LETTERS TO EDITOR
Is it possible to eliminate sternal wound infection after cardiac surgery?

„If you always do what you’ve always done,
You’ll always get what you’ve always got.”
Henry Ford (1863-1947)

Sternal wound infection (SWI) is a serious and expensive complication after cardiac surgical procedures. A large array of risk factors including obesity, chronic obstructive pulmonary disease, diabetes, reoperation, use of bilateral internal thoracic artery (ITA) conduits, long operation time, low cardiac output, prolonged ventilation, and re-exploration for bleeding are associated with its occurrence [1]. At the same time a variety of therapeutic options such as debridement with early or delayed closure, closed continuous irrigation, vacuum-assisted closure, partial or complete sternectomy with flap reconstruction and omental transposition [1], or the innovative but expensive titanium rib bridge system (STRATOS) [2] are available for dealing with this frustrating and often lethal complication after routine cardiac surgery.
Despite our enormous understanding of the pathophysiology of SWI after cardiac surgery and massive advances in its management it remains a major physical disability, psychological impediment, as well as a financial liability.
At Harefield Hospital, over the past five years, we have shifted our focus from management of SWI to its pre-emption and prevention. This paradigm shift has resulted in an enormous reduction in the rates of SWI infection at our institution (Fig. 1), encouraging everyone to believe that it is possible to eliminate SWI after cardiac surgery. We have adopted a three-pronged strategy to tackle SWI. This strategy involves focus on modifiable pre-, intra- and postoperative risk factors, adoption of a standardized sternal wound care bundle, and an efficient infection control, prevention and surveillance service.
As a first step we risk stratify all our cardiac surgical patients on admission using the Brompton & Harefield Infection Score (BHIS). This risk scoring system categorizes patients as low (BHIS = 0-1), medium (BHIS = 2-3), or high risk (BHIS ≥ 4) for SWI taking into considerationwhether they are female (score = 2), diabetic (score = 1), Hb1Ac > 7.5% (score = 3), BMI ≥ 35 (score = 2), ejection fraction ≤ 45% (score = 1), and emergency surgery (score = 2). Identification of patients who are at high or medium risk for SWI then triggers a cascade of events and interventions aimed at eliminating the occurrence of SWI. One of the key areas we have aggressively focused on...


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