ABC | Volume 112, Nº6, June 2019

Original Article Surgical Site Infection Prevention Bundle in Cardiac Surgery Lilian Silva de Andrad e, E rci Maria Onzi Siliprandi , Larissa Lemos Karsbur g, F rancine Possebon Berlesi , Otávio Luiz da Fontoura Carvalh o, Darlan Sebastião da Ros a, R odrigo Pires dos Santos Instituto de Cardiologia do Rio Grande do Sul - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS – Brazil Mailing Address: Lilian de Andrade • Avenida Princesa Isabel, 395, setor SCIH. Postal Code 90040-371, Santana, Porto Alegre, RS – Brazil E-mail: lilianandrade16@gmail.com Manuscript received June 01, 2018, revised manuscript September 05, 2018, accepted November 01, 2018 DOI: 10.5935/abc.20190070 Abstract Background: Surgical site infections (SSI) are among the most prevalent infections in healthcare institutions, attributing a risk of death which varies from 33% to 77% and a 2- to 11-fold increase in risk of death. Patients submitted to cardiac surgery are more susceptible to SSI, accounting for 3.5% to 21% of SSI. The mortality rate attributable to these causes is as high as 25%. Prevention of SSI in cardiac surgery is based on a bundle of preventive measures, which focus on modifiable risks. Objective: The objective of this study was to identify SSI risk factors in clean cardiac surgery. Methods: A retrospective cohort study analyzed 1,846 medical records from patients who underwent clean cardiac surgery. Fisher’s exact test was used for bivariate comparison, and Poisson regression was used for independent analysis of SSI risk, considering a significance level of p < 0.05. Results: The results of the study comprised a multivariate analysis. The variables that were associated with the diagnosis of SSI were: surgical risk index (OR: 2.575; CI: 1.224–5.416), obesity (OR: 2.068; CI: 1.457–2.936), diabetes mellitus (OR: 1,678; CI: 1.168–2.409), and blood glucose level (OR: 1.004; CI: 1.001–1.007). Conclusions: This study evidenced that complete adherence to the bundle was not associated with a reduction in the risk of surgical infections. Diabetes mellitus, obesity, and surgical risk index assessment were, however, identified to increase association and consequently risk of SSI in cardiac surgery. (Arq Bras Cardiol. 2019; 112(6):769-774) Keywords: Cardiac Surgical Procedures; Adult; Risk Factors/prevention and control; Patient Care Bundles; Anti-Infective Agents; Surgical Wound Infection; Cross Infection. Introduction Healthcare associated infections (HAI) are defined as any infection that occurs in a patient during the process of care in a health facility within 48 to 72 hours of initial contact with the healthcare system. Infection rates are higher in developing countries and in intensive care units. 1,2 Surgical site infections (SSI) are among the most prevalent in health institutions. In the United States, in the year 2011, SSI affected an average of 157,500 patients. The risk of death attributable to this type of infection is high, varying from 33% to 77%, and SSI are associated with a 2- to 11-fold increase in risk of death. 3 Patients who undergo cardiac surgery are particularly susceptible to hospital infections and SSI, which result in further interventions and additional costs for the health institution. SSI rates can vary from 3.5% to 21%, and the mortality rate due to these causes can reach 25%. 4,5 Various risk factors are associated with SSI in cardiac surgery, including: age, nutritional status, diabetes mellitus, tobacco use, obesity, coexistence of infections in other sites, length of preoperative stay, skin preparation, mechanical ventilation, failure to comply with aseptic techniques, inadequate hand hygiene, distractions in the operating area, number of times doors are opened, and other environment-related factors. 6 “Bundles” of preventive measures applied to surgical procedures have been effective in reducing infection rates. These measures include: delivering antibiotic prophylaxis within 1 hour before incision, discontinuing antibiotic use within 48 hours after cardiac surgery, performing hair removal during the immediate preoperative period, maintaining intraoperative normothermia of 35.5ºC or more, and blood glucose control during the immediate postoperative period, extended for 48 hours after the procedure. 7 The objective of this study was to identify risk factors for SSI in major clean cardiac surgery procedures in a cardiology referral center. Methods This is a retrospective cohort study, conducted in the Instituto de Cardiologia (Cardiology Institute), a hospital with 250 beds for cardiology patients in the South of Brazil. The study evaluated patients who underwent major surgical procedures with and without the use of extracorporeal circulation during the period from January 2013 to December 2014. The study included all major surgeries in adults (age 18 or over). The following were excluded: pediatric patients, patients with incomplete medical records data, patients who died during immediate pre-, intra-, or postoperative, and patients who were hospitalized for less than 48 hours. 769