ABC | Volume 112, Nº6, June 2019

Original Article Andrade et al. Surgical site infection prevention bundle in cardiac surgery Arq Bras Cardiol. 2019; 112(6):769-774 Table 2 – Multivariate Analysis. Poisson Regression Risk Factor Odds Ratio (OR) Confidence Interval (IC) p Surgical risk index 2.575 1.224–5416 0.013 Public vs. private healthcare 1.473 0.974–2.229 0.067 Systemic arterial hypertension 1.770 0.877–3.573 0.111 Diabetes mellitus 1.678 1.168–2.409 0.005 Dyslipidemia 1.083 0.777–1.510 0.637 Obesity 2.068 1.457–2.936 < 0.001 Adequate glycemia (< 200 mg/dl) 1.077 0.724–1.601 0.715 Blood glucose level 1.004 1.001–1.007 0.007 In our study, 96% of patients used either a first or second- generation cephalosporin. Meta-analysis evidenced that the use of cefuroxime as a cardiac surgery prophylaxis demonstrated better protection against respiratory infections in the immediate preoperative period. Although our study did not evaluate this type of outcome, there was no difference in the comparison between cefazolin (institutional protocol effective before May 2014) and cefuroxime (institution recommendation as of June 2014) for SSI (data not shown). The prevention bundle used at our research institution included six preventive measures. Complete adherence to the bundle was not associated with reduced risk of surgical infections. Regarding the CDC’s bundle of measures, it establishes the following preventive measures with respect to the perioperative period: surgical antibiotic prophylaxis during the pre-, intra-, and postoperative periods; performing hair removal when necessary, without the use of razors; blood glucose level control during the pre- and postoperative periods; normothermia throughout the perioperative period; optimization of tissue oxygenation; skin preparation with alcoholic solutions; and finally the use of the Surgical Safety Checklist. 3 Blood glucose level alone was associated with a reduced surgical infection risk. Nonetheless, dichotomized levels below 200 mg/dl were not associated with reduced infection rates. Various studies have associated blood glucose level with risk of infection in cardiac surgery. There is recent evidence that strict blood glucose control (levels below 180 mg/dl) can Table 1 – Sociodemographic data associated with SSI SSI (N/%) No infection (N/%) Total (N) Male sex 92 (64.8%) 1,057 (67.9%) 1,149 Type of procedure – Myocardial revascularization 85 (8.4%) 923 (91.6%) 1,008 – Valve replacement 49 (34.5%) 545 (35.0%) 594 – Aortic dissection 8 (5.6%) 88 (5.7%) 96 Hypertension 133 (94.3%) 1,345 (87.2%) 1,478 Tobacco use 63 (44.7%) 620 (40.2%) 683 Diabetes mellitus 75 (53.2%) 484 (31.4%) 559 Dyslipidemia 58 (41.1%) 504 (32.7%) 562 Obesity 38 (27.1%) 169 (11.0%) 207 COPD 7 (5.0%) 70 (4.5%) 77 Renal insufficiency 9 (6.3%) 84 (5.4%) 93 Public healthcare 112 (78.9%) 1,061 (68.2%) 1,173 ASA class III 111 (78.2%) 1,282 (82.4%) 1,393 Adequate use of antibiotic bundle 33 (23.2%) 332 (21.4%) 365 Complete adherence to total bundle 6 (4.3%) 61 (3.9%) 67 Death 11 (7.7%) 165 (10.6%) 176 SSI: surgical site infection; COPD: chronic obstructive pulmonary disease; ASA: American Society of Anesthesiologists. 771