Thirteen-year experience with universal Staphylococcus aureus nasal decolonization prior to cardiac surgery: a quasi-experimental study.

INTRODUCTION: Sternal wound infection (SWI) after cardiac surgery is a severe complication. Among preventive measures, pre-operative decolonization of nasal carriage of Staphylococcus aureus has recently been shown to be beneficial. This quasi-experimental study assessed the effect of decolonization on the incidence of S. aureus-associated SWI based on 19 years of prospective surveillance. METHODS: Segmented negative binomial regression was used to analyse the change over time in the incidence of S. aureus mediastinitis requiring re-operation after cardiac surgery in a French university hospital between 1996 and 2014. Universal nasal decolonization with mupirocin was introduced in December 2001. The association between pre-operative nasal carriage and SWI due to S. aureus was analysed between 2006 and 2012. RESULTS: Among 17,261 patients who underwent a cardiac surgical procedure, 565 developed SWI (3.3%), which was caused by S. aureus in 181 cases (1%). The incidence of mediastinitis caused by S. aureus decreased significantly over the study period (1.43% in 1996-2001 vs 0.61% and 0.64% in 2002-2005 and 2006-2014, respectively; P<0.001). In segmented analysis, there was a significant break in 2002, corresponding to the introduction of decolonization. Despite this intervention, pre-operative nasal carriage remained a significant risk factor for S. aureus mediastinitis (adjusted odds ratio 2.2; 95% confidence interval 1.2-4.2), as were obesity, critical pre-operative status, coronary artery bypass grafting (CABG), and combined surgery with valve replacement and CABG. CONCLUSION: Universal nasal decolonization before cardiac surgery was effective in decreasing the incidence of mediastinitis caused by S. aureus. Nasal carriage of S. aureus remained a risk factor for S. aureus-associated SWI.

Surgical site infection with extended-spectrum ß-lactamase-producing Enterobacteriaceae after cardiac surgery: incidence and risk factors.

OBJECTIVE: To determine the incidence, microbiology and risk factors for sternal wound infection (SWI) with extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) following cardiac surgery. METHODS: We performed a retrospective analysis between January 2006 and December 2015 of prospective surveillance of a cohort of patients with cardiac surgery at a single centre (Paris, France). SWI was defined as the need for reoperation due to sternal infection. All patients with an initial surgery under extracorporeal circulation and diagnosed with an SWI caused by Enterobacteriaceae isolates were included. We compared patients infected with at least one ESBL-PE with those with SWI due to other Enterobacteriaceae by logistic regression analysis. RESULTS: Of the 11 167 patients who underwent cardiac surgery, 412 (3.7%) developed SWI, among which Enterobacteriaceae were isolated in 150 patients (36.5%), including 29 ESBL-PE. The main Enterobacteriaceae (n = 171) were Escherichia coli in 49 patients (29%) and Enterobacter cloacae in 26 (15%). Risk factors for SWI with ESBL-PE in the multivariate logistic regression were previous intensive care unit admission during the preceding 6 months (adjusted odds ratio (aOR) 12.2; 95% CI 3.3-44.8), postoperative intensive care unit stay before surgery for SWI longer than 5 days (aOR 4.6; 95% CI 1.7-11.9) and being born outside France (aOR 3.2; 95% CI 1.2-8.3). CONCLUSIONS: Our results suggest that SWI due to ESBL-PE was associated with preoperative and postoperative unstable state, requiring an intensive care unit stay longer than the usual 24 or 48 postoperative hours, whereas being born outside France may indicate ESBL-PE carriage before hospital admission.

Eclipsed mitral regurgitation: an unusual cause of acute heart failure.

AIMS: So far, a total of five patients with eclipsed mitral regurgitation (MR) have been reported in the literature by three different teams. The aim of this article was to detail clinical and echocardiographic characteristics, and outcome of patients presenting eclipsed MR. METHODS AND RESULTS: We defined eclipsed MR as spontaneous appearance, at rest, from 1 min to the next of an acute restriction in the motion of mitral leaflets preventing coaptation and leading to massive MR in patients with normal left ventricular end-diastolic diameter, left ventricular ejection fraction >45%, and baseline MR ≤2. Spontaneous regression occurred within 30 min, and no obvious trigger such as acute hypertension, new-onset arrhythmia, or myocardial ischaemia is present. Clinical data, ECG, echocardiographic data, surgery report, and follow-up status of six patients with eclipsed MR are reported: all were post-menopausal women with median age of 74 [57-80] years presenting hypertension (4/6), chronic kidney disease (5/6), or chronic anaemia (4/6). Five out of six patients experienced acute pulmonary oedema requiring hospitalization and underwent mitral valve replacement because of heart failure recurrence. Two patients died in the first days after surgery while the three others are free of symptoms at, respectively, 56, 18, and 10 months follow-up. CONCLUSION: Eclipsed MR is a clinical and echocardiographic syndrome responsible for heart failure with preserved EF. It is presently underdiagnosed and should be evoked in cases of recurrent acute pulmonary oedema without obvious trigger, in particular in patients presenting discordant evaluation of MR severity over time.

[Correlation between previous coronary artery stenting and early mortality in patients undergoing coronary artery bypass graft surgery]. / Corrélations entre antécédents d'angioplastie coronaire et mortalité précoce après chirurgie coronaire.

BACKGROUND: In this study, we examine the effect of previous percutaneous intervention on the rate of adverse perioperative outcome in patients undergoing coronary artery bypass graft surgery (CABG). METHODS: Outcomes of 240 CABG patients, collected consecutively in an observational study, were compared. Gp A (n=35) had prior PCI before CABG and Gp B (n=205) underwent primary CABG. RESULTS: Statistically significant results were obtained for the following preoperative criteria: previous myocardial infarction: 48.6% vs 36.6% (P=0.003), distribution of CAD (P=0.0001), unstable angina: 45.7% vs 39% (P=0.04). For intraoperative data, the total number of established bypasses was 2.6 (GpA) vs 2.07 (Gp B) (P=0.017), with the number of arterial bypass grafts being: 20% vs 13% (P=ns). Regarding the postoperative course, no significant difference in troponine I rate, 24-hour bleeding: 962 ml (Gp A) vs 798 ml (Gp B) (P=0.004), transfusion (PRBC unit): 3.63 (Gp A) vs 2.5 (Gp B) (P=0.006). Previous PCI emerged as an independent predictor of postoperative in-hospital mortality (OR 2.24, 95% CI [1.52-2.75], P<0.01). CONCLUSION: Patients with prior PCI presented for CABG with more severe CAD. Thirty-day mortality and morbidity were significantly higher in patients with prior PCI.