Elsevier

The Annals of Thoracic Surgery

Volume 88, Issue 6, December 2009, Pages 1905-1909
The Annals of Thoracic Surgery

Original article
Adult cardiac
Emerging Role of Candida in Deep Sternal Wound Infection

https://doi.org/10.1016/j.athoracsur.2009.08.012Get rights and content

Background

This study evaluated the overall incidence, prognosis, and risk factors for microbiologically documented Candida deep sternal wound infection (DSWI) after cardiac operations.

Methods

A retrospective observational study was performed at Aalborg Hospital, Aarhus University Hospital, Denmark, from January 1999 through November 2006. Included were all 83 of 4222 cardiac surgical patients with microbiologically documented DSWI requiring surgical revision. Various potential risk factors in patients with Candida DSWI were compared with those of patients with non-Candida DSWI. We compared markers of morbidity, in-hospital mortality, and 1-year mortality to evaluate the prognosis of the disease.

Results

DSWI developed in 2% of all patients, of whom, 17 (20.5%) had Candida DSWI, and 66 (79.5%) had non-Candida etiology. Candida was the primary causative organism in 11 of 17 Candida DSWI cases. No Candida DSWI was found during the first 3 years of the study. In-hospital and 1-year mortality were doubled in patients with Candida DSWI compared with patients with non-Candida DSWI. Candida DSWI was associated with significantly longer stay in the intensive care unit and need of prolonged mechanical ventilation. Risk factors for Candida etiology were Candida colonization in tracheal secretions or urine and reoperation before diagnosis of DSWI.

Conclusions

Candida was a frequent causative agent of DSWI in our series and was associated with a very high morbidity and mortality. Cardiothoracic patients on mechanical ventilation when colonized with Candida were identified as a high-risk population for subsequent development of Candida DSWI.

Section snippets

Patients and Methods

The study was approved by the local ethics committee, and no patient approval was considered necessary.

Results

We identified 76 patients with DSWI from 4222 eligible patients by the specific procedure code for reoperation for deep infection after cardiac operation. An additional 10 patients were retrieved from our clinical microbiology database with positive mediastinal tissue cultures. Chart review confirmed the diagnosis in all but 2 patients with sternal instability with neither clinical signs of DSWI nor positive mediastinal tissue cultures. One patient was excluded from further analysis because of

Comment

Several previous studies demonstrate that systemic Candida infections are associated with increased morbidity and mortality in critically ill patients [10, 11, 12]. Mortality attributable to candidemia in cardiothoracic ICU patients has been estimated to be as high as 33% [13]. The effect Candida infection in terms of mortality and morbidity in patients with DSWI has not been studied previously in a systematic fashion.

In our study, we found remarkable differences in mortality between the

References (24)

  • L. Ridderstolpe et al.

    Superficial and deep sternal wound complications: incidence, risk factors and mortality

    Eur J Cardiothorac Surg

    (2001)
  • M. Sharma et al.

    Sternal surgical-site infection following coronary artery bypass graft: prevalence, microbiology, and complications during a 42 month period

    Infect Control Hosp Epidemiol

    (2004)
  • Cited by (19)

    • Strategies to reduce deep sternal wound infection after bilateral internal mammary artery grafting

      2015, International Journal of Surgery
      Citation Excerpt :

      Centers for Disease Control and prevention (CDC) criteria for the diagnosis of deep sternal wound infection are (1) organisms cultured from mediastinal tissue or fluid obtained during a surgical operation or needle aspiration, (2) evidence of mediastinitis seen during a surgical operation or histopathological examination, (3) atleast one of the following signs or symptoms with no other recognized cause; fever > 38 °C, chest pain or sternal instability and one of the following (i) purulent discharge from the mediastinal area, (ii) organisms cultured from the blood or discharge from mediastinal area (iii) mediastinal widening on X-ray [27]. The most common pathogens identified in deep sternal wound infections are Gram positive cocci, Staphylococcus epidermidis and Staphylococcus aureus account for more than two-third of cases [28–30]. Gram negative bacteria (E. coli, Pseudomonas species, Klebsiella) and Corynebacterium have been isolated in 5–22% of cases, while multiple pathogens are reported in upto one quarter of cases [14,29,30].

    • Mediastinitis

      2014, Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases
    • Postoperative mediastinitis due to Candida tropicalis: First reported case in Morocco

      2014, Journal de Mycologie Medicale
      Citation Excerpt :

      Regarding the case we are reporting, the current emergence of fungal mediastinitis is due to a better recognition of the role of yeasts in this nosological entity. Candida species represents up to 7.5% of the isolates in mediastinitis, especially in patients receiving mechanical ventilation [17]. It is a serious complication with high-risk of mortality (40 to 60%) and difficulties of diagnosis [15].

    • Invited Commentary

      2009, Annals of Thoracic Surgery
    View all citing articles on Scopus
    View full text