Journal of Hospital Infection (2004) 57, 14–24

www.elsevierhealth.com/journals/jhin

Surgical-site infections within 60 days of coronary

artery by-pass graft surgery
C.L. Swennea,b,*, C. Lindholmc, J. Borowieca, M. Carlssonb

a
Department of Cardiothoracic Surgery, Uppsala University Hospital, Thoraxcentrum, ing 40, 4tr,
SE-751 85 Uppsala, Sweden
b
Department of Public Health and Caring Sciences, Uppsala Science Park, SE 751 85 Uppsala, Sweden
c
FoUU-board, Karolinska University Hospital, H4:06, SE-171 76 Stockholm, Sweden

Received 22 October 2003; accepted 30 January 2004

KEYWORDS
Coronary artery by-pass
graft; Surgical wound
infections; Infection
control; Definition; Risk
factor
Summary Surgical wound infections (SWIs) after coronary artery by-pass graft
(CABG) within 30 and 60 days of operation were registered. Already known
risk factors and possible risk factors for wound infection were studied. SWIs of
sternal and/or leg wounds have been reported to occur in 2 –20% of patients
after CABG. Deep sternal infection, mediastinitis, occurs after 0.5 –5% of
CABG procedures. The duration and methods of follow-up, as well as
definitions of SWI, vary in different studies. Previously known and possible
new risk factors were registered for 374 patients. Patients were contacted by
telephone 30 and 60 days after surgery and interviewed in accordance with a
questionnaire about symptoms and signs of wound infections. Our definition
of SWI was based on the Centers for Disease Control and Prevention (CDC)
definition. SWIs were diagnosed in 114 of 374 (30.5%) of the patients. In total
SWI were diagnosed in 120 surgical-site incisions. Almost all SWIs of the
sternum (93.3%) were diagnosed within 30 days of surgery. Most of the SWIs of
the leg (73%) were diagnosed within 30 days of surgery and 27% were
diagnosed within 31 to 60 days of surgery. Being female was the most
important risk factor for SWI of the leg. Low preoperative haemoglobin
concentrations were the most important risk factor for superficial SWI on the
sternum. Patients with mediastinitis had higher BMI and had more often
received erythrocyte transfusions on postoperative day two or later than
those without infections.
Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.

Introduction

Postoperative wound infections are a serious

*Corresponding author. Tel.: þ46-18-611-3994; fax: þ 46-18-
healthcare problem, causing suffering and
50-93-55. increased costs. Surgical wound infections (SWIs)
E-mail address: christine.leo.swenne@akademiska.se of the leg and/or sternal wound have been reported

0195-6701/$ - see front matter Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2004.02.005
SSIs within 60 days of coronary artery by-pass graft surgery
to occur in 2 – 20% of the patients after a coronary
artery by-pass graft (CABG). Deep sternal infection,
mediastinitis, after CABG has been reported to
occur after 0.5 – 5% of the CABG procedures.1 A
Swedish study has shown that postoperative med-
iastinitis increases the hospital costs for CABG
procedure from $15 000 for non-infected patients
to $30 000 for patients with a postoperative sternal
infection.2 In the US, mediastinitis after thoracic
surgery increases costs by $41 559.3
To diagnose SWI after discharge from hospital
has been a demanding task. Different surveillance
protocols have been used with varying degrees of
success. Examples of various methods are: direct
examination of surgical wounds at follow-up visits
to surgery clinics or physicians’ offices,4 or retro-
spective reviews of medical records.5 Other
methods are patient surveys by mail or tele-
phone,6,7 and direct examination conducted else-
where in the healthcare system and reported back
to the infection control office of the operating
hospital.8 – 10
Different definitions of SWI are used in different
studies. The Centers for Disease Control and
Prevention (CDC) definitions of SWI are the most
commonly used in the US,11 but not always in
Europe.12 CDC defines a superficial SWI as one
involving skin and subcutaneous tissues. A deep SWI
is defined as one involving muscle and fascia. An
organ space SWI is defined as an infection involving
any part of the anatomy, other than the incision
opened or manipulated during the operative pro-
cedure. The diagnosis of SWI should be made when
there is purulent discharge from the wound or when
microbiological culture of fluid or tissue from the
wound is positive. The CDC definition also includes
the time restriction that the symptoms of SWI are
present within 30 days of the operative procedure.
Consequently, as a result of this definition medias-
tinitis is organ space SWI.11
After general surgery, trauma surgery, thoracic
surgery and transplant surgery almost 90% of SWIs
occur within 21 days and 96% within 30 days of
surgery.4 However, the incidence of SWIs after
CABG varies among different reports,1 as well as
follow-up time.
Many studies of SWI after CABG have attempted
to discriminate specific risk factors for SWI.3,13,14
Risk factors for SWI may be patient-related or
related to the pre-, intra- and postoperative
surgical treatment and care of the patient. Pre-
viously demonstrated patient-related risk factors
are older age,15 gender,16 obesity,17 current smok-
ing,18 and the presence of diabetes.19 A preopera-
tive risk factor is the duration of preoperative stay
in hospital.2 Intra-operative risk factors are the use
15
of the internal mammary artery (IMA),20 duration of
operation, duration of cardiopulmonary by-pass
(CPB), duration of aortic cross clamping,21 hygiene
in the operating room,22,23 and presence of glove
punctures.24 Postoperative risk factors are reopera-
tion due to causes other than infection2,20 and
erythrocyte concentrate transfusions.25 Although
many of these risk factors are recognized as well-
known and well-documented, they are not consist-
ently demonstrated in all studies.
The first aim of the present study was to register
the incidence of SWI after vein graft harvesting on
the leg and after sternotomy within 60 days of a
CABG procedure using a precise definition of SWI
and attempting to reach a high degree of ascertain-
ment. The second aim was to investigate potential
risk factors for the development of SWI, related to
the patient and the preoperative, intra-operative
and postoperative surgical treatment and care.
Methods
Patients
Patients who were to undergo CABG procedures at
the Department of Cardiothoracic Surgery at the
University Hospital of Uppsala were considered to
be included in the study. Inclusion criteria were
patients with tablet or insulin-treated diabetes and
patients without a preoperative diagnosis of dia-
betes. The exclusion criteria were malignant
disease, steroid or immune-suppressive medi-
cation, and patients unable to speak Swedish.
Patients were recruited from September 1998 to
June 2002 during the academic periods, two days a
week from the schedule for operation the following
day. An attempt was made to recruit all patients
with diabetes and a random sample of patients
without diabetes. In total 437 were considered for
inclusion. Twenty-seven (eight with diabetes, 19
without diabetes) were excluded because of steroid
or immune-suppresive medication or language
difficulties. In all, 410 patients were approached
and 396 (97%) agreed to participate. Only 14
patients refused participation. In total, 192
patients with diabetes and 204 patients without
diabetes were included. When patient records were
reviewed postoperatively it was found that five
patients in the non-diabetic group had preopera-
tively diagnosed diabetes treated with diet only.
These patients were transferred to the diabetic
group.
The study thus included 197 patients with and
199 without diabetes. Twenty-two patients did not
16
Table I Included and lost patients during the study period
Patients with diabetes
Included
Not operated
Intra or postoperative death
Speech difficulties due to stroke
Lost to follow-up
Completed follow-up
complete the study, resulting in 184 patients with
diabetes and 190 patients without diabetes for
surveillance of surgical-site infections (Table I).
The present study is part of a larger protocol, which
focuses on SWI in patients with diabetes. It was
therefore planned that 50% of the patients should
have a preoperative diagnosis of diabetes. The
prevalence of diagnosed diabetes in patients under-
going CABG procedures at the department is
approximately 24% (2002).
The study was approved by the Ethic Committee
of the Faculty of Medicine of Uppsala University
(Dnr 98-237). The names, dates of birth and
telephone numbers of the patients were registered
to allow review of patients’ records and follow-up,
but were removed at completion of data collection.
Procedure for SWI evaluation
The study design was a prospective, post-discharge
evaluation of SWI at 30 and 60 days after surgery. In
addition to already known risk factors, a number of
potential risk factors were registered. Potential
patient-related risk factors in this study were
preoperative haemoglobin and creatinine concen-
tration and insulin-like growth factor 1 (IGF1).26
Potential intra-operative risk factors were number
of saphenous vein grafts, number with leg harvest-
ing, duration of leg operation, intact sterile draping
during surgery and whether the non-operated leg
was covered. Potential postoperative risk factors
were number of days in the intensive care unit (ICU)
and postoperative bleeding. For calculations, the
day of operation was denoted day zero and day one
started at 6.00 a.m. the morning after surgery.
The nurse responsible for the study recruited the
patients, gave instructions to the patients for the
telephone interviews and interviewed the patients
30 and 60 days after the operation. The same
person registered patient-related and preoperative
risk factors. The nurses and nursing aids in the
operating room registered the intra-operative risk
factors. The nurses, nursing aids and the nurse
responsible for the study registered potential post-
operative risk factors in the ICU and in the ward.
C.L. Swenne et al.
Patients without diabetes
197 199
5 1
5 5
1 1
2 2
184 190
The definition of SWI used in the study was based on
the CDC definition.10 The patients received a
structured infection surveillance questionnaire
concerning symptoms and signs of SWI before
discharge from the hospital. It included questions
about occurrence of discharge, purulent discharge,
and signs like redness, local rise in temperature,
pain or oedema in the incision of the wounds. They
were asked to make notes if any complications
occurred. If the patient reported discharge from
the wound they were asked at the telephone
interviews whether bacterial culture had been
performed, and if so the nurse responsible for the
study confirmed the culture with the Department of
Microbiology. The patients were also asked whether
they had been treated with antibiotics for any kind
of postoperative infection. They were considered
to have a SWI if they reported purulent discharge
from the wound. They were also considered to have
a SWI if they had inflammatory signs and a positive
bacterial culture had been obtained. The isolation
of any micro-organism was then considered a
positive culture. After completion of telephone
interviews it was possible to review patient records
for missing data. Before the present study the
questionnaire had been tested on 40 patients and
found applicable for the surveillance of SWI in
cardiothoracic patients. The staff were informed
and instructed about the study before it started.
Eighteen patients were not operated on the leg
but had grafts taken from the arm and/or the
internal mammary arteries were used. Reoperation
was performed in six cases because of mediastini-
tis. In these cases reoperation on the sternum, the
number of days in ICU and the number of erythro-
cyte transfusions on day two or later could not be
used as risk factors for mediastinitis. For these
patients, these risk factors were removed from
calculations. One patient had a superficial sternum
infection within 0 –30 days after the operation but a
mediastinitis was diagnosed within 31 – 60 days.
Perioperative procedures
Patients were usually admitted to the hospital the
SSIs within 60 days of coronary artery by-pass graft surgery
day before surgery. Preoperative preparation of the
skin of the patients consisted of two showers and
scrubbing with a 4% chlorhexidine detergent sol-
ution and removing the hair on the chest and leg the
night before surgery. In the operating room, the
skin was scrubbed with 4% chlorhexidine solution
followed by disinfection with 0.5% chlorhexidine in
70% ethanol. Cloxacillin, 2 g three times a day, was
administered intravenously six times. The first dose
started 1 h before the skin incision. The surgical
procedures were performed in a operating room
with ultra clean air with , 10 cfu/m3.22 The staff
wore tightly woven scrub suits, which prevented
bacteria from the skin flora being released into the
air.23 All patients had intravenous glucose infusions
during the operation and during the first 24 h
postoperatively. During the study period there was
no policy of strict normalization of blood glucose
concentrations during the immediate postoperative
period. The patients were discharged from the
cardiothoracic ward approximately one week after
surgery.
Statistics
Possible predictors for SWI were compared in
patients with and without SWI. Nominal data were
analysed using the X2 test. The Kolmogorov –
Smirnov goodness-of-fit test was used to analyse
data distribution for the remaining risk factors. If
distributions deviated significantly ðP , 0:05Þ from
the normal distribution the data were analysed
using the Mann –Whitney U or Kruskal– Wallis tests.
Those variables not deviating from the normal
distributions were analysed using Student’s t-test
or one-way analysis of variance (ANOVA). Continu-
ous variables are given as mean (and SD, standard
deviation), categorical variables as percentages.
Some data were further analysed with a logistic
regression analysis. All calculations were made
using SPSS (Statistical Package for Social Sciences).
Results
After CABG, SWIs were diagnosed in 114 (30.5%)
patients. Six patients had simultaneous infections
of leg and sternum and SWIs were thus diagnosed in
120 surgical-site incisions. Sixty-three (17.7%)
patients had leg infections, 45 (12.0%) had super-
ficial sternum infections and 12 (3.2%) cases of
mediastinitis were diagnosed within 60 days of
surgery (Table II). There were 289 men and 85
women with a mean age of 66 years (range 38 – 85
years) in the study. The yearly recruitments of
17
patients for the study were 1998: 27 patients, 1999:
97 patients, 2000: 102 patients, 2001: 106 patients
and 2002: 42 patients. During the study period there
was no trend towards change in the yearly rate of
SWI ðP . 0:05Þ:
Discharge from hospital was 8.4 (SD 4.2) days
after surgery. Before discharge SWI had been
diagnosed in 36 (9.6%) of the patients. Of these,
13 patients had leg infections, 15 had superficial
sternum infections and eight had mediastinitis.
Almost all SWIs on the sternum (93.3%) were
diagnosed within 30 days of surgery. Most of the
SWI on the leg (73.0%) were diagnosed within 30
days of surgery and 27.0% were diagnosed within 31
to 60 days of surgery (Table II).
The risk factors for SWI of the leg are presented
in Table III. Patients with infections were more
often female and had lower preoperative haemo-
globin concentrations than those without infec-
tions. The preoperative duration of hospital stay
was longer in patients with infection. The intra-
operative risk factor CBP time was increased in
patients with infections. Of the postoperative risk
factors haemoglobin concentration on postopera-
tive day two was lower in infected patients. Also,
the patients with infections had more often
received erythrocyte transfusions on postoperative
day 1. When infections were subdivided into early
(day 0 –30) and late (day 31 – 60) infections new risk
factors for late infections emerged. The number of
saphenous vein grafts, the number of internal
mammary artery grafts, the duration of aortic
cross clamping time and the number of scrubbed
persons present in the operating theatre during
surgery, were different between early and late SWI.
Also, patients with late infections had more often
low haemoglobin concentration on day one and they
received erythrocyte transfusions on postoperative
day two or later more frequently.
The risk factors for superficial SWI of the sternum
are listed in Table IV. Patients with infections of the
sternum had higher body mass index (BMI), more
often diabetes and lower preoperative haemoglobin
concentrations than those without infections. Pre-
operative and intra-operative risk factors did not
differ between patients with and without super-
ficial sternum infections. Of the postoperative risk
factors, reoperation on sternum, number of days in
ICU, postoperative haemoglobin concentrations day
two and erythrocyte transfusions postoperative on
day one differ significantly in patients with
infections.
The risk factors for mediastinitis are also
presented in Table IV. Patients with infections had
higher BMI than those without infections. Preopera-
tive and intra-operative risk factors did not differ
18
Table II Different surgical-site infections in 374 patients operated with coronary artery by-pass graft
Number of infections
Leg 63/356 (17.7%)
Superficial sternum 45/374 (12.0%)
Mediastinitis 12/374 (3.2%)
Three hundred and fifty-six patients had grafts taken from the leg. Surgical wound infections were diagnosed in 120 surgical-site
incisions.
between patients with and without mediastinitis.
Patients with infections had more often received
erythrocyte transfusions on postoperative day two
or later than those without infections.
In addition, an analysis of possible risk factors for
any infection, irrespective of its site and timing,
was performed. This analysis did not reveal any
additional risk factors for SWI but confirmed the
findings of the analyses of the separate type of
infection. Thus, patients with infections were more
often female ðP , 0:001Þ; had higher BMI ðP ,
0:001Þ; more often had diabetes ðP , 0:01Þ; and
had lower preoperative haemoglobin concen-
trations ðP , 0:000Þ than those without infections.
Preoperative risk factors did not differ between
patients with and without SWI. The intra-operative
risk factor duration of leg operation ðP , 0:05Þ
differed between the groups. Postoperative reo-
peration on the sternum ðP ¼ 0:005Þ and number of
days in the ICU ðP , 0:001Þ were higher in patients
with infections. The infected patients were more
likely to have received erythrocyte transfusions on
postoperative day one ðP , 0:01Þ and on post-
operative day two or later ðP , 0:01Þ than those
without infections.
Preoperative haemoglobin concentration as a
risk factor for SWI was further analysed in a logistic
regression analysis (Table V). Patients were
grouped into those with preoperative haemoglobin
concentrations below (, 140 g/L) or above
($ 140 g/L) average. The odds ratio (OR) for an
early leg SWI was not significantly increased by a
preoperative haemoglobin concentration below
average. The uncorrected OR for a late leg SWI
was 3.59 [95% confidence interval (CI) 1.23 –10.5]
but did not remain significant when corrected for
gender. The uncorrected OR for superficial SWI of
the sternum was 3.01 (CI 1.55 – 5.84). When cor-
rected for BMI, diabetes, sex, age, postoperative
haemoglobin concentration on day one, CPB and
reoperation on sternum, the OR increased to 4.16
(CI 1.80 – 9.62).
The types of bacteria associated with SWI of the
leg are presented in Table VI. Staphylococcus
aureus followed by coagulase-negative staphylo-
cocci (CoNS) were the most common isolates in
C.L. Swenne et al.
Proportion of infections day 0–30 Proportion of infections day 31–60
46/63 (73.0%) 17/63 (27.0%)
42/45 (93.3%) 3/45 (6.7%)
11/12 (91.7%) 1/12 (8.3%)
early SWI of the leg. Seventy percent of the SWI in
patients with early infection and 53% of the SWI in
patients with late infection of the leg were
confirmed by bacterial cultures. Bacteria associ-
ated with superficial SWI of the sternum and
mediastinitis are presented in Table VII. S. aureus
and CoNS were the most common types of bacteria
in the superficial SWI of sternum, and nine isolates
of CoNS were obtained in the patients with
mediastinitis. Bacteria in 78% of the patients with
any superficial SWI of the sternum, and in all
patients with mediastinitis, were confirmed with
bacterial cultures. One hundred and fifty-six
(41.7%) patients had been treated with antibiotics
for SWI or inflammatory signs in the wounds within
30 days of surgery. Forty-seven (12.6%) patients
were treated with antibiotics for SWI or inflamma-
tory signs of the wounds within 31 – 60 days of
surgery.
Discussion
The incidence of SWI in this study was 30.5%. Almost
all (90.4%) of the SWI were diagnosed after
discharge from hospital. Ninety-three percent of
the SWI of the sternum and 73% of the leg were
diagnosed within 30 days of surgery, but as many as
27% of the SWI of the leg were diagnosed later
during the second month of follow-up. In a recent
study, Tegnell et al.9 observed an incidence of SWI
after CABG at approximately the same level. In that
study all patients were contacted by telephone or
by mail. Records of all patients who had visited
healthcare facilities within 3 months of surgery
were reviewed to determine whether they had had
a SWI according to a classification system based on a
protocol by Wilson et al.27 The overall postopera-
tive wound infection rate in that study reached
30.3%. The present data and the results of Tegnell
et al.9 indicate that the infection rate after CABG is
higher than the rate reported in many previous
studies.1 The possible explanation of this may be
that the meticulous follow-up, the extended dur-
ation of follow-up and the low incidence of drop-out
during follow-up led to few infections remaining
 SSIs within 60 days of coronary artery by-pass graft surgery
Table III Risk factors for surgical wound infection on the graft leg after coronary artery by-pass graft in 356 patients

Patients without infection Patients with P-valuea Patients with early Patients with P-valueb
ðN ¼ 293Þ leg infection leg infection late infection
ðN ¼ 63Þ ðN ¼ 46Þ ðN ¼ 17Þ

Patient related risk factors

Age (years) 65.48 (8.19) 67.10 (9.04) 0.191 66.76 (8.85) 68.00 (9.76) 0.252
Sex M/F 239/54 36/27 0.000* 26/20 10/7 0.000*
Body mass index (kg/m2) 27.46 (3.49) 28.22 (4.33) 0.130 28.11 (4.21) 28.51 (4.76) 0.296
Current smoking (%) 25/292 (8.6%) 4/58 (6.5%) 0.582 3/45 (6.7%) 1/17 (5.9%) 0.855
Diabetes (%) 142/293 (48.5%) 37/63 (58.7%) 0.139 25/46 (54.3) 127/17 (70.6%) 0.425
Preoperative insulin-like growth factor 1 (mg/L) 134.37 (40.23) 134.00 (39.45) 0.966 132.80 (37.87) 138.80 (49.92) 0.956
Preoperative haemoglobin concentrations (g/L) 141.39 (12.32) 137.13 (12.50) 0.013* 138.67 (12.39) 132.94 (12.17) 0.012*
Preoperative serum creatinine concentrations (mmol/L) 101.96 (42.72) 105.16 (38.94) 0.682 102.35 (37.70) 112.76 (42.34) 0.348
Preoperative risk factors
Preoperative days in hospital (N) 2.53 (1.90) 3.56 (3.34) 0.034* 3.39 (2.67) 4.00 (4.78) 0.096
Intra-operative risk factors
Number of saphenous vein grafts (N) 2.07 (0.69) 2.22 (0.66) 0.135 2.09 (0.55) 2.59 (0.80) 0.022*
Number of legs operated 0/1/2 (N) 20/293 (6.8%) 7/63 (11.1%) 0.244 5/46 (10.9%) 2/17 (11.8%) 0.174
Internal mammary artery 0/1/2 (N) 15/277/1 6/56/1 0.191 6/40/0 0/16/1 0.006*
Duration of operation (min) 200.91 (50.03) 213.35 (66.87) 0.294 202.37 (56.15) 243.06 (84.71) 0.130
Duration of leg operation (min) 70.83 (32.08) 83.34 (44.58) 0.070 81.40 (46.92) 88.47 (38.54) 0.082
Duration of cardiopulmonary by-pass time (min) 85.15 (24.73) 97.42 (36.78) 0.032* 90.91 (28.47) 114.94 (50.12) 0.007*
Duration of aortic cross clamp time (min) 47.04 (15.71) 47.71 (15.42) 0.673 43.61 (13.53) 58.75 (15.12) 0.002*
Number of persons in theatre (N) 12.94 (2.64) 13.95 (4.60) 0.088 13.82 (5.18) 14.31 (2.39) 0.084
Number of scrubbed persons (N) 4.47 (0.95) 4.58 (0.95) 0.279 4.44 (0.99) 4.94 (0.75) 0.040*
Number of glove changes (N) 1.25 (1.61) 1.36 (1.70) 0.502 1.36 (1.87) 1.36 (1.22) 0.707
Number of door openings in theatre (N) 56.63 (18.64) 61.91 (24.48) 0.079 59.37 (19.80) 68.33 (33.58) 0.060
Intact sterile draping (%) 214/221 (96.8%) 45/48 (93.8%) 0.306 31/33 (93.9%) 143/15 (93.3%) 0.589
Non-operated leg covered (%) 178/277 (64.3%) 41/62 (66.1%) 0.781 29/45 (64.4%) 1/17 (70.6%) 0.869
Postoperative risk factors
Reoperation on sternum (%) 11/293 (3.8%) 3/63 (4.8%) 0.709 2/46 (4.3%) 1/17 (5.9%) 0.897
Reoperation on the leg (%) 3/292 (1.0%) 0/63 0.419 0/46 0/17 0.722
Postoperative bleeding (mL) 960.56 (581.23) 1077.14 (1046.24) 0.911 1113.59 (1185.57) 978.53 (523.78) 0.993
Number of days in intensive care unit (N) 3.20 (2.55) 3.59 (2.17) 0.057 3.63 (2.36) 3.47 (1.59) 0.136
Haemoglobin concentrations day 1 (gL) 107.50 (11.97) 103.89 (10.58) 0.099 105.02 (10.61) 100.82 (10.19) 0.040*
Haemoglobin concentrations day 2 (gL) 105.73 (10.91) 102.69 (9.71) 0.007* 103.80 (9.70) 99.82 (9.42) 0.009*
Haemoglobin concentrations day 3 (gL) 107.76 (12.88) 106.05 (10.34) 0.306 106.95 (10.20) 103.50 (10.63) 0.398
Erythrocyte transfusions day 0 (%) 95/291 (32.7%) 21/62 (33.9%) 0.852 14/45 (31.1%) 7/17 (41.2%) 0.740
Erythrocyte transfusions day 1 (%) 81/291 (27.8%) 28/62 (45.2%) 0.007* 22/45 (48.9%) 6/17 (35.3%) 0.016*
Erythrocyte transfusions day 2 or later (%) 89/291 (30.6%) 23/62 (37.1%) 0.317 13/45 (28.9%) 10/17 (58.8%) 0.047*

* P , 0.05
a
Comparison between data for ‘infection’ and ‘no infection’ by Student’s t-test, X2 test or Mann–Whitney U-test.
b
Comparison between data for ‘infection’, ‘early infection’ and ‘late infection’ by one-way ANOVA, X2 test or Kruskal–Wallis test.

19
Unless otherwise specified, numbers in parentheses are standard deviations (SD)
 20
Table IV Risk factors for superficial sternal wound infection and mediastinitis after coronary artery by-pass graft in 374 patients

Patients without infection Patients with superficial sternal infection P-valuea Patients with mediastinitis P-valueb
ðN ¼ 318Þ ðN ¼ 45Þ ðN ¼ 12Þ

Patient related risk factors

Age (years) 65.93 (8.20) 64.68 (9.65) 0.516 61.67 (9.16) 0.124
Sex M/F 250/68 31/14 0.121 3/9 0.765
Body mass index (kg/m2) 27.34 (3.58) 28.94 (4.00) 0.007* 29.97 (3.42 0.013*
Current smoking (%) 25/317 (7.9%) 4/43 (9.3%) 0.749 2/12 (16.7%) 0.277
Diabetes (%) 148/318 (46.5%) 30/44 (68.2%) 0.007* 6/12 (50%) 0.814
Preoperative insulin-like growth factor 1 (mg/L) 133.95 (39.93) 117.13 (37.68) 0.119 135.00 (42.59) 0.949
Preoperative haemoglobin concentrations (g/L) 141.58 (12.26) 135.61 (13.65) 0.003* 138.25 (10.39) 0.354
Preoperative serum creatining concentrations (mmol/L) 100.41 (38.84) 114.07 (57.06) 0.288 106.92 (23.05) 0.130
Preoperative risk factors
Preoperative days in hospital (N) 2.69 (2.14) 3.02 (2.98) 0.999 1.83 (0.94) 0.251
Intra-operative risk factors
Number of saphenous vein grafts (N) 2.03 (0.77) 2.02 (0.72) 0.881 1.75 (1.06) 0.425
Number of legs operated 0/1/2 (N) 12/284/22 2/37/4 0.811 2/9/1 0.089
Internal mammary artery 0/1/2 (N) 20/291/8 2/40/2 0.592 0/11/1 0.280
Duration of operation (min) 202.48 (50.94) 211.36 (87.83) 0.915 224.58 (65.90) 0.265
Duration of leg operation (min) 72.13 (35.07) 78.50 (33.07) 0.226 75.00 (39.62) 0.973
Duration of cardiopulmonary by-pass time (min) 87.13 (28.29) 86.38 (27.58) 0.841 83.30 (24.03) 0.782
Duration of aortic cross clamp time (min) 46.98 (15.84) 47.24 (16.18) 0.920 42.80 (12.06) 0.632
Number of persons in theatre (N) 13.05 (2.71) 13.36 (5.21) 0.395 13.92 (3.68) 0.481
Number of scrubbed persons (N) 4.47 (0.95) 4.48 (0.85) 0.794 4.75 (1.49) 0.921
Number of glove changes (N) 1.285 (1.59) 1.14 (1.15) 0.987 2.00 (2.99) 0.383
Number of door openings in theatre (N) 58.03 (20.30) 53.00 (17.52) 0.143 67.70 (23.19) 0.142
Intact sterile draping (%) 232/241 (96.3%) 31/33 (93.9%) 0.523 0/9 0.555
Non-operated leg covered (%) 193/295 (65.4%) 26/41 (63.4%) 0.800 5/10 (50%) 0.315
Postoperative risk factors
Reoperation on sternum (%) 6/318 (1.9%) 4/44 (9.1%) 0.006* 0/6 0.734
Reoperation on the leg (%) 2/317 (0.6%) 1/44 (2.3%) 0.261 0/11 0.792
Postoperative bleeding (mL) 964.19 (598.32) 1145.91 (1217.07) 0.695 872.92 (262.23) 0.959
Number of days in intensive care unit (N) 2.98 (1.88) 4.61 (3.77) 0.000* 4.00 (2.68) 0.190
Haemoglobin concentrations day 1 (gL) 106.88 (11.62) 108.02 (11.24) 0.540 104.67 (16.22) 0.524
Haemoglobin concentrations day 2 (gL) 104.81 (10.53) 108.80 (10.17) 0.023* 105.08 (15.67) 0.680

C.L. Swenne et al.

Haemoglobin concentrations day 3 (gL) 107.35 (12.73) 109.49 (11.06) 0.294 105.92 (10.60) 0.702
Erythrocyte transfusions day 0 (%) 101/315 (32.1%) 14/44 (31.8%) 0.974 6/12 (50%) 0.194
Erythrocyte transfusions day 1 (%) 91/315 (28.9%) 21/44 (47.2%) 0.012* 5/12 (41.7%) 0.340
Erythrocyte transfusions day 2 or later (%) 90/315 (28.6%) 18/44 (40.9%) 0.095 0/6 0.000*

* P , 0.05
a
Comparison between data for ‘no infection’ and ‘SWI sternum’ by Student’s t-test, X2 test and Mann–Whitney U-test.
b
Comparison between data for ‘no infection’ and ‘mediastinitis’ by Student’s t-test, X2 test and Mann–Whitney U-test.
Unless otherwise specified, numbers in parentheses are standard deviations (SD)
SSIs within 60 days of coronary artery by-pass graft surgery 21

Table V Preoperative haemoglobin concentration as a risk factor for development of surgical wound infections following coronary
artery by-pass grafting operation

Patients with infections (%) Uncorrected Corrected

Hb ,140 g/L Hb $140 g/L OR 95% CI P OR 95% CI P

Any leg wound infection 35/152 (23.0) 28/203 (13.8) 1.87 (1.08 –3.22) 0.026 1.36a (0.75–2.46) 0.312
Early leg wound infection 23/152 (15.1) 23/203 (11.3) 1.40 (0.75 –2.60) 0.293 – – –
Late leg wound infection 12/129 (9.3) 5/180 (2.7) 3.59 (1.23 –10.5) 0.019 2.91a (0.95–8.89) 0.061
Superficial sternal wound infection 29/153 (19.0) 15/208 (7.2) 3.01 (1.55 –5.84) 0.001 4.16b (1.80–9.62) 0.001

OR, odds ratio; CI, confidence interval.

a
Corrected for sex.
b
Corrected for BMI (kg/m2), diabetes, sex, age, postoperative haemoglobin concentrations day one, cardiopulmonary by-pass time
and reoperation on sternum.

Table VI Type of bacteria associated with surgical-site infections of the leg

Bacteria No. of isolates early infection leg No. of isolates late infection leg

Staphylococcus aureus 18 4
Coagulase-negative staphylococci 14 1
Corynebacteria 1 1
Enterococci 4 2
Streptococci 2 1
Propionebacteria 0 0
Enterobacteriacae 4 4

Cultures were obtained from 32 (69.6%) patients with early infections and nine (52.9%) patients with late infection. In 11 of the early
cultures more than one species was isolated. In three of the late cultures more than one species was isolated.

undiagnosed. It should be noted that 49% of the
patients in the present study had diabetes, which is
an established risk factor for SWI.18 This might
increase our incidence of infection, but direct
comparison with other studies is difficult as the
proportion of patients with diabetes is not always
given.
As most SWIs were diagnosed after discharge
from hospital and by the patients themselves, it is
important to have an easily applicable definition of
SWI. The CDC definition has clear clinical criteria
defining SWI as pus visible to the eye.10 Using such
criteria patients can be taught before discharge
from hospital to diagnose SWIs themselves.
However, Seaman and Lammers28 reported an
underestimation of infection when patients self-
diagnosed infected laceration wounds. In as many
as 48% of the infections diagnosed by hospital staff
the patients themselves had failed to recognize the
symptoms of infection. In that study, the patients
had received only written instructions explaining
home wound care and signs of infection, together
with an appointment to check the wound. This
contrasts the present study, where patients were
individually taught signs and symptoms of SWI, were
asked to make notes of such and were instructed by
the surveillance questionnaire and the telephone
interviews to follow. The patients in the present

Table VII Type of bacteria associated with superficial surgical-site infections of sternum and mediastinitis

Bacteria No. of isolates superficial sternum No. of isolates mediastinitis

Staphylococcus aureus 10 5
Coagulase-negative staphylococci 25 9
Corynebacteria 2 0
Enterococci 0 0
Streptococci 2 0
Propionibacteria 3 1
Enterobacteriacae 1 3

Cultures were obtained from 35 (77.8%) patients with superficial sternum infections and all patients with mediastinitis. In six of the
superficial sternum cultures more than one species was isolated. In four of the mediastinitis cultures more than one species was
isolated.
22
study were, therefore, well prepared not to over-
look signs of SWI.
Tammelin and co-workers29 suggested a micro-
biological definition of SWI as patients with med-
iastinitis often have CoNS in their wounds. CoNS do
not always produce purulent discharge, and there-
fore such infections may be difficult to diagnose by
clinical criteria. The use of such a definition would
preclude the diagnosis of a considerable proportion
of the present SWI, which were diagnosed by
clinical criteria not always being subject to micro-
biological culture. In cases when microbiological
culture was performed, it confirmed the SWI
diagnosed by clinical criteria. This suggests that
the clinical definition presently used does not
overestimate the incidence of SWI. Underestima-
tion of SWI is possible if the infection is caused by
organisms causing little inflammatory response and
which therefore do not fit with the criteria for SWI.
The present study confirms that the vast
majority of SWIs are diagnosed after discharge
from hospital.9 It has been suggested that 95% of
SWIs can be identified within 30 days of surgery.4
This contrasts with the present finding of a
substantial proportion of SWI being diagnosed
during the second month of follow-up. An extended
duration of follow-up is thus necessary in order to
reach a high degree of identification of SWI in
patients who have a harvest site on the leg. This is,
in turn, necessary to achieve the correct identifi-
cation of risk factors for SWI after CABG
procedures.
Previously recognized patient-related risk fac-
tors for SWI such as sex,15,30,31 BMI16 diabetes18,20
are confirmed by the present study. SWI on the leg
had an especially strong association with being
female. The reason for this is unclear. Non-healing
incision above the knee after vein harvest often
occurs because of technical operative problems.30
Complications below the knee may, however, be
due to pre-existing, but undetected peripheral
vascular disease,30,31 which in one study was more
prevalent in women.31 These findings would suggest
that more attention to female leg anatomy and
gender difference in preoperative evaluation might
influence the risk for leg complications.
The patients with a late SWI of the leg had been
operated with a larger number of saphenous vein
grafts and more often with the internal mammary
artery. They had been on CPB for a long time and
had a longer duration of aortic cross clamping. A
larger number of scrubbed persons had been
present during the operation, immediate post-
operative haemoglobin concentrations were lower
and postoperative erythrocyte transfusions more
frequent. Altogether, these observations can be
C.L. Swenne et al.
interpreted to indicate that this group of patients
had a longer and more complicated surgical
procedure. Complicated surgery would constitute
the underlying risk factors generating the above
observations. This set of observations was specific
for late SWIs on the leg and would have remained
unobserved if follow-up had not been extended
beyond 30 days postoperatively. This again under-
scores the importance of extended follow-up to
detect SWI.
In this study, intra-operative factors associated
with operating room hygiene did not appear to be
risk factors for SWI. This is not to say that operating
room hygiene is unimportant in this context. If
operating rooms are technically equipped to main-
tain an ultraclean air environment and procedures
are observed that do not disturb airflow or other-
wise impair sterility, the risk of SWI diminishes.32
When this is achieved, attention can be focussed on
other risk factors so that the incidence of SWI can
be diminished.
A novel finding was that low preoperative
haemoglobin concentration was a risk factor for
superficial SWI on the sternum independently of
postoperative haemoglobin concentration and a
number of patient-related risk factors. Poor tissue
oxygenation impairs wound healing and increases
the risk for SWI. Even during an uncomplicated
CABG procedure there is haemodilution, lowering
of body temperature during CPB, lowered blood
pressure during CPB, blood loss and adrenergic
vasoconstriction caused by pain, all which could
diminish oxygen transport to peripheral tissues.
Patients with a low preoperative haemoglobin
concentration would then be at a disadvantage
when all the effects of the CABG procedure are
added. In support of this notion is the observation
that low preoperative haemoglobin concentration
is associated with increased risk for postoperative
mortality and morbidity, including SWI after gen-
eral surgery.33 Moreover, perioperative oxygen
supplementation appears to reduce SWI.34 Conver-
sely, low preoperative haemoglobin concentration
did not constitute an independent risk factor for
SWI of the leg. For these infections it appears that
handling of local risk factors are of primary
importance for the outcome.
The strength of this study was that as many as
97% of patients approached agreed to participate.
Of the 396 patients included, 374 (94%) participated
in the post-discharge follow up. Of those not
followed up, only four were lost because they
could not be located. Thus, results of the study may
be assumed to be representative for patients
operated with CABG at the department, even
though 49% had diabetes.
SSIs within 60 days of coronary artery by-pass graft surgery
The postoperative stay in hospital tends to
become shorter. Not all surgical specialities have
the benefit of patients returning to their outpatient
clinics for follow-up. The result of this study shows
that the post-discharge surveillance is feasible by
teaching the patients signs and symptoms of SWI.
This results in the diagnosis of more SWIs in the
present study compared with previous studies with
retrospective designs. To correctly and effectively
diagnose SWI serves several purposes. The patients
get immediate and correct medical care. With high
ascertainment of SWI a correct incidence and a
correct identification of risk factors can be
achieved. This is necessary if a wound surveillance
protocol is to be used for quality control and
improvement.
Acknowledgements
This study was supported by the Vardal Foundation
for Health Care Sciences and Allergy Research, the
Swedish Diabetes Association and Uppsala Univer-
sity. This study would not have been possible
without the help of the nursing staff of the
Department of Cardiothoracic Surgery. Associate
Professor Ulrika Ransjö is thanked for helpful
discussions during the preparation of this paper.
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