Nosocomial Infection After Lung Surgery: Incidence and Risk Factors

doi:10.1378/chest.128.4.2647

Chest

Volume 128, Issue 4, October 2005, Pages 2647-2652

https://doi.org/10.1378/chest.128.4.2647 Get rights and content

Study objectives

To assess the incidence and risk factors for nosocomial infection after lung surgery.

Design

Prospective cohort study.

Setting

Service of thoracic surgery of an acute-care teaching hospital in Santander, Spain.

Patients

Between June 1, 1999, and January 31, 2001, all consecutive patients undergoing lung surgery were prospectively followed up for 1 month after discharge from the hospital to assess the development of nosocomial infection, the primary outcome of the study.

Interventions

During the hospitalization period, patients were visited on a daily basis. Postdischarge surveillance was based on visits to the surgeon.

Measurements and results

We studied 295 patients (84% men; mean age, 60.9 years), 89% of whom underwent resection operations. Ninety episodes of nosocomial infection were diagnosed in 76 patients, including pneumonia (n = 10), lower respiratory tract infection (n = 47), wound infection (n = 16; one third were detected after hospital discharge), urinary tract infection (n = 9), and bacteremia (n = 8; three fourths were catheter-related bacteremia). Twenty patients had severe infections (pneumonia or empyema), with a mortality rate of 60%. COPD (adjusted odds ratio [OR], 2.70; 95% confidence interval [CI], 1.52 to 4.84), duration of surgery with an increased risk for each additional minute (Mantel-Haenzel χ² test for trend, p = 0.037), and ICU admission (OR, 3.69; 95% CI, 1.94 to 7.06) were independent risk factors for nosocomial infection. The use of an epidural catheter was a protective factor (OR, 0.45; 95% CI, 0.22 to 0.95). There were no differences according to the use of amoxicillin/clavulanate or cefotaxime for surgical prophylaxis.

Conclusions

Nosocomial infections are common after lung surgery. One third of wound infections were detected after hospital discharge. The profile of a high-risk patient includes COPD as underlying disease, prolonged operative time, and postoperative ICU admission.

Section snippets

Study Location and Patients

The study was conducted at a university-affiliated teaching hospital, Marqués de Valdecilla (1,100 beds), in Santander, Spain. The Division of Thoracic Surgery includes four staff surgeons and one resident. Approximately 400 thoracic procedures are performed annually, 150 of which are lung resections. During a 19-month period (June 1999 to January 2001), all patients undergoing pulmonary surgery were potentially eligible for this investigation. Patients < 14 years of age and patients undergoing

Study Design and Data Collection

Patients were visited on a daily basis to collect all pertinent data, which was recorded on a standardized data collection form. The following characteristics were prospectively recorded by one of the investigators: age; sex; body mass index; smoking history; alcohol consumption; presence of COPD; diabetes mellitus; hypoalbuminemia (serum albumin level < 3 g/L); anemia (hemoglobin < 12 g/dL); renal failure (serum creatinine level > 2 mg/dL); preoperative American Society of Anesthesiologists

Statistical Analysis

For each category of potential risk factors for infection, the incidence of nosocomial infection was calculated by dividing the number of events by the number of patients in each category. Relative risks (RRs) and their 95% confidence intervals (CIs) were calculated. All tests of significance were two tailed, and p values ≤ 0.05 were considered to indicate statistical significance. Multiple logistic regression analysis was performed to identify variables that were significantly related to the

Patients

A total of 295 consecutive patients undergoing lung surgery were prospectively evaluated. The mean age of the patients was 60.9 years (range, 14 to 83 years); 247 patients were men. The mean (± SD) length of preoperative stay was 3.0 ± 3.5 days. The surgical procedures performed included pneumonectomy (n = 78), lobectomy (n = 110), lung-sparing procedures (n = 76), and other surgical procedures (n = 31; including chest wall resections). Lung cancer was diagnosed in 231 patients, and benign

Incidence of Nosocomial Infection

Nosocomial infections developed in 76 patients (25.8%). Sixty-four patients presented a single infection episode, 10 patients had two infection episodes, and 2 patients had three episodes, a total of 90 nosocomial infections. These included respiratory infection (n = 57; pneumonia [n = 10], lower respiratory tract infection [n = 47]), wound infection (n = 16), urinary tract infection (n = 9), and bacteremia (n = 8; three fourths were catheter-related bloodstream infection). Of the 16 cases of

Antibiotic Prophylaxis

A total of 283 patients received perioperative antibiotic prophylaxis: cefotaxime (n = 96), amoxicillin/clavulanate (n = 174), and vancomycin or teicoplanin due to penicillin allergy (n = 13). There were no statistically significant differences in the risk of infections between the two first regimens (RR, 1.41; 95% CI, 0.9 to 2.3).

Risk Factors

With regard to preoperative variables (Table 2), COPD (OR, 2.70; 95% CI, 1.5 to 4.8), FEV₁ < 1,500 mL (OR, 2.46; 95% CI, 1.1 to 6.0), ASA physical status > 3 (OR, 1.82; 95% CI, 1.1 to 3.3), and anemia (serum hemoglobin < 12 g/dL) [OR, 1.90; 95% CI, 1.1 to 3.5] were risk factors for nosocomial infection. Other comorbidities (eg, chronic heart failure), body mass index, hypoalbuminemia, and renal failure as well as the length of preoperative stay were not identified as risk factors for the

Discussion

This study shows that nosocomial infections are common among patients undergoing lung surgery, with a rate of 25.8%. As far as we are aware, this is the first epidemiologic study of nosocomial infections in the subset of patients undergoing pulmonary surgery. Previous studies²¹¹ were comparative studies of antibiotic prophylactic regimens or studies on mortality. We included all types of infections, varying from respiratory or wound infections developing in patients undergoing major operations,

Acknowledgement

We thank Marta Pulido, MD, for editorial assistance.

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Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

Dr. Nan received a fellowship from the “Fundación Marqués de Valdecilla,” Santander, Spain.

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Chest

Clinical InvestigationsNosocomial Infection After Lung Surgery: Incidence and Risk Factors

Study objectives

Design

Setting

Patients

Interventions

Measurements and results

Conclusions

Section snippets

Study Location and Patients

Study Design and Data Collection

Statistical Analysis

Patients

Incidence of Nosocomial Infection

Antibiotic Prophylaxis

Risk Factors

Discussion

Acknowledgement

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Arch Bronconeumol

J Hosp Infect

Ann Thorac Surg

Chest

Am J Infect Control

Ann Thorac Surg

J Thorac Cardiovasc Surg

Chest

Clinical Investigations
Nosocomial Infection After Lung Surgery: Incidence and Risk Factors