (DOI)10579 (Local ID)10579 (Archive number)10579 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
2. Wound infections after cardiac surgery: a Wound Scoring System may Improve Early Detection
Open this publication in new window or tab >>Wound infections after cardiac surgery: a Wound Scoring System may Improve Early Detection
2002 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 36, no 1, 60-64 p.Article in journal (Refereed) Published
Abstract [en]

Objective - This study was aimed at describing the early development of wound infections after cardiac surgery to identify markers for upcoming infections.

Design - We followed a cohort of 200 patients for 3 months after cardiac surgery to establish the incidence of all types of postoperative infections. Wound healing and C-reactive protein (CRP) were followed for the first 2 weeks.

Results - A total of 175 patients out of 200 could be followed up. Using a broad definition of wound infection a total of 30% of the patients had some kind of wound infection. The diagnosis of most infections occurred after the patients had left the cardiac surgery unit (median 12 d after surgery). Our wound scoring method shows significant differences at an early stage between infected and non-infected wounds. At the time of diagnoses CRP was elevated in patients with deep sternal infection.

Conclusion - A long follow-up period is needed to establish the true incidence of infection. Wound scoring can give an early indication of wound infections and CRP can help in the diagnoses of deep infections.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26593 (URN)10.1080/140174302317282401 (DOI)11158 (Local ID)11158 (Archive number)11158 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
3. Changes in the appearance and treatment of deep sternal infections
Open this publication in new window or tab >>Changes in the appearance and treatment of deep sternal infections
2002 (English)In: Journal of Hospital Infection, ISSN 0195-6701, E-ISSN 1532-2939, Vol. 50, no 4, 298-303 p.Article in journal (Refereed) Published
Abstract [en]

The Department of Thoracic Surgery at the University Hospital, Linköping, Sweden, has actively followed up infectious complications of cardiac surgery since 1989. The aim of this study was to investigate whether changes occurred during the 1990s in the appearance and the management of deep infections. This was done by studying patients undergoing surgical revision of infected wounds. We studied 42 patients during 1990–94 and 49 during 1997–98 (total number of operations in these periods, 3075 and 1646, respectively). Pre-operative and intra-operative variables were recorded for the two patient populations. The proportion of cardiac surgery procedures followed by a surgical revision for an infection in the sternal wound increased between the two periods (1.4% vs. 3.0%). Variables associated with the surgical procedures preceding the infection remained unchanged. In the later period, treatment was started earlier (64 vs. 24 days), and the length of antibiotic treatment was decreased (115 vs. 72 days). The incidence of osteomyelitis of the sternal bone was lower (61% vs. 27%). It appears that as the proportion of patients undergoing surgical revision increased, management of the infections became more effective, with aggressive surgical and antibiotic treatment policies and shorter treatment periods. This indicates that in order to evaluate the overall impact of measures designed to reduce infections after cardiac surgery, not only the incidence of infection needs to be followed up but other factors also need to be taken into account.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26497 (URN)10.1053/jhin.2002.1178 (DOI)11053 (Local ID)11053 (Archive number)11053 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
4. A clone of coagulase-negative staphylococci among patients with post-cardiac surgery infections
Open this publication in new window or tab >>A clone of coagulase-negative staphylococci among patients with post-cardiac surgery infections
Show others...
2002 (English)In: Journal of Hospital Infection, ISSN 0195-6701, E-ISSN 1532-2939, Vol. 52, no 1, 37-42 p.Article in journal (Refereed) Published
Abstract [en]

Coagulase-negative staphylococci (CoNS) are important causes of hospital-acquired infections such as infections after cardiac surgery. Efforts to reduce these infections are hampered by the lack of knowledge concerning the epidemiology of CoNS in this setting. Forty strains of CoNS collected during the surgical revision of 27 patients operated on between 1997 and 2000 were analysed. Strains were also collected from the ambient air in the operating suite. Their pulsed-field gel electrophoresis (PFGE) characteristics and antibiotic resistance were analysed. Using PFGE 19 of 40 strains from 15 of 27 patients were shown to belong to one clone, and strains from this clone were also isolated from the ambient air. This clone had caused infections throughout the period. Antibiotic resistance did not correlate with PFGE patterns. Using PFGE one clone could be identified that caused 56% of the CoNS infections during this period. A strain from this clone was also found in the air of the operating suite suggesting the origin of the CoNS causing infections was the hospital environment.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26496 (URN)10.1053/jhin.2002.1267 (DOI)11052 (Local ID)11052 (Archive number)11052 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
5. Study of developed resistance due to antibiotic treatment of coagulase-negative staphylococci
Open this publication in new window or tab >>Study of developed resistance due to antibiotic treatment of coagulase-negative staphylococci
Show others...
2003 (English)In: Microbial Drug Resistance, ISSN 1076-6294, E-ISSN 1931-8448, Vol. 9, no 1, 1-6 p.Article in journal (Refereed) Published
Abstract [en]

Coagulase-negative Staphylococci (CoNS) are a major cause of postoperative infections. These infections are often associated with foreign material implants and/or a compromised immune system in the patient. Multiresistant strains are increasingly common in the hospital environment and there is concern that the infections will become difficult or impossible to treat. This report is based on a study of 75 patients, with postoperative infections caused by CoNS after thoracic surgery. All patients were treated with surgical revision and antibiotic therapy. One or more bacterial cultures were made in each case, and the resistance pattern of the CoNS found was determined. The goal of the study was to evaluate possible relationships between antibiotic therapy and the appearance of resistance to antibiotics in CoNS found. To describe this relationship, three models were constructed and analyzed by multiple logistic regression. The results indicate an increased resistance to β-lactam antibiotics and clindamycin after the use of cephalosporins. Also, the use of vancomycin or vancomycin combination with rifampicin or fusidic acid increases the risk for development of resistance to β-lactam antibiotics, ciprofloxacin, fusidic acid, clindamycin, netilmycin, and rifampicin. The hypothesis that a combination of antibiotics will curtail the development of resistance was not supported in this study.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-48659 (URN)10.1089/107662903764736283 (DOI)
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-12Bibliographically approved

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