Risk factors for deep sternal wound infection after cardiac surgery: Influence of red blood cell transfusions and chronic infection


      • Case-control study of DSWI over 3 year period in a contemporary cardiac surgery service, including a period of increased incidence.
      • Corroborates the role of red blood transfusions as a risk factor for DSWI, with an interaction with preoperative anemia.
      • Novel finding of chronic infections (defined as HIV, HBV, HCV, or bacterial infection ≥ 4 weeks, on antibiotics at surgery) as a risk factor for DSWI.
      • Antibiotic prophylaxis chosen did not cover organisms found in 77% of DSWIs.


      Deep sternal wound infection (DSWI) following cardiac surgery is a serious complication, but risk factors associated with DSWI have not been fully elucidated.


      We analyzed all DSWI cases at our institution from 2010-2013 in adult cardiac median sternotomy cases, based on Society of Thoracic Surgeons or National Healthcare Safety Network definitions, but with 1-year surveillance postsurgery. Controls were matched 3:1 per case for procedure, age, and year of surgery. Demographic and operative data were pulled from Society of Thoracic Surgeons database and chart review. Potential variables were evaluated using univariate and multivariate conditional logistic regression.


      Out of 1,894 surgeries performed, 39 DSWI cases (2%) and 117 controls were identified. In univariate analyses, patients with red blood cell (RBC) transfusion ≥ 4 units, any platelet transfusion, previous infections, and chronic infections were associated with higher DSWI. RBC transfusion ≥ 4 units (P = .037) and chronic infections (P = .029) remained significant risk factors for DSWI in multivariate analysis. Preoperative anemia alone was not associated with more DSWI, but its interaction with RBC transfusion ≥ 4 units was significant.


      High-volume RBC transfusions and chronic infections were strongly associated with DSWI in our population and represent potentially modifiable areas for improvement.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Fowler V.G.
        • O'Brien S.M.
        • Muhlbaier L.H.
        • Corey G.R.
        • Ferguson B.
        • Peterson E.D.
        Clinical predictors of major infections after cardiac surgery.
        Circulation. 2005; 112: I358-65
        • Shahian D.M.
        • O'Brien S.M.
        • Filardo G.
        • Ferraris V.A.
        • Haan C.K.
        • Rich J.B.
        • et al.
        The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1-coronary artery bypass grafting surgery.
        Ann Thorac Surg. 2009; 88: S2-22
        • Filsoufi F.
        • Rahmanian P.B.
        • Castilla J.G.
        • Pinney S.
        • Broumand S.R.
        • Adams D.H.
        Incidence, treatment strategies and outcome of deep sternal wound infection after orthotopic heart transplantation.
        J Heart Lung Transplant. 2007; 26: 1084-1090
        • Haley V.B.
        • Van Antwerpen C.
        • Tsivitis M.
        • Doughty D.
        • Gase K.A.
        • Hazamy P.
        • et al.
        Risk factors for coronary artery bypass graft chest surgical site infections in New York State, 2008.
        Am J Infect Control. 2012; 40: 22-28
        • Kubota H.
        • Miyata H.
        • Motomura N.
        • Ono M.
        • Takamoto S.
        • Harii K.
        • et al.
        Deep sternal wound infection after cardiac surgery.
        J Cardiothorac Surg. 2013; 8: 1-6
        • Buja A.
        • Zampieron A.
        • Cavalet S.
        • Chiffi D.
        • Sandonà P.
        • Vinelli A.
        • et al.
        An update review on risk factors and scales for prediction of deep sternal wound infections.
        Int Wound J. 2012; 9: 372-386
        • Robinson P.J.
        • Billah B.
        • Leder K.
        • Reid C.M.
        Factors associated with deep sternal wound infection and haemorrhage following cardiac surgery in Victora.
        Interact Cardiovasc Thorac Surg. 2007; 6: 167-171
        • Crabtree T.D.
        • Codd J.E.
        • Fraser V.J.
        • Bailey M.S.
        • Olsen M.A.
        • Damiano Jr, R.J.
        Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center.
        Semin Thorac Cardiovasc Surg. 2004; 16: 53-61
        • Ariyaratnam P.
        • Bland M.
        • Loubani M.
        Risk factors and mortality associated with deep sternal wound infections following coronary artery bypass surgery with or without concomittant procedures in a UK population: a basis for a new risk model?.
        Interact Cardiovasc Thorac Surg. 2010; 11: 543-546
        • Graf K.
        • Ott E.
        • Vonberg R.P.
        • Kuehn C.
        • Haverich A.
        • Chaberny I.F.
        Economic aspects of deep sternal wound infections.
        Eur J Cardiothorac Surg. 2010; 37: 893-896
        • O'Brien S.M.
        • Shahian D.M.
        • Filardo G.
        • Ferraris V.A.
        • Haan C.K.
        • Rich J.B.
        • et al.
        The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2-isolated valve surgery.
        Ann Thorac Surg. 2009; 88: S23-42
        • Shahian D.M.
        • O'Brien S.M.
        • Filardo G.
        • Ferraris V.A.
        • Haan C.K.
        • Rich J.B.
        • et al.
        The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 3- valve plus coronary artery bypass grafting surgery.
        Ann Thorac Surg. 2009; 88: S43-62
        • CDC
        CDC/NHSN Surveillance Definitions for Specific Types of Infections.
        Centers for Disease Control and Prevention, Atlanta, GA2015
        • Carson J.L.
        • Carless P.A.
        • Hebert P.C.
        Transfusion thresholds and other strategies for guiding allogenic red blood cell transfusion.
        Cochrane Database Syst Rev. 2012; (CD002042)
        • Carson J.L.
        • Terrin M.L.
        • Noveck H.
        • Sanders D.W.
        • Chaitman B.R.
        • Rhoads G.G.
        • et al.
        Liberal of restrictive transfusion in high-risk patients after hip surgery.
        N Engl J Med. 2011; 365: 2453-2462
        • Hajjar L.A.
        • Vincent J.L.
        • Galas F.R.
        • Nakamura R.E.
        • Silva C.M.
        • Santos M.H.
        • et al.
        Transfusion requirements after cardiac surgery. The TRACS randomized controlled trial.
        JAMA. 2010; 304: 1559-1567
        • Banbury M.K.
        • Brizio M.E.
        • Rajeswaran J.
        • Lytle B.W.
        • Blackstone E.H.
        Transfusion increases the risk of postoperative infection after cardiovascular surgery.
        J Am Coll Surg. 2006; 202: 131-138
        • Horvath K.A.
        • Acker M.A.
        • Chang H.
        • Bagiella E.
        • Smith P.K.
        • Iribarne A.
        • et al.
        Blood transfusion and infection after cardiac surgery.
        Ann Thorac Surg. 2013; 95: 2194-2201
        • Baryshnikova R.M.
        • Castelvecchio S.
        • Pelissero G.
        • Surgical and Clinical Outcome Research (SCORE) Group
        Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery.
        Ann Thorac Surg. 2013; 96: 478-485
        • Koch C.G.
        • Li L.
        • Duncan A.I.
        • Mihaljevic T.
        • Cosgrove D.M.
        • Loop F.D.
        • et al.
        Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting.
        Crit Care Med. 2006; 34: 1608-1616
        • Ferraris V.A.
        • Davenport D.L.
        • Saha S.P.
        • Austin P.C.
        • Zwischenberer J.B.
        Surgical outcomes and transfusion of minimal amounts of blood in the operating room.
        Arch Surg. 2012; 147: 49-55
        • Murphy G.J.
        • Pike K.
        • Rogers C.A.
        • Wordsworth S.
        • Stokes E.A.
        • Angelini G.D.
        • et al.
        Liberal or restrictive transfusion after cardiac surgery.
        N Engl J Med. 2015; 372: 997-1008
        • Li J.
        • Wu W.
        • Peng G.
        • Chen F.
        • Bai M.
        • Zheng M.
        • et al.
        HBcAg induces interleukin-10 production, inhibiting HBcAg-specific Th17 responses in chronic hepatitis B patients.
        Immunol Cell Biol. 2010; 88: 834-841
        • Miroux C.
        • Vausselin T.
        • Delhem N.
        Regulatory T cells in HBV and HCV liver diseases: implication of regulatory T lymphocytes in the control of immune response.
        Expert Opin Biol Ther. 2010; 10: 1563-1572
        • Peng G.
        • Li S.
        • Wu W.
        • Sun Z.
        • Chen Y.
        • Chen Z.
        Circulating CD4+ CD25+ regulatory T cells correlate with chronic hepatitis B infection.
        Immunology. 2008; 123: 57-65
        • Sousa R.
        • Munoz-Mahamud E.
        • Quayle J.
        • Dias da Costa L.
        • Casals C.
        • Scott P.
        • et al.
        Is asymptomatic bacteriuria a risk factor for prosthetic joint infection?.
        Clin Infect Dis. 2014; 59: 41-47
        • Mastoraki S.
        • Michaelopoulos A.
        • Kriaras I.
        • Geroulanos S.
        Cefuroxime as antibiotic prophylaxis in coronary artery bypass grafting surgery.
        Interact Cardiovasc Thorac Surg. 2007; 6: 442-446
        • Teillant A.
        • Gandra S.
        • Barter D.
        • Morgan D.J.
        • Laxminarayan R.
        Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: a literature review and modelling study.
        Lancet Infect Dis. 2015; 15: 1429-1437
        • Manian F.A.
        The role of postoperative factors in surgical site infections: time to take notice.
        Clin Infect Dis. 2014; 59: 1272-1276
        • Petherick E.S.
        • Dalton J.E.
        • Moore P.J.
        • Cullum N.
        Methods for identifying surgical wound infection after discharge from hospital: a systematic review.
        BMC Infect Dis. 2006; 6: 170