Percentage of adult patients undergoing open cardiac surgery with the recommended antibiotic agents administered for surgical site infection prophylaxis.

Surgical site infections (SSIs) are associated with significant morbidity and mortality.^1-4 Antimicrobial prophylaxis is one mechanism to prevent surgical site infections. It is recommended that the agent administered for prophylaxis should be selected based on procedure type, safety profile, and patient’s medication allergies.² An antimicrobial agent for surgical prophylaxis should prevent SSI while limiting the adverse consequences to the patient’s microbial flora.² The Society of Thoracic Surgeons (STS) Practice Guidelines as well as the American Society of Health-System Pharmacists (ASHP) recommend the use of a first- or second-generation cephalosporin as the primary prophylactic antibiotic for adult cardiac surgery.^2,4 If the patient has a beta-lactam allergy, STS recommends the use of vancomycin for prophylaxis. The STS Guidelines also recommend gentamicin or other aminoglycoside be administered with vancomycin for gram negative coverage, however, the efficacy of adding an aminoglycoside is not well established in the literature, yet is still recommended.^2,4-8 For this reason, the measure flags cases where vancomycin alone was administered.  

120 minutes prior to Anesthesia Start through Anesthesia End

Adult patients undergoing open cardiac surgical procedures (determined by Procedure Type: Cardiac value code: 1)

• Age < 18 years
• ASA 6 including Organ Procurement (CPT: 01990)
• Patients already on scheduled antibiotics or had a documented infection prior to surgery (determined by ABX Notes value code: 2)
• Procedures:
  • Lung transplants, as defined by the Procedure Type: Lung Transplant phenotype
  • Non-cardiac, Transcatheter/Endovascular, EP/Cath, and Other Cardiac cases (determined by Procedure Type: Cardiac value codes: 0, 2, 3, 4)

Documentation of appropriate antibiotics administered preoperatively or intraoperatively - see ‘Other Measure Build Details’ for table of appropriate antibiotic combinations.

Acceptable Antibiotics:

MPOG Antibiotic Concepts:

• If an antibiotic is administered but not included on the list of ‘acceptable’ antibiotics for cardiac surgery (above), the case will be flagged for ‘non-standard antibiotic selection.’
• Only doses administered via IV route (MPOG Concept ID: 2001) will be considered.
• Measure will only look for the prophylactic variance note (as determined by the ABX Notes Phenotype) if an antibiotic is not documented within the measure time frame. 
• Cases will be flagged for review if there is documentation indicating prophylactic antibiotics were given (Concept ID: 50181, 50182, 50622) but administration dose, route, and time are not documented in the electronic medication administration record.
• Cases will be flagged for review if there is documentation that an antibiotic was not ordered or there is documentation that the antibiotic is ‘not indicated.’
• Cases will be assigned one of the following results:
  • Passed - Vancomycin + Cephalosporin
  • Passed - Vancomycin + Aminoglycoside
  • Passed - Cephalosporin Only
  • Flagged - Non-standard antibiotic selection
  • Flagged - Prophylactic antibiotic administered (Not documented in MAR)
  • Flagged - Antibiotic not ordered/indicated per surgeon
  • Flagged - Not administered for medical reasons
  • Flagged-  No documentation found that an antibiotic was administered during measure time period
  • Excluded - Scheduled antibiotics/documented infection

*This measure will include only valid MPOG cases as defined by the Is Valid Case phenotype.

Not applicable

All anesthesia providers signed in at the time of Anesthesia Start

1. Surat G, Bernsen D, Schimmer C: Antimicrobial stewardship measures in cardiac surgery and its impact on surgical site infections. J Cardiothorac Surg 2021; 16:309
2. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA, American Society of Health-System Pharmacists (ASHP), Infectious Diseases Society of America (IDSA), Surgical Infection Society (SIS), Society for Healthcare Epidemiology of America (SHEA): Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect 2013; 14:73–156 
3. Bardia A, Michel G, Farela A, Fisher C, Mori M, Huttler J, Lang AL, Geirsson A, Schonberger RB: Association of adherence to individual components of Society of Thoracic Surgeons cardiac surgery antibiotic guidelines and postoperative infections. J Thorac Cardiovasc Surg 2023 doi:10.1016/j.jtcvs.2023.03.031
4. Engelman R, Shahian D, Shemin R, Guy TS, Bratzler D, Edwards F, Jacobs M, Fernando H, Bridges C; Workforce on Evidence-Based Medicine, Society of Thoracic Surgeons. The Society of Thoracic Surgeons practice guideline series: Antibiotic prophylaxis in cardiac surgery, part II: Antibiotic choice. Ann Thorac Surg. 2007 Apr;83(4):1569-76. doi: 10.1016/j.athoracsur.2006.09.046. PMID: 17383396. https://www.sts.org/sites/default/files/documents/Clinical%20Guidelines/AntibioticProphylaxisCardiacSurgeryPart_IIAntibiotic_Choice.pdf  (Summary of ‘The Society of Thoracic Surgeons practice guideline series: Antibiotic prophylaxis in cardiac surgery, part II: Antibiotic choice’ also published in Guideline Central: https://www.guidelinecentral.com/guideline/19852/
5. Kaiser AB, Petracek MR, Lea JW IV, et al. Efficacy of cefazolin, cefamandole, and gentamicin as prophylactic agents in cardiac surgery. Results of a prospective, randomized, double-blind trial in 1030 patients. Ann Surg 1987;206:791–7.
6. Peghin M., Pompei E., Vendramin I., Tascini C. Gram-negative bacteria as a cause of mediastinitis after cardiac surgery. Curr. Opin. Infect. Dis. 2021;34:710–717. doi: 10.1097/QCO.0000000000000785.
7. Wojnarski C.M., Elgudin Y., Rubelowsky J.J., Wilson B.M., Donskey C.J., Cmolik B.L. Emerging trends in mediastinitis: National Veterans Health Administration experience with methicillin-resistant Staphylococcus aureus prevention. J. Thorac. Cardiovasc. Surg. 2021;162:1125–1130.e1. doi: 10.1016/j.jtcvs.2020.02.116.
8. Charbonneau H., Maillet J.M., Faron M., Mangin O., Puymirat E., Le Besnerais P., Du Puy-Montbrun L., Achouh P., Diehl J.L., Fagon J.Y., et al. Mediastinitis due to Gram-negative bacteria is associated with increased mortality. Clin. Microbiol. Infect. 2014;20:O197–O202. doi: 10.1111/1469-0691.12369