Multi-centre prospective internal and external evaluation of the Brompton Harefield Infection Score (BHIS)

Abstract

Background:

Previously, we reported that the Brompton Harefield Infection Score (BHIS) accurately predicts surgical site infection (SSI) after coronary artery bypass grafting (CABG). The BHIS was developed using two-centre data and stratifies SSI risk into three groups based on female gender, diabetes or HbA1c > 7.5%, body mass index ≥ 35, left ventricular ejection fraction < 45% and emergency surgery. The purpose of this study was to prospectively evaluate BHIS internally as well as externally.

Methods:

Multi-centre prospective evaluation involving three tertiary centres took place between October 2012 and November 2015. SSI was classified using the Public Health England protocol. Receiver operating characteristic (ROC) curves assessed predictive accuracy.

Results:

Across the four hospital sites, 168 of 4308 (3.9%) CABG patients had a SSI. Categorising the hospitals by BHIS score revealed that 65% of all patients were low risk (BHIS 0–1), 26% were medium risk (BHIS 2–3) and 8% were high risk (BHIS ≥ 4). The area under the ROC curve was in the range of 0.702–0.785. Overall area under the ROC curve was 0.709.

Conclusions:

BHIS provides a novel, internally and externally evaluated score for a patient’s risk of SSI after CABG. It enables clinicians to focus on strategies to prospectively identify high-risk patients and improve outcomes.

Keywords

Surgical site infection surveillance statistics

Get full access to this article

View all access options for this article.

References

Abuzaid

Zaki

Al Tarief

(2015) Potential risk factors for surgical site infection after isolated coronary artery bypass grafting in a Bahrain cardiac centre: A retrospective, case-controlled study. Heart Views 16: 79–84.

Birkmeyer

Charlesworth

Hernandez

Leavitt

Marrin

Morton

Olmstead

O’Connor

. (1998) Obesity and risk of adverse outcomes associated with coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group. Circulation 97: 1689–1694.

Cannoletta

Soo

Rochon

Mahiout

de Souza

Yadav

(2015) Brompton and Harefield Infection Score (BHIS): A novel scoring system for detection and treatment of sternal wound infection. Journal of Cardiothoracic Surgery 10 (Suppl. 1): A12.

Casqueiro

Alves

(2012) Infections in patients with diabetes mellitus: A review of pathogenesis. Indian Journal of Endocrinology and Metabolism 16 (Suppl. 1): S27–S36.

Fowler

Jr O’Brien

Muhlbaier

Corey

Ferguson

Peterson

. (2005) Clinical predictors of major infections after cardiac surgery. Circulation 112 (Suppl. 9): I358–365.

Friedman

Russo

Bull

Richards

Kelly

(2007) Validation of coronary artery bypass graft surgical site infection surveillance data from a statewide surveillance system in Australia. Infection Control and Hospital Epidemiology 28: 812–817.

Gan

. (2013) Host susceptibility factors to bacterial infections in type 2 diabetes. PLoS Pathogens 9: e1003794.

Gatti

Perrotti

Reichart

Maschietto

Onorati

Chocron

Dalen

Svenarud

Faggian

Santarpino

Fischlein

Pappalardo

Maselli

Dominici

Nardella

Rubino

De Feo

Santini

Nicolini

Gherli

Mariscalco

Tauriainen

Kinnunen

Ruggieri

Saccocci

Biancari

(2016) Glycated hemoglobin and risk of sternal wound infection after isolated coronary surgery. Circulation Journal 81: 36–43.

Graf

Ott

Vonberg

Kuehn

Haverich

Chaberny

. (2010) Economic aspects of deep sternal wound infections. European Journal of Cardiothoracic Surgery 37: 893–896.

10.

Harrington

Russo

Spelman

Borrell

Watson

Barr

Martin

Edmonds

Cocks

Greenbough

Lowe

Randle

Castell

Browne

(2004) Surgical-site infection rates and risk factor analysis in coronary artery bypass graft surgery. Infection Control and Hospital Epidemiology 25: 472–476.

11.

Heilmann

Stahl

Schneider

Sukhodolya

Siepe

Olschewski

Beyersdorf

(2013) Wound complications after median sternotomy: a single-centre study. Interactive Cardiovascular and Thoracic Surgery 16: 643–648.

12.

Koh

Peacock

van der Poll

Wiersinga

. (2012) The impact of diabetes on the pathogenesis of sepsis. European Journal of Clinical Microbiology & Infectious Diseases 31: 379–388.

13.

Lemaignen

Birgand

Ghodhbane

Alkhoder

Lolom

Belorgey

Lescure

Armand-Lefevre

Raffoul

Dilly

Nataf

Lucet

. (2015) Sternal wound infection after cardiac surgery: incidence and risk factors according to clinical presentation. Clinical Microbiology and Infect 21: 674.e11–18.

14.

Lenz

Brandt

Fraund-Cremer

Cremer

(2016) Coronary artery bypass surgery in diabetic patients – risk factors for sternal wound infections. GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW 5: Doc18.

15.

Loop

Lytle

Cosgrove

Mahfood

McHenry

Goormastic

Stewart

Golding

Taylor

. (1990) J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Annals of Thoracic Surgery 49: 179–186; discussion 186–187.

16.

Grayson

Jha

Srinivasan

Fabri

. (2003) Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery. European Journal of Cardiothoracic Surgery 23: 943–949.

17.

Martin

Kaye

Knott

Nguyen

Santarossa

Evans

Bertran

Jaber

(2016) Diabetes and risk of surgical site infection: A systematic review and meta-analysis. Infection Control and Hospital Epidemiology 37: 88–99.

18.

Moulton

Creswell

Mackey

Cox

Rosenbloom

. 1996) Obesity is not a risk factor for significant adverse outcomes after cardiac surgery. Circulation 94 (Suppl. 9): II87–192.

19.

Olsen

Sundt

Lawton

Damiano

Jr. Hopkins-Broyles

Lock-Buckley

Fraser

. (2003) Risk factors for leg harvest surgical site infections after coronary artery bypass graft surgery. Journal of Thoracic and Cardiovascular Surgery 126: 992–999.

20.

Public Health England. (2013) Protocol for the surveillance of surgical site infection. London: Public Health England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/364412/Protocol_for_surveillance_of_surgical_site_infection_June_2013.pdf.

21.

Public Health England. (2016) Surveillance of surgical site infections in NHS Hospitals in England, 2015/16. London: Public Health England.

22.

Raja

Rochon

Jarman

JWE

. (2015) Brompton Harefield Infection Score (BHIS): development and validation of a stratification tool for predicting risk of surgical site infection after coronary artery bypass grafting. International Journal of Surgery 16: 69–73.

23.

Rochon

Gibb

Soler Castells

Gott

Neville

Morais

Viana

Ashpole

Jakeman

Bahrami

(2017) Quality improvement: chest support to aid recovery following median sternotomy in female cardiac patients. Wounds UK 13: 50–57.

24.

Sakamoto

Fukuda

Oosaka

Nakata

(2003) Risk factors and treatment of deep sternal wound infection after cardiac operation. Annals of Thoracic and Cardiovascular Surgery 9: 226–232.

25.

Sharma

Berriel-Cass

Baran

Jr. (2004) Sternal surgical-site infection following coronary artery bypass graft: prevalence, microbiology, and complications during a 42-month period. Infection Control and Hospital Epidemiology 25: 468–471.

26.

Tolpin

Collard

Lee

Elayda

Pan

(2009) Obesity is associated with increased morbidity after coronary artery bypass graft surgery in patients with renal insufficiency. Journal of Thoracic and Cardiovascular Surgery 138: 873–879.

27.

Vandenbroucke

von Elm

Altman

Gøtzsche

Mulrow

Pocock

Poole

Schlesselman

Egger

(2014) STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. International Journal of Surgery 12: 1500–1524.

28.

Vuorisalo

Haukipuro

Pokela

Syrjala

(1998) Risk features for surgical-site infections in coronary artery bypass surgery. Infect Control and Hospital Epidemiology 19: 240–247.

29.

Wetzel

Kneebone

Woloshynowych

Nestel

Moorthy

Kidd

Darzi

(2006) The effects of stress on surgical performance. American Journal of Surgery 191: 5–10.

30.

Wheatley

. (2002) Coronary artery surgery at the dawn of the 21st century. Journal of the Royal College of Surgeons 47: 608–612.

31.

Wigfield

Lindsey

Muñoz

Chopra

Edwards

Love

. (2006) Is extreme obesity a risk factor for cardiac surgery? An analysis of patients with a BMI > or = 40. European Journal of Cardiothoracic Surgery 29: 434–440.

32.

World Health Organization. (2016) Global guidelines on prevention of surgical site infection. Geneva: WHO. Available at: www.who.int (accessed 3 November 2016).