Sternal surgical site infection prevention - is there any room for improvement?

The objectives of this multicenter study are to evaluate current clinical practices in cardiac surgery concerning the prevention and management of sternal wound infections, to identify room for improvement, and to support implementation of systematic measures.

As a part of a campaign for infection prevention in cardiac surgery in Germany, a multiple-choice questionnaire with two main sections was developed and submitted to all cardiac surgery units in Germany (79). The project was realized in cooperation with the German Society for Thoracic and Cardiovascular Surgery, the BQS Institute for Quality and Patient Safety, and the National Reference Center for Nosocomial Infection Surveillance.

A representative number (54 of 79 or 68%) of German cardiac surgery centers participated in the survey, in which heterogeneous procedures and various standards for prevention were observed. Surveillance, standards, and advanced training regarding hygiene measures are present in almost all participating hospitals. Methicillin-resistant Streptococcus aureus (MRSA) screening is performed in 81.5% (44/54) of all participating departments. A little less than one-tenth (7.4%) perform decolonization measures on all patients, while 85.2% perform decolonization measures only on MRSA-positive patients. Application of perioperative antibiotic prophylaxis ranges from single-shot application to 3 days of treatment. Longer treatment is expensive and time-intensive, and also increases the risk of Clostridium difficile-associated diarrhea. Nearly three-quarters (70.4%) of all participating hospitals perform preoperative hair removal 1 day before surgery. Common techniques are clipping machines (53.7%), razors (40.7%), clipping machines and depilatory cream (1.9%), or depilatory cream only (1.9%). Remanent (37.0%) and non-remanent disinfectants (55.6%) are used for preoperative skin disinfection. The time of the first wound-dressing change varies from the day of surgery (1.9%) over the first (42.6%) or second (46.3%) day after surgery to up to 3 or more days after surgery (9.3%).

The results of the evaluation show that basic measures for infection prevention in cardiac surgery in Germany are well implemented. Nevertheless, a relevant heterogeneity in the use of special measures was observed, although research-based guidelines for infection prevention in surgery do exist and many studies have demonstrated the usefulness and feasibility of these measures.