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J Thorac Cardiovasc Surg 2006;132:537-543
© 2006 The American Association for Thoracic Surgery

General Thoracic Surgery

Risk factors for 1-year mortality after postoperative mediastinitis

Ravi Karra, MD, MHS*, Lisa McDermott, MD, Sarah Connelly, MD, Peter Smith, MD, Daniel J. Sexton, MD, Keith S. Kaye, MD, MPH1

Departments of Medicine and Surgery, Division of Infectious Diseases, Duke University Medical Center, Durham, NC.

Received for publication February 8, 2006; revisions received March 29, 2006; accepted for publication April 11, 2006.

* Address for reprints: Ravi Karra, MD, MHS, Brigham and Women's Hospital, PBB-B-4, 75 Francis St, Boston, MA 02115 (Email: rkarra{at}partners.org).


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
OBJECTIVE: Postoperative mediastinitis after median sternotomy is associated with disability and mortality. The aim of this study was to identify risk factors for mortality 1 year after postoperative mediastinitis diagnosis.

METHODS: Postoperative mediastinitis was defined as an organ-space infection involving the mediastinum and necessitating debridement. A total of 183 cases of postoperative mediastinitis were prospectively identified from infection control databases. By using univariate and multivariate analysis, clinical risk factors for 1-year mortality were identified.

RESULTS: Of 183 patients, 36 (19.7%) died within 3 months of the initial operation. Overall, 51 (33%) died during the study period (the median time to death from the date of diagnosis was 37 days [interquartile range, 11,139 days]). In multivariate analysis, independent predictors of 1-year mortality were a greater than 3-day delay in sternal closure after debridement (hazard ratio, 6.27; P < .001), age greater than 65 years (hazard ratio, 2.29; P = .015), serum creatinine level greater than 2 mg/dL before debridement (hazard ratio, 2.52; P = .019), stay in an intensive care unit before sternal debridement (hazard ratio, 5.56; P < .001), and postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus (hazard ratio, 2.13; P = .02). Treatment with antibiotics with in vitro activity against the infecting pathogen within 7 days of initial debridement was associated with a decreased risk for mortality (hazard ratio, 0.40; P = .03).

CONCLUSIONS: Our data suggest that, to improve long-term survival, patients with postoperative mediastinitis should undergo sternal closure within 72 hours after sternal debridement and should receive effective antimicrobial therapy based on operative culture results.

Abbreviations and Acronyms CABG = coronary artery bypass grafting; HR = hazard ratio; ICU = intensive care unit; IQR = interquartile range; MRSA = methicillin-resistant Staphylococcus aureus ; POM = postoperative mediastinitis


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Postoperative mediastinitis (POM) is a dreaded complication of median sternotomy associated with increased patient mortality and markedly increased costs. The mortality rate among patients with POM in the immediate postoperative period is high, with reports ranging from 11.8% to 14%, compared with only 2.7% to 5.5% in uninfected controls.1-3Go Although the incidence of poststernotomy mediastinitis is low (most reports range from 0.7% to 3.4%), because median sternotomy is a common operation, the effect of POM on individual patients and institutions is great. Thus, POM continues to be an important topic of study.

Mediastinitis typically occurs approximately 2 weeks after surgery and is usually heralded by sternal wound dehiscence or frank purulent drainage. Standard therapy includes sternal debridement, sternal drainage, intensive intravenous antibiotics, and flap closure of the mediastinum. Independent risk factors for POM have been well chronicled and include host factors (age, obesity, diabetes, smoking status, and New York Heart Association functional class III or IV), variables associated with hospitalization (prolonged mechanical ventilation, duration of stay in the intensive care unit [ICU], and concurrent surgical-site infection), and technical factors (previous heart operation, duration of initial operation, and need for surgical re-exploration).1-14Go

A few studies have identified risk factors related to mortality in patients with POM; in every such study, mortality in the immediate postoperative period was the only end point analyzed. These studies concluded that the following were risk factors for mortality in the immediate postoperative period: (1) variables pertaining to the host (advanced age and persistent bacteremia), (2) variables related to hospitalization (need for an intra-aortic balloon pump, prolonged mechanical ventilation, and type of organism cultured), and (3) variables related to the operative procedure (prolonged duration of operation and need for reoperation).2,15-17Go

Milano and colleagues3Go were the first to report an increased risk of long-term mortality in patients with POM, with the increased risk persisting for up to 2 years after diagnosis. Since then, other groups have demonstrated that patients with POM have a twofold to fourfold increased risk for death anywhere from 1 to 10 years after the initial cardiothoracic operation.3,11,18,19Go Because the standard treatment for POM necessitates surgical drainage and can result in considerable morbidity, the observed increase in long-term mortality in patients with POM compared with controls is not surprising.20Go Consequently, some investigators have postulated that POM may indeed produce long-term adverse effects on cardiac, pulmonary, and renal function.3Go Identification of risk factors for long-term adverse outcomes in patients with POM may potentially lead to risk-factor modification, decreased mortality, and improved health and functional status. The purpose of this study was to determine risk factors for 1-year mortality in patients with POM.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Study Design, Patient Population, and Study Setting
This was a cohort study. Patients with documented cases of potential POM were prospectively identified by infection control practitioners using standard Centers for Disease Control definitions.21Go Patients with POM after coronary artery bypass grafting (CABG) and/or valve replacement at Duke University Medical Center from 1994 to 2001 were studied. Duke University Medical Center is a 725-bed tertiary academic medical center located in Durham, North Carolina. During the study period, 10,144 CABG and/or valve replacement operations were conducted at Duke University Medical Center. Institutional review board approval was obtained for this research project.

Subject Inclusion/Exclusion Criteria
For this study, all patients with POM after CABG without a valve operation were included. The diagnosis of POM was confirmed by using the Centers for Disease Control definitions for surgical-site infection criteria.21Go Patients were required to have purulent organ-space infection of the mediastinum, confirmed by sternal debridement. Infections of sternotomy sites that did not warrant debridement clinically or that could not be confirmed by debridement were deemed superficial. Exclusion criteria for the study included age less than 18 years, patients who were heart and/or lung transplant recipients, patients with superficial sternal infections and deep infections not involving the mediastinum, patients with suspected POM who were too ill to undergo debridement, and patients who did not have a diagnosis of mediastinitis confirmed by sternal debridement.

Study Databases and Variables
Data were obtained from the Duke Infection Control Operative Database, the Duke cardiothoracic surgery database, and patient charts. The following variables were prospectively recorded in the Duke Infection Control Operative Database: age, sex, procedure type, procedure date, National Nosocomial Infection Surveillance risk factors (American Society of Anesthesiologists score, wound class, and operative duration), and the pathogen type and in vitro antimicrobial susceptibility pattern. The date of POM diagnosis was defined as the date when frank purulent drainage was first noted from the incision site. If no purulent drainage was noted from the incision site, then the date of diagnosis was the date of sternal debridement when pus was drained from the mediastinum. Data obtained from the Duke cardiothoracic surgery database were prospectively collected and included the following: basic patient characteristics (weight, body-surface area, and race), comorbid conditions before sternotomy (diabetes, congestive heart failure, chronic obstructive pulmonary disease, hypertension, tobacco use, and liver disease), and the Charlson Index before sternotomy.22Go Information pertaining to hospital exposures was collected retrospectively by chart review and included the following: type of surgical closure of the sternum (immediate, delayed, or healing by secondary intention); type of surgical flap (pectoral or omental); use of wound vacuum; admission to an ICU; use of vasopressors; and the need for intubation, mechanical ventilation, or both. Vital signs (temperature, blood pressure, and heart rate) and laboratory values (white blood cell count, serum creatinine, and serum blood glucose) from 24 hours before sternal debridement until 72 hours after debridement were also collected. Results of blood and wound cultures along with the antibiotics used at the time of hospital admission for treatment of POM, on the day of sternal debridement, and on days 7 and 14 after debridement were also obtained via chart review. The date of death was obtained from the Duke cardiothoracic surgery database or from the Social Security Death Index (http://www.ssa.gov/).

Statistics
Statistical analysis was performed with version 8.3 of the SAS software package (SAS Institute, Cary, NC). Estimates of survival were generated by using the Kaplan-Meier method. Dichotomous variables were analyzed by using Cox proportional hazards methods, and continuous and ordinal variables were analyzed by using the Student t test and the Wilcoxon rank sum test. Hazard ratios (HRs) for 1-year mortality were determined by bivariate analysis with Cox proportional hazards regression methodology.

Multivariate analysis was performed with Cox proportional hazards methods. Risk factors from the bivariate analysis with a P value less than or equal to .2 and variables considered to be important by the study investigators were considered for inclusion in multivariate models. Variables to be included in the final multivariate regression model were identified by a stepwise selection process. The final model was controlled for confounding covariates. If a covariate changed the coefficient of a model variable by 10% or more, then the confounding covariate was retained in the final model. For each variable in the final multivariate model, the proportional hazards assumption was verified by generating parallel log-log plots. All reported P values are two tailed, and a P value less than or equal to .05 was considered to be significant.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Of the 10,144 patients who underwent CABG and/or valve replacement operations from 1994 to 2001, 299 potential cases of POM were prospectively identified by infection control practitioners. Of these 299 potential cases of POM, 107 cases were excluded on the basis of inclusion/exclusion criteria, and 9 cases were excluded because the patient charts were unavailable. The most common reason for exclusion was superficial infection (n = 58). Other patients were excluded because they had an infection at another site as opposed to POM (n = 9), because no infection was identified (n = 11), because they were heart transplant recipients (n = 11), because they were too ill to undergo debridement (n = 5), because sternal debridement was not performed (n = 3), or because of age less than 18 years (n = 10).

A total of 183 cases of POM met study criteria (the incidence of POM was 1.8% by study criteria; Table 1). Of these 183 patients, 139 (75.96%) initially underwent CABG, 27 (14.75%) initially underwent valve operation and CABG, 10 (5.46%) underwent a revision of a prior CABG, 6 (3.28%) had valve surgery only, and 1 (0.55%) underwent pericardial stripping. The median time for diagnosis of POM from the initial operation was 16 days (interquartile range [IQR], 11, 25.5 days). Sternal closure methods after sternal debridement included flap closure (n = 131; 71.58%), primary closure without a flap (n = 29; 15.85%), and healing by secondary intention (n = 23; 12.57%). Of the 131 patients who underwent sternal flap closure, 87 (66.4%) were closed by using a pectoralis major flap, and 44 (33.4%) were closed by using an omental flap. The median duration from diagnosis of POM to sternal debridement was 2 days (IQR, 1.4 days). Pathogens causing POM included methicillin-resistant Staphylococcus aureus (MRSA; n = 61; incidence 33%), methicillin-susceptible S aureus (n = 60; incidence 33%), and gram-negative rods (n = 24; incidence 13%; Table 1).


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  		TABLE 1. Bivariate predictors of 1-year mortality
 
One-Year Survival Incidence Data
Survival in the study population as a function of days after the diagnosis of POM is shown in Figure 1. Thirty-six patients died within the immediate 3-month postoperative period (incidence of 19.6%; the median time to death was 21 days [IQR, 33.3 days] for these patients). Fifty-one patients died within 1 year of their initial operation (1-year mortality rate of 28%), and the median time to death was 37 days (IQR, 11,139 days) after the diagnosis of POM (Figure 1).


Figure 1
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  		Figure 1. Survival after diagnosis of postoperative mediastinitis (POM). The probability of survival is plotted as a function of days after the initial diagnosis of POM.

 
Bivariate Analysis of 1-Year Mortality
Bivariate predictors of 1-year mortality were analyzed (Table 1). Of the host factors studied, the following were associated with 1-year mortality: a Charlson score of 3 or more (HR, 2.55; P = .004), a history of peptic ulcer disease (HR, 3.17; P = .011), a history of congestive heart failure (HR, 2.41; P = .002), and a serum creatinine level greater than 2.0 mg/dL before initial sternal debridement (HR, 2.62; P = .004; Table 1). Hospital-related risk factors associated with 1-year mortality after the diagnosis of mediastinitis included an ICU stay before the initial sternal debridement (HR, 3.66; P < .001), use of vasoactive drugs before the initial sternal debridement (HR, 4.793; P < .001), and the need for mechanical ventilation before debridement (HR, 3.75; P < .001). Treatment variables associated with mortality included a time from sternal debridement to sternal closure longer than 3 days (compared with patients who underwent sternal closure in 3 days or shorter; HR, 2.38; P = .027; Figure 2) and no flap performed after sternal debridement (HR, 3.65; P = .008). In terms of pathogens, POM due to MRSA was significantly associated with 1-year postoperative mortality compared with POM due to other pathogens (HR, 2.65; P < .001).


Figure 2
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  		Figure 2. Survival after the diagnosis of postoperative mediastinitis (POM) and the time to flap closure. Survival in days after the diagnosis of POM is plotted for the group receiving no flap, the group receiving a flap within 3 days of diagnosis, and the group receiving a flap more than 3 days after diagnosis.

 
Multivariate Analysis of 1-Year Mortality
Independent predictors of 1-year mortality among patients with POM included age older than 65 years (HR, 2.29; P = .015); serum creatinine level greater than 2.0 mg/dL before sternal debridement (HR, 2.52; P = .019); stay in an ICU before initial sternal debridement (HR, 5.56; P < .001); POM due to MRSA (HR, 2.13; P = .019); a delay in sternal closure after sternal debridement of more than 3 days (compared with patients who underwent closure in ≤3 days; HR, 6.27; P < .001); and not receiving flap closure after sternal debridement (HR, 7.70; P = .002; Table 2). Treatment with antibiotics with in vitro activity against the infecting pathogen within 7 days after initial debridement was associated with a decreased risk for mortality (HR, 0.40; P = .030). The final multivariate model was controlled for the presence or absence of heart failure.


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  		TABLE 2. Multivariate predictors of 1-year mortality *
 

   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
This was the first study, to our knowledge, that analyzed risk factors for 1-year mortality after POM. In addition to identifying risk factors previously reported as predictors of mortality in the immediate postoperative period (such as age and type of infecting organism), we also identified risk factors for mortality not previously identified, including the lack of flap closure, the time to flap closure after sternal debridement, treatment with antibiotics effective against the infecting organism within 7 days of debridement, renal failure, and ICU stay before surgery.2,15-17Go

We found that a greater than 3-day delay between sternal debridement and sternal closure was the strongest independent predictor of 1-year mortality in patients with POM, increasing the risk for mortality more than sixfold. Patients with delayed sternal closure likely represented two diverse populations: the first, patients with severe infection and/or hemodynamic instability, clinical features that may have prevented prompt sternal closure; and the second, hemodynamically stable patients who had delays in sternal closure possibly due to competing issues or scheduling difficulties. To address potential bias between delayed sternal closure and an increased severity of illness or hemodynamic instability, the final multivariate model was adjusted for indices of baseline health and acute illness. After adjustment for severity of illness, the association between delayed sternal closure and mortality persisted. Although this finding will need to be verified in subsequent data sets, on the basis of the current study results, every effort should be made to close the sternum within 3 days of sternal debridement.

Furthermore, patients who received antibiotics active against the infecting pathogen within 7 days of sternal debridement had a significantly decreased risk for mortality. This finding underscores the importance of using antibiotics with a spectrum of activity to include MRSA, obtaining deep cultures during sternal debridement, verifying culture results, and modifying therapy promptly according to in vitro susceptibility results. Other therapeutic interventions (including the type of mediastinal flap and use of a WoundVac) were not significantly associated with 1-year mortality. Increased age, renal failure before CABG, and ICU admission before sternal debridement were also associated with increased mortality and likely represent markers for patients with increased acute illness and chronic comorbid conditions that predispose to severe POM and death. Patients with these risk factors may require specific interventions to prevent POM, perhaps by maintaining health status through adequate hydration and minimizing the use of nephrotoxic agents during the perioperative and postoperative periods.

Our results provide some insight into the epidemiology and pathophysiology of POM. Although S aureus has been well documented as the most common pathogen isolated in patients with POM, we identified MRSA in particular as the pathogen most strongly associated with mortality.2Go This finding is consistent with previous work by our group that reported a greater than 3-fold increase in 90-day postoperative mortality in patients with surgical-site infection due to MRSA compared with surgical-site infection due to methicillin-susceptible S aureus and an 11-fold increase in mortality compared with uninfected surgical patients.23-25Go POM due to MRSA might represent a particularly refractory type of POM, because antibiotic options are limited and suboptimal. Because standard perioperative antimicrobial prophylaxis regimens do not provide coverage against MRSA, altering perioperative surgical prophylaxis regimens that provide coverage against MRSA and/or using mupirocin before surgery to reduce rates of colonization with MRSA might prevent some cases of POM due to MRSA and thus secondarily reduce POM-related mortality.26-28Go

This study had limitations. Although the study represents one of the largest cohorts of patients with documented POM, statistical power was limited when subgroups were analyzed. For example, small sample sizes precluded intensive analysis of patients who underwent different methods of mediastinal flap closure. Another limitation is that the study results come from a single institution and might not be generalizable to other hospitals. Finally, although cases were identified prospectively, detailed data were abstracted from patient charts retrospectively, thus potentially introducing bias into the study. However, we used detailed protocols to obtain data and reviewed these protocols carefully with study personnel, thus limiting the extent of bias. Because of the observational nature of the study, we cannot rule out the presence of other possible confounding variables that might have affected study results.

In summary, our work has identified risk factors for 1-year mortality in patients with POM. When patients with POM initially present, they should undergo adequate debridement and sternal closure in less than 72 hours after sternal debridement and should receive effective definitive antimicrobial therapy based on operative culture results. Our findings illustrate the clinical importance of selecting preoperative surgical antimicrobial prophylaxis to cover pathogens that are known or expected to cause POM. The best way to do this is for hospitals to monitor and trend their rates of POM and analyze the pathogens that commonly cause postoperative infections in their institutions. Indeed, we believe that it is notable and important that in this study, MRSA caused approximately one third of cases of POM at our hospital. This in turn has prompted us to develop preoperative strategies to identify patients who are likely to be colonized with MRSA. These patients then receive antimicrobial prophylaxis that includes activity against MRSA.29Go


   Footnotes
 
1 Dr Kaye was supported by National Institutes of Health grant K23 AG23621-01A1. Back


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. El Oakley R, Paul E, Wong PS, et al. Mediastinitis in patients undergoing cardiopulmonary bypass. risk analysis and midterm results. J Cardiovasc Surg (Torino) 1997;38:595-600.[Medline]
  2. Munoz P, Menasalvas A, Bernaldo de Quiros JC, et al. Postsurgical mediastinitis. a case-control study. Clin Infect Dis 1997;25:1060-1064.[Medline]
  3. Milano CA, Kesler K, Archibald N, et al. Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival. Circulation 1995;92:2245-2251.[Abstract/Free Full Text]
  4. Hammermeister KE, Burchfiel C, Johnson R, et al. Identification of patients at greatest risk for developing major complications at cardiac surgery. Circulation 1990;82:IV380-IV389.
  5. Newman LS, Szczukowski LC, Bain RP, et al. Suppurative mediastinitis after open heart surgery. A case control study of risk factors. Chest 1988;94:546-553.[Abstract/Free Full Text]
  6. Ottino G, De Paulis R, Pansini S, et al. Major sternal wound infection after open-heart surgery. a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987;44:173-179.[Abstract]
  7. Gaynes R, Marosok R, Mowry-Hanley J, et al. Mediastinitis following coronary artery bypass surgery. a 3-year review. J Infect Dis 1991;163:117-121.[Medline]
  8. Abboud CS, Wey SB, Baltar VT. Risk factors for mediastinitis after cardiac surgery. Ann Thorac Surg 2004;77:676-683.[Abstract/Free Full Text]
  9. Ridderstolpe L, Gill H, Granfeldt H, et al. Superficial and deep sternal wound complications. incidence, risk factors and mortality. Eur J Cardiothorac Surg 2001;20:1168-1175.[Abstract/Free Full Text]
  10. Gummert JF, Barten MJ, Hans C, et al. Mediastinitis and cardiac surgery—an updated risk factor analysis in 10,373 consecutive adult patients. Thorac Cardiovasc Surg 2002;50:87-91.[Medline]
  11. Olsen MA, Lock-Buckley P, Hopkins D, et al. The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different. J Thorac Cardiovasc Surg 2002;124:136-145.[Abstract/Free Full Text]
  12. Borger MA, Rao V, Weisel RD, et al. Deep sternal wound infection. risk factors and outcomes. Ann Thorac Surg 1998;65:1050-1056.[Abstract/Free Full Text]
  13. Nagachinta T, Stephens M, Reitz B, et al. Risk factors for surgical-wound infection following cardiac surgery. J Infect Dis 1987;156:967-973.[Medline]
  14. Demmy TL, Park SB, Liebler GA, et al. Recent experience with major sternal wound complications. Ann Thorac Surg 1990;49:458-462.[Abstract]
  15. Rutledge R, Applebaum RE, Kim BJ. Mediastinal infection after open heart surgery. Surgery 1985;97:88-92.[Medline]
  16. Gardlund B, Bitkover CY, Vaage J. Postoperative mediastinitis in cardiac surgery—microbiology and pathogenesis. Eur J Cardiothorac Surg 2002;21:825-830.[Abstract/Free Full Text]
  17. Trouillet JL, Vuagnat A, Combes A, et al. Acute poststernotomy mediastinitis managed with debridement and closed-drainage aspiration. factors associated with death in the intensive care unit. J Thorac Cardiovasc Surg 2005;129:518-524.[Abstract/Free Full Text]
  18. Braxton JH, Marrin CA, McGrath PD, et al. Mediastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg 2000;70:2004-2007.[Abstract/Free Full Text]
  19. Braxton JH, Marrin CA, McGrath PD, et al. 10-year follow-up of patients with and without mediastinitis. Semin Thorac Cardiovasc Surg 2004;16:70-76.[Medline]
  20. Robicsek F. Postoperative sterno-mediastinitis. Am Surg 2000;66:184-192.[Medline]
  21. Horan TC, Gaynes RP, Martone WJ, et al. CDC definitions of nosocomial surgical site infections, 1992. a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606-608.[Medline]
  22. Poses RM, McClish DK, Smith WR, et al. Prediction of survival of critically ill patients by admission comorbidity. J Clin Epidemiol 1996;49:743-747.[Medline]
  23. Mekontso-Dessap A, Kirsch M, Brun-Buisson C, et al. Poststernotomy mediastinitis due to Staphylococcus aureus . comparison of methicillin-resistant and methicillin-susceptible cases. Clin Infect Dis 2001;32:877-883.[Medline]
  24. Engemann JJ, Carmeli Y, Cosgrove SE, et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003;36:592-598.[Medline]
  25. Kaye KS, Engemann JJ, Mozaffari E, et al. Reference group choice and antibiotic resistance outcomes. Emerg Infect Dis 2004;10:1125-1128.[Medline]
  26. Zanetti G, Goldie SJ, Platt R. Clinical consequences and cost of limiting use of vancomycin for perioperative prophylaxis. example of coronary artery bypass surgery. Emerg Infect Dis 2001;7:820-827.[Medline]
  27. Spelman D, Harrington G, Russo P, et al. Clinical, microbiological, and economic benefit of a change in antibiotic prophylaxis for cardiac surgery. Infect Control Hosp Epidemiol 2002;23:402-404.[Medline]
  28. Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002;346:1871-1877.[Abstract/Free Full Text]
  29. Dodds Ashley ES, Carroll DN, Engemann JJ, et al. Risk factors for postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus . Clin Infect Dis 2004;38:1555-1560.[Medline]



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