Surgical site infection in pediatric patients undergoing cardiac surgery with delayed sternal closure: experience from a center in Chile, South America (2015–2020)

Surgical site infection in pediatric patients undergoing cardiac surgery with delayed sternal closure: experience from a center in Chile, South America (2015–2020) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical site infection in pediatric patients undergoing cardiac surgery with delayed sternal closure: experience from a center in Chile, South America (2015–2020) Daniela Jiménez, Paulo Valderrama, Nicolás Correa, Jaime Cerda, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7115282/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Oct, 2025 Read the published version in Pediatric Cardiology → Version 1 posted 8 You are reading this latest preprint version Abstract Introduction : Delayed sternal closure (DSC) is a technique used in complex cardiac surgery (CCS) and is associated with an increased risk of surgical site infection (SSI). SSI increases hospital stay and healthcare costs, with an incidence ranging from 1.5% to 34%. Objectives: To determine the SSI rate and associated risk factors in patients with congenital heart disease (CHD) undergoing CCS with DSC between January 2015 and December 2020, and to compare them with previous results, before the implementation of measures by the Healthcare-Associated Infections Committee (HAIC). Materials and Methods: A descriptive study was conducted in patients under 18 years of age who required DSC between 2015 and 2020 at the Hospital of Pontifical Catholic University of Chile, meeting the Chilean Ministry of Health's definition of SSI. SSI rates were compared between the periods 2009-2010 and 2015-2020 using the Poisson rate ratio. Results: A total of 1,471 surgeries were performed, of which 138 (9.3%) required DSC and 6 (4.3%) presented SSI. 67% were males older than 7 days, with one patient premature. 66.7% had extracorporeal circulation (ECC) >200 minutes and 83.3% required mechanical ventilation (MV) >5 days. Several SSI-causing microorganisms were identified. Comparing both studies, a decrease in the prevalence of SSI in DSC was found from 22% to 4.3%, with a rate ratio of 5.16 (95% IC 1.83-16.54, p = 0.001), with no significant differences in the risk factors identified in the initial study (ECC > 200 min and MV > 5 days). Conclusions: The SSI rate was 4.3%, a significant decrease compared to the previous study, attributed to improvements in cardiovascular management and IAAS Committee measures. Surgical site infection delayed sternal closure pediatric cardiac surgery Introduction Delayed sternal closure (DSC) is a widely used technique in highly complex cardiac surgery (CCS). It was first described in adults in 1975 [1] and was used in 1978 in a two-month-old pediatric patient with transposition of the great arteries (D-TGA).[2] DSC involves postponing definitive closure of the sternotomy after surgery, which involves keeping the patient in the intensive care unit (ICU) with a polyethylene membrane sutured to the skin to cover the sternal opening. This technique has established itself as an effective alternative to avoid the constrictive effect of the chest in the immediate postoperative period of CCS, which are often associated with significant edema and the presence of extracardiac devices. It also facilitates the management of early postoperative complications, such as bleeding.[3] With the advancement of pediatric cardiac surgery, which has shifted from being predominantly palliative to corrective surgery at younger ages, the usefulness of DSC has increased. [4] However, this strategy may be associated with a higher risk of surgical site infection (SSI), increased duration of mechanical ventilation (MV), longer hospital stays, and, consequently, greater morbidity and mortality, additional surgical interventions, and increased costs associated with medical care. [5-7] The incidence of SSI in patients undergoing DSC varies widely in the literature, with reports ranging from 1.5% to 34%. [8-12]. In Chile, the Hospital of Pontifical Catholic University is one of the four national referral centers for pediatric cardiac surgery in the management of congenital heart disease (CHD). At this center, Retamal J. et al. (2016)[13] published a retrospective case-control study that evaluated the SSI rate in children undergoing cardiac surgery with DSC, reporting an incidence of 22%. Logistic regression analysis identified extracorporeal circulation (ECC) greater than 200 minutes and MV use for more than five days as risk factors. Since then, with the goal of reducing the prevalence of infections, the Healthcare-Associated Infections Committee (HAIC), in conjunction with the Cardiovascular ICU, has implemented new strategies to improve the management of cardiac surgery patients. These strategies were applied during the current study period. Which include: 1. Preoperative Management: - Two preoperative baths with chlorhexidine (one the night before and another 30 minutes before surgery). 2. Postoperative Management (DSC protocol): - Strengthening nursing care: dry bath on the third postoperative day. - Rigorous antiseptic measures for the use of echocardiography equipment. - Weekly visits by the HAIC to monitor patients at high risk of infection and ensure early removal of invasive devices. Objective To determine the rate of SSI in pediatric patients with CHD who underwent cardiac surgery with DSC between January 2015 and December 2020. Furthermore, to compare this rate with the results obtained during the 2009–2010 period at the same center, assessing exposure to the risk factors identified in the previous study. Materials and methods A descriptive study was conducted. Patients under 18 years of age who underwent cardiac surgery with DSC between January 2015 and December 2020 at the Hospital of Pontifical Catholic University and who met the definition of SSI established by the Chilean Ministry of Health were included. [ 14 ] Between the two periods of time SSI was defined as postoperative patients who met any of the following three criteria: Discharge from the surgical site. Local inflammatory changes (pain, edema, erythema) with or without fever, as well as the presence or absence of discharge from the surgical site. Isolation of microorganisms in culture and local inflammatory changes with or without fever. For data collection, institutional database records were reviewed for patients who met the inclusion criteria. Those requiring DSC were identified, and in parallel, the HAIC was requested for records of surgical patients who presented SSI. The database used contained information on all pediatric patients undergoing CCS during the study period. The Three main researchers independently reviewed the records to filter out cases with DSC, and subsequently cross-referenced their findings to ensure accurate sample selection. Epidemiological variables were collected from each patient (age, sex); clinical variables (diagnosis, RACHS-1 score, weight for gestational age, gestational age, comorbidities, history of previous surgeries); postoperative variables (ECC duration, open chest days, MV days, need for surgical re-exploration, cardiorespiratory arrest, egresses condition) and infectious variables (type of SSI, isolated microorganism, antibiotic prophylaxis, emergency sternal opening, and presence of other associated infections). The SSI rate in patients with EDC between the periods 2009–2010 and 2015–2020 was compared by calculating the Poisson rate ratio, with its respective 95% confidence interval (95% CI) and p-value. Statistical analysis was performed using R 4.4.1 software. The study was approved by the Scientific Ethics Committee of the Pontifical Catholic University of Chile (Institutional Review Code: 210127002). Results During the study period (2015–2020), a total of 1,471 cardiac surgeries were performed in pediatric patients. Of these, 138 procedures (9.3%) required DSC, and 6 of these patients (4.3%) developed SSI, according to the criteria established by the Chilean Ministry of Health. Among the patients with SSI, 4 of the 6 were more than 7 days old at the time of the procedure and were male. Only one was a 35-week preterm infant, small for gestational age. Three of the patients had a high surgical risk score (RACHS-1 of 5–6), and all had additional comorbidities. Two patients had undergone previous surgeries related to their underlying heart disease. Regarding intraoperative and postoperative variables: ECC duration: four patients had a duration equal to or greater than 200 minutes. Open chest duration: only one lasted less than 2 days; the others ranged from 3 to 13 days. MV: five patients required MV for more than 5 days. Regarding infectious findings, a causative microorganism was identified in five of the six patients. The sixth case presented a fibrin-based sternal dehiscence, although the culture was negative. Two patients required surgical re-exploration, one of them directly related to the infectious process. Four of the patients with SSI also presented other associated infections, such as urinary tract infection (UTI), tracheitis, and bacteremia. Two patients suffered cardiorespiratory arrest, from which they recovered, although they subsequently died of multifactorial causes. In patients with conotruncal heart defects, in whom a 22q11 deletion was suspected, genetic and immunological studies were performed, all were negative. The details of the clinical characteristics and outcome of the SSI cases are presented in Table 1 . Table 1 Characterization of patients with SSI in DSC. Age Sex Diagnosis Gestational age and weight for gestational age Comorbidities Previous Surgeries RACHS-1 ECC time Open chest days Days of MV Tipe of SSI Microorganism Antibiotic prophylaxis Surgical re-exploration due to infectious cause Emergency sternal opening Other infections CPA Egresses condition Patient 1 200 minutes > 2 days > 5 days Superficial Staphylococcus hominis/ Pseudomona aeruginosa Yes No No No No Alive Patient 2 > 7 days old (20 do) F Truncus arteriosus type II. Crossover of pulmonary arteries. Right pulmonary artery. Stenosis Single right coronary artery TNB 37 w AGA Suspected 22q11 Imperforate anus with sufficient rectoperineal fistula CPA (3) Recovered MOF Pneumothorax Pneumomediastinum EIH Secondary epilepsy No 5–6 points > 200 minutes > 2 days > 5 days Deep Enterobacter cloacae complex Yes Yes No Bacteriemia: Klebsiella spp UTI: Enterobacter cloacae complex Tracheitis: Enterobacter cloacae complex Yes Dies Patient 3 < 7 days old (10 do) M Truncus arteriosus type I TNB 39 w AGA Severe aortic coarctation, repaired Suspected Goldenhar syndrome Polyhydramnios Body dysmorphic syndrome Hypocortisolism Chylothorax No 5–6 points ≤ a 200 minutes > 2 days > 5 days Deep Klebisella pneumoniae BLEE Yes Yes No Bacteriemia: Klebsiella pneumoniae No Transferred to another center (alive) Patient 4 > 7 days old (1 year old) M Shone syndrome with residual severe mitral and aortic valve stenosis TNB 38 w AGA Cardiogenic shock Pulmonary hypertension MOF CPA Thalamic infarction Yes 1–4 points > 200 minutes > 2 days > 5 days Superficial Enteroco faecium Yes No No Bacteriemia: Enteroco faecium y Cándida parapsilosis Yes Transferred to another center (Dies) Patient 5 > 7 days old (20 do) M D-TGA s/p Rashkind TNB 39 w AGA Body dysmorphic syndrome Yes 1–4 points > 200 minutes > 2 days > 5 days Superficial Klebsiella oxytoca Yes No No UTI Klebsiella Oxytoca Tracheitis: Klebsiella Oxytoca, enteroco cloacae complex No Alive Patient 6 > 7 days old (7 months old) F Dilated cardiomyopathy ALCAPA to the left pulmonary artery PTNB 35 w SGA Malnutrition No 1–4 points ≤ a 200 minutes ≤ 2 days ≤ 5 days Superficial No Microorganism isolated Yes No No No No Alive DO : days old; M : male; F : female; LVH : Left ventricular hypoplasia syndrome; D-TGA : Transposition of the great vessels; S/p : Status post; GA : Gestational age; TNB : Term newborn; PTNB : Preterm newborn; W : weeks; AGA : Adequate for gestational age; SGA : Small for gestational age; ECC : extracorporeal circulation; VM : mechanical ventilation; SSI : surgical site infection. MOF : Multiple organ failure; CPA : Cardiopulmonary arrest; HIE : Hypoxic-ischemic encephalopathy; UTI : Urinary tract infection. In the study published by Retamal et al., which analyzed the period 2009–2010, 514 cardiac surgeries were reported, of which 58 patients (11%) required delayed sternal closure. Of these, 13 presented with surgical site infection, corresponding to a rate of 22%. Furthermore, the incidence of SSI in patients with primary thoracic closure in the current period (2015–2020) was 0.67% (VS 4.3% in DSC), confirming that DSC itself is a risk factor for SSI. Table 2 Surgical site infection in delayed sternal closure and closed chest between the current and previous study. Current study (2015–2020) Previous study (2009–2010) 2015 2016 2017 2018 2019 2020 Total 2009 2010 Heart surgeries 283 285 247 230 224 202 1471 514 DSC 32 23 24 21 15 23 138 (9,30%) 58 (11,20%) SII in DSC 1 1 1 2 1 0 6 (4,30%) 13 (22%) PTC 251 262 223 209 209 179 1333 (90%) 447 (86,9%) SII in PTC 2 3 1 2 1 0 9 (0.67%) Data not available. DSC : Delayed sternal closure, SSI : Surgical site infection; PTC : Primary thoracic closure. In the 2009–2010 period, the main risk factors associated with SSI were identified as extracorporeal circulation (ECC) time greater than 200 minutes (adjusted OR = 9.53; 95% CI: 1.37–66.35) and mechanical ventilation (MV) for more than 5 days (adjusted OR = 8.98; 95% CI: 1.16–69.40). When comparing these factors with data from the current period (2015–2020), no statistically significant differences were found (p > 0.05), suggesting that both periods are comparable in terms of risk factors associated with SSI. Likewise, the complexity of surgical interventions was evaluated using the RACHS-1 score, specifically 5–6, corresponding to highly complex procedures. No statistically significant differences were observed between both periods in this variable either (Table 3 ). Table 3 Exposure to risk factors between the current and previous study. Current study (2015–2020) Previous study (2009–2010) P value ECC > 200 minutes 53/138 (38,4%) 31/58 (53,4%) 0,181 MV > 5 days 57/138 (41,3%) 34/58 (58,6%) 0,136 RACHS-1 Score (Between 5–6 points) 46/138 (33,3%) 22/58 (37,9%) 0,703 ECC : Extracorporeal circulation; MV : mechanical ventilation. Additionally, a significant decrease in the use of DSC was observed in patients with transposition of the great arteries (D-TGA) during the current period. Between 2015 and 2020, 19% of DSC cases corresponded to this pathology, compared with 36% during the 2009–2010 period (p = 0.038), a difference that was statistically significant. This change is accompanied by a greater predominance of other diagnoses in the current study, such as tetralogy of Fallot, ventricular septal defect, aortic coarctation, atrioventricular canal, anomalous pulmonary venous drainage, anomalous origin of the left coronary artery from the pulmonary artery and Ebstein's anomaly. In contrast, the previous study showed a more homogeneous distribution of heart disease among patients with DSC (Table 4 ). Table 4 Use of CED in congenital heart disease between the current and previous study. Current study (2015–2020) Previous study. (2009–2010) D-TGa 27/138 (19%) 21/58 (36%) LVH 41/138 (29%) 16/58 (27%) Others 70/138 (50%) 21/58 (36%) D-TGA : Transposition of the great arteries; LVH : Left ventricular hypoplasia syndrome. Discussion This study determined the SSI rate in patients with congenital heart disease who underwent CCS with DSC between January 2015 and December 2020 and compared it with the results obtained during the 2009–2010 period at the same center, also considering exposure to previously identified risk factors. Compared to the study published in 2016 by Retamal et al., which reported a 22% SSI rate in patients with EDC, the present analysis shows a significant reduction to 4.3%. This decrease corresponds to a fivefold relative reduction in the infection rate (rate ratio: 5.16; 95% CI 1.83–16.54; p = 0.001). This result is consistent with findings from other centers. Von Stumm et al. [ 15 ] reported an SSI rate of 7.3% in a study of 358 patients undergoing DSC between 2013 and 2017. In their analysis, risk factors such as younger age, greater surgical complexity, and longer DSC duration were associated with SSI; however, in the multivariate analysis, DSC itself was the only independent predictor (p = 0.013; OR = 8.6). In our cohort, previously identified risk factors, such as ECC time greater than 200 minutes and MV for more than 5 days, were comparable between the two study periods, although with a slight decrease in the prevalence of these factors in the more recent period. This could contribute, in part, to the observed reduction in SSI incidence. Other authors, such as Harder et al. [ 16 ], have also described higher morbidity and mortality in younger patients with elevated RACHS-1 scores and prolonged ECC durations, without finding any association with acidosis, inotropic support, or postoperative shock. Although the number of SSI cases in the present study was small, certain clinical patterns are relevant. Patients who died shared characteristics such as ECC ≥ 200 minutes, open chest for more than 2 days, and prolonged MV, in addition to presenting concomitant infections (such as UTI, bacteremia, or tracheitis). This suggests that a more complicated postoperative course may predispose to secondary infections or reflect a more severe clinical condition from the outset. The optimal duration of DSC remains controversial, and there is no clear consensus [ 17 ]. Some studies, such as the retrospective analysis by the American Society of Thoracic Surgeons in 2023 [ 18 ], found no significant differences between primary closure and DSC performed on the third postoperative day in terms of complications. Recently, predictive algorithms applied to the pediatric population have been proposed as tools for the early identification of patients at higher risk of developing SSI after DSC [ 19 ] Their implementation could optimize clinical decision-making and reduce associated complications. At our center, the reduction in the SSI rate could be attributed to multiple factors: progressive implementation of multidisciplinary measures led by the Healthcare-Associated Infections Committee (HAIC), decreased exposure to risk factors, lower use of the DSC in certain patient subgroups (such as those with transposition of the great arteries), and optimization of postoperative care. As described in the literature, a more restrictive and rational use of the EDC could be linked to a lower incidence of SSI, as well as a reduction in complications related to ICU stay and mortality. However, additional causal studies are needed to more precisely determine the relationship between the measures implemented and the reduction of postoperative infections in patients with DSC. Conclusions The SSI rate in patients with congenital heart disease undergoing cardiac surgery with a DSC was 4.3% during the 2015–2020 period. This figure represents a statistically significant decrease compared to the 2009–2010 period. This improvement could be explained by the strengthening of perioperative cardiovascular care, greater experience of the clinical team, and the preventive measures implemented by the HAI Committee. Despite the risks that could be associated with the use of a DSC, it continues to be a useful measure in reducing operative mortality. Therefore, strategies focused on preventing infectious complications in CCS are vitally important. Declarations Author Contribution D.J., C.C., P.V. and N.C. wrote the main manuscript text with help of diferent experts in the area: J.C (epidemiologist prepared the estadistics); M.I.R as part of the Healthcare-Associated Infections Committee provited information and guideence; P.B. and R.G. as cardiadic surgeons provited information and guideence and C.S. as Pediatric Intensivist provited information and guideence. All authors reviewed the manuscript and sugested upgrades. Acknowledgement Dr. María Inés Cerón, internist and head of the Healthcare-Associated Infections Committee at the Hospital of Pontifical Catholic University of Chile, for her valuable support and contributions to the development of this study. References Riahi M, Tomatis LA, Schlosser RJ, Bertolozzi E, Johnston DW. Cardiac compression due to closure of the median sternotomy in open heart surgery. Chest. 1975 Jan;67(1):113-4. doi: 10.1378/chest.67.1.113. Ott DA, Cooley DA, Norman JC, Sandiford FM. Delayed sternal closure: a useful technique to prevent tamponade or compression of the heart. Cardiovasc Dis. 1978 Mar;5(1):15-18. Yabrodi M, Hermann JL, Brown JW, Rodefeld MD, Turrentine MW, Mastropietro CW. Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg. 2019 Jul;10(4):400-406. doi: 10.1177/2150135119846040. 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Cite Share Download PDF Status: Published Journal Publication published 31 Oct, 2025 Read the published version in Pediatric Cardiology → Version 1 posted Editorial decision: Revision requested 29 Sep, 2025 Reviews received at journal 08 Sep, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 17 Aug, 2025 Reviewers invited by journal 04 Aug, 2025 Editor assigned by journal 14 Jul, 2025 Submission checks completed at journal 14 Jul, 2025 First submitted to journal 13 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7115282","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495697959,"identity":"7d4668a8-e7be-470b-9627-27048a709ea8","order_by":0,"name":"Daniela Jiménez","email":"data:image/png;base64,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","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":true,"prefix":"","firstName":"Daniela","middleName":"","lastName":"Jiménez","suffix":""},{"id":495697960,"identity":"93884144-8051-405d-88de-21459c5c8473","order_by":1,"name":"Paulo Valderrama","email":"","orcid":"","institution":"Finis Terrae University","correspondingAuthor":false,"prefix":"","firstName":"Paulo","middleName":"","lastName":"Valderrama","suffix":""},{"id":495697961,"identity":"b0f51a41-a9dc-4fd6-abd3-f8d8f9c18986","order_by":2,"name":"Nicolás Correa","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Nicolás","middleName":"","lastName":"Correa","suffix":""},{"id":495697962,"identity":"95191122-8027-4f5b-bd37-425106da65cb","order_by":3,"name":"Jaime Cerda","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Jaime","middleName":"","lastName":"Cerda","suffix":""},{"id":495697963,"identity":"562d2b31-f67c-4bb1-af89-e95b5c7a1635","order_by":4,"name":"María Inés Riquelme","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Inés","lastName":"Riquelme","suffix":""},{"id":495697964,"identity":"946cc480-2c4a-47e7-ad92-c1e19bae924d","order_by":5,"name":"Pedro Becker","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Pedro","middleName":"","lastName":"Becker","suffix":""},{"id":495697965,"identity":"735263bc-e3b6-4eeb-8f8d-a86c0d0e5844","order_by":6,"name":"Rodrigo González","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Rodrigo","middleName":"","lastName":"González","suffix":""},{"id":495697966,"identity":"31ccd8a9-4ee0-4dd2-9b94-50e6b953ef85","order_by":7,"name":"Christian Scheu","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Scheu","suffix":""},{"id":495697967,"identity":"3d14cbf8-8a26-4db2-8a50-0ac5d3646a34","order_by":8,"name":"Cristian Clavería","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Cristian","middleName":"","lastName":"Clavería","suffix":""}],"badges":[],"createdAt":"2025-07-13 20:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7115282/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7115282/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00246-025-04080-4","type":"published","date":"2025-10-31T15:57:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":95040453,"identity":"c03c76b8-18cf-4cf0-8521-f778460c7243","added_by":"auto","created_at":"2025-11-03 16:08:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":781286,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7115282/v1/c355ef94-a853-404c-9ba4-3732213d6482.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical site infection in pediatric patients undergoing cardiac surgery with delayed sternal closure: experience from a center in Chile, South America (2015–2020)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDelayed sternal closure (DSC) is a widely used technique in highly complex cardiac surgery (CCS). It was first described in adults in 1975\u0026nbsp;[1]\u0026nbsp;and was used in 1978 in a two-month-old pediatric patient with transposition of the great arteries (D-TGA).[2]\u003c/p\u003e\n\u003cp\u003eDSC involves postponing definitive closure of the sternotomy after surgery, which involves keeping the patient in the intensive care unit (ICU) with a polyethylene membrane sutured to the skin to cover the sternal opening. This technique has established itself as an effective alternative to avoid the constrictive effect of the chest in the immediate postoperative period of CCS, which are often associated with significant edema and the presence of extracardiac devices. It also facilitates the management of early postoperative complications, such as bleeding.[3]\u003c/p\u003e\n\u003cp\u003eWith the advancement of pediatric cardiac surgery, which has shifted from being predominantly palliative to corrective surgery at younger ages, the usefulness of DSC has increased. [4] \u0026nbsp;However, this strategy may be associated with a higher risk of surgical site infection (SSI), increased duration of mechanical ventilation (MV), longer hospital stays, and, consequently, greater morbidity and mortality, additional surgical interventions, and increased costs associated with medical care. [5-7]\u003c/p\u003e\n\u003cp\u003eThe incidence of SSI in patients undergoing DSC varies widely in the literature, with reports ranging from 1.5% to 34%. [8-12]. In Chile, the Hospital of Pontifical Catholic University is one of the four national referral centers for pediatric cardiac surgery in the management of congenital heart disease (CHD). At this center, Retamal J. et al. (2016)[13] published a retrospective case-control study that evaluated the SSI rate in children undergoing cardiac surgery with DSC, reporting an incidence of 22%. Logistic regression analysis identified extracorporeal circulation (ECC) greater than 200 minutes and MV use for more than five days as risk factors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince then, with the goal of reducing the prevalence of infections, the Healthcare-Associated Infections Committee (HAIC), in conjunction with the Cardiovascular ICU, has implemented new strategies to improve the management of cardiac surgery patients. These strategies were applied during the current study period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhich include:\u003c/p\u003e\n\u003cp\u003e1. Preoperative Management:\u003c/p\u003e\n\u003cp\u003e- Two preoperative baths with chlorhexidine (one the night before and another 30 minutes before surgery).\u003c/p\u003e\n\u003cp\u003e2. Postoperative Management (DSC protocol):\u003c/p\u003e\n\u003cp\u003e- Strengthening nursing care: dry bath on the third postoperative day.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Rigorous antiseptic measures for the use of echocardiography equipment.\u003c/p\u003e\n\u003cp\u003e- Weekly visits by the HAIC to monitor patients at high risk of infection and ensure early removal of invasive devices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine the rate of SSI in pediatric patients with CHD who underwent cardiac surgery with DSC between January 2015 and December 2020. Furthermore, to compare this rate with the results obtained during the 2009\u0026ndash;2010 period at the same center, assessing exposure to the risk factors identified in the previous study.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eA descriptive study was conducted. Patients under 18 years of age who underwent cardiac surgery with DSC between January 2015 and December 2020 at the Hospital of Pontifical Catholic University and who met the definition of SSI established by the Chilean Ministry of Health were included. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eBetween the two periods of time SSI was defined as postoperative patients who met any of the following three criteria:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDischarge from the surgical site.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eLocal inflammatory changes (pain, edema, erythema) with or without fever, as well as the presence or absence of discharge from the surgical site.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIsolation of microorganisms in culture and local inflammatory changes with or without fever.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eFor data collection, institutional database records were reviewed for patients who met the inclusion criteria. Those requiring DSC were identified, and in parallel, the HAIC was requested for records of surgical patients who presented SSI. The database used contained information on all pediatric patients undergoing CCS during the study period. The Three main researchers independently reviewed the records to filter out cases with DSC, and subsequently cross-referenced their findings to ensure accurate sample selection.\u003c/p\u003e\u003cp\u003eEpidemiological variables were collected from each patient (age, sex); clinical variables (diagnosis, RACHS-1 score, weight for gestational age, gestational age, comorbidities, history of previous surgeries); postoperative variables (ECC duration, open chest days, MV days, need for surgical re-exploration, cardiorespiratory arrest, egresses condition) and infectious variables (type of SSI, isolated microorganism, antibiotic prophylaxis, emergency sternal opening, and presence of other associated infections).\u003c/p\u003e\u003cp\u003eThe SSI rate in patients with EDC between the periods 2009\u0026ndash;2010 and 2015\u0026ndash;2020 was compared by calculating the Poisson rate ratio, with its respective 95% confidence interval (95% CI) and p-value. Statistical analysis was performed using R 4.4.1 software.\u003c/p\u003e\u003cp\u003e The study was approved by the Scientific Ethics Committee of the Pontifical Catholic University of Chile (Institutional Review Code: 210127002).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period (2015\u0026ndash;2020), a total of 1,471 cardiac surgeries were performed in pediatric patients. Of these, 138 procedures (9.3%) required DSC, and 6 of these patients (4.3%) developed SSI, according to the criteria established by the Chilean Ministry of Health. Among the patients with SSI, 4 of the 6 were more than 7 days old at the time of the procedure and were male. Only one was a 35-week preterm infant, small for gestational age. Three of the patients had a high surgical risk score (RACHS-1 of 5\u0026ndash;6), and all had additional comorbidities. Two patients had undergone previous surgeries related to their underlying heart disease.\u003c/p\u003e\u003cp\u003eRegarding intraoperative and postoperative variables:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eECC duration: four patients had a duration equal to or greater than 200 minutes.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOpen chest duration: only one lasted less than 2 days; the others ranged from 3 to 13 days.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMV: five patients required MV for more than 5 days.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eRegarding infectious findings, a causative microorganism was identified in five of the six patients. The sixth case presented a fibrin-based sternal dehiscence, although the culture was negative.\u003c/p\u003e\u003cp\u003eTwo patients required surgical re-exploration, one of them directly related to the infectious process. Four of the patients with SSI also presented other associated infections, such as urinary tract infection (UTI), tracheitis, and bacteremia.\u003c/p\u003e\u003cp\u003eTwo patients suffered cardiorespiratory arrest, from which they recovered, although they subsequently died of multifactorial causes.\u003c/p\u003e\u003cp\u003eIn patients with conotruncal heart defects, in whom a 22q11 deletion was suspected, genetic and immunological studies were performed, all were negative.\u003c/p\u003e\u003cp\u003eThe details of the clinical characteristics and outcome of the SSI cases are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacterization of patients with SSI in DSC.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"19\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGestational age and weight for gestational age\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComorbidities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePrevious Surgeries\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eRACHS-1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eECC time\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eOpen chest days\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eDays of MV\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003eTipe of SSI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c13\"\u003e\u003cp\u003eMicroorganism\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c14\"\u003e\u003cp\u003eAntibiotic prophylaxis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c15\"\u003e\u003cp\u003eSurgical re-exploration due to infectious cause\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c16\"\u003e\u003cp\u003eEmergency sternal opening\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c17\"\u003e\u003cp\u003eOther infections\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c18\"\u003e\u003cp\u003eCPA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c19\"\u003e\u003cp\u003eEgresses condition\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient 1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;7 days old\u003c/p\u003e\u003cp\u003e(6 do)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLVH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTNB 39 w AGA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMitoaortic atresia\u003c/p\u003e\u003cp\u003eCommon atrial thrombus\u003c/p\u003e\u003cp\u003eVocal cord paralysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5\u0026ndash;6 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;200 minutes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 days\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eSuperficial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e\u003cem\u003eStaphylococcus hominis/\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePseudomona aeruginosa\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient 2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;7 days old\u003c/p\u003e\u003cp\u003e(20 do)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTruncus arteriosus type II. Crossover of pulmonary arteries.\u003c/p\u003e\u003cp\u003eRight pulmonary artery. Stenosis\u003c/p\u003e\u003cp\u003eSingle right coronary artery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTNB 37 w AGA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSuspected 22q11\u003c/p\u003e\u003cp\u003eImperforate anus with sufficient rectoperineal fistula\u003c/p\u003e\u003cp\u003eCPA (3) Recovered\u003c/p\u003e\u003cp\u003eMOF\u003c/p\u003e\u003cp\u003ePneumothorax\u003c/p\u003e\u003cp\u003ePneumomediastinum\u003c/p\u003e\u003cp\u003eEIH\u003c/p\u003e\u003cp\u003eSecondary epilepsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5\u0026ndash;6 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;200 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 days\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eDeep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e\u003cem\u003eEnterobacter cloacae complex\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003eBacteriemia: \u003cem\u003eKlebsiella spp\u003c/em\u003e\u003c/p\u003e\u003cp\u003eUTI: \u003cem\u003eEnterobacter cloacae complex\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTracheitis: \u003cem\u003eEnterobacter cloacae complex\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eDies\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient 3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;7 days old\u003c/p\u003e\u003cp\u003e(10 do)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTruncus arteriosus type I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTNB 39 w AGA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSevere aortic coarctation, repaired\u003c/p\u003e\u003cp\u003eSuspected Goldenhar syndrome\u003c/p\u003e\u003cp\u003ePolyhydramnios\u003c/p\u003e\u003cp\u003eBody dysmorphic syndrome\u003c/p\u003e\u003cp\u003eHypocortisolism\u003c/p\u003e\u003cp\u003eChylothorax\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5\u0026ndash;6 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026le; a 200 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 days\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eDeep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e\u003cem\u003eKlebisella pneumoniae BLEE\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003eBacteriemia: \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eTransferred to another center\u003c/p\u003e\u003cp\u003e(alive)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient 4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;7 days old\u003c/p\u003e\u003cp\u003e(1 year old)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eShone syndrome with residual severe mitral and aortic valve stenosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTNB 38 w AGA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCardiogenic shock Pulmonary hypertension\u003c/p\u003e\u003cp\u003eMOF\u003c/p\u003e\u003cp\u003eCPA\u003c/p\u003e\u003cp\u003eThalamic infarction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u0026ndash;4 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;200 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 days\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eSuperficial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e\u003cem\u003eEnteroco faecium\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003eBacteriemia: \u003cem\u003eEnteroco faecium y C\u0026aacute;ndida parapsilosis\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eTransferred to another center (Dies)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient 5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;7 days old\u003c/p\u003e\u003cp\u003e(20 do)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eD-TGA\u003c/p\u003e\u003cp\u003es/p Rashkind \u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTNB 39 w AGA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBody dysmorphic syndrome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u0026ndash;4 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;200 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 days\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eSuperficial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e\u003cem\u003eKlebsiella oxytoca\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003eUTI \u003cem\u003eKlebsiella Oxytoca\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTracheitis:\u003cem\u003eKlebsiella Oxytoca, enteroco cloacae complex\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient 6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;7 days old\u003c/p\u003e \u003cp\u003e(7 months old)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDilated cardiomyopathy\u003c/p\u003e\u003cp\u003eALCAPA to the left pulmonary artery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePTNB 35 w SGA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMalnutrition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u0026ndash;4 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026le; a 200 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;2 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;5 days\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eSuperficial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003eNo Microorganism isolated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDO\u003c/b\u003e: days old; \u003cb\u003eM\u003c/b\u003e: male; \u003cb\u003eF\u003c/b\u003e: female; \u003cb\u003eLVH\u003c/b\u003e: Left ventricular hypoplasia syndrome; \u003cb\u003eD-TGA\u003c/b\u003e: Transposition of the great vessels; \u003cb\u003eS/p\u003c/b\u003e: Status post; \u003cb\u003eGA\u003c/b\u003e: Gestational age; \u003cb\u003eTNB\u003c/b\u003e: Term newborn; \u003cb\u003ePTNB\u003c/b\u003e: Preterm newborn; \u003cb\u003eW\u003c/b\u003e: weeks; \u003cb\u003eAGA\u003c/b\u003e: Adequate for gestational age; \u003cb\u003eSGA\u003c/b\u003e: Small for gestational age; \u003cb\u003eECC\u003c/b\u003e: extracorporeal circulation; \u003cb\u003eVM\u003c/b\u003e: mechanical ventilation; \u003cb\u003eSSI\u003c/b\u003e: surgical site infection.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMOF\u003c/b\u003e: Multiple organ failure; \u003cb\u003eCPA\u003c/b\u003e: Cardiopulmonary arrest; \u003cb\u003eHIE\u003c/b\u003e: Hypoxic-ischemic encephalopathy; \u003cb\u003eUTI\u003c/b\u003e: Urinary tract infection.\u003c/p\u003e\u003cp\u003eIn the study published by Retamal et al., which analyzed the period 2009\u0026ndash;2010, 514 cardiac surgeries were reported, of which 58 patients (11%) required delayed sternal closure. Of these, 13 presented with surgical site infection, corresponding to a rate of 22%. Furthermore, the incidence of SSI in patients with primary thoracic closure in the current period (2015\u0026ndash;2020) was 0.67% (VS 4.3% in DSC), confirming that DSC itself is a risk factor for SSI.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSurgical site infection in delayed sternal closure and closed chest between the current and previous study.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"7\" nameend=\"c8\" namest=\"c2\"\u003e\u003cp\u003eCurrent study\u003c/p\u003e\u003cp\u003e(2015\u0026ndash;2020)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003ePrevious study (2009\u0026ndash;2010)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2015\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2017\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2009\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2010\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHeart surgeries\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e283\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e285\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e230\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e202\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1471\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e514\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDSC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e138\u003c/p\u003e\u003cp\u003e(9,30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e58\u003c/p\u003e\u003cp\u003e(11,20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSII in DSC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e(4,30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e13\u003c/p\u003e\u003cp\u003e(22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePTC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e251\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e262\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e223\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e209\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e209\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e179\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1333\u003c/p\u003e\u003cp\u003e(90%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e447\u003c/p\u003e\u003cp\u003e(86,9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSII in PTC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e9\u003c/p\u003e\u003cp\u003e(0.67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003eData not available.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDSC\u003c/b\u003e: Delayed sternal closure, \u003cb\u003eSSI\u003c/b\u003e: Surgical site infection; \u003cb\u003ePTC\u003c/b\u003e: Primary thoracic closure.\u003c/p\u003e\u003cp\u003eIn the 2009\u0026ndash;2010 period, the main risk factors associated with SSI were identified as extracorporeal circulation (ECC) time greater than 200 minutes (adjusted OR\u0026thinsp;=\u0026thinsp;9.53; 95% CI: 1.37\u0026ndash;66.35) and mechanical ventilation (MV) for more than 5 days (adjusted OR\u0026thinsp;=\u0026thinsp;8.98; 95% CI: 1.16\u0026ndash;69.40). When comparing these factors with data from the current period (2015\u0026ndash;2020), no statistically significant differences were found (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), suggesting that both periods are comparable in terms of risk factors associated with SSI. Likewise, the complexity of surgical interventions was evaluated using the RACHS-1 score, specifically 5\u0026ndash;6, corresponding to highly complex procedures. No statistically significant differences were observed between both periods in this variable either (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eExposure to risk factors between the current and previous study.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCurrent study\u003c/p\u003e\u003cp\u003e(2015\u0026ndash;2020)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrevious study (2009\u0026ndash;2010)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eECC\u0026thinsp;\u0026gt;\u0026thinsp;200 minutes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53/138 (38,4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31/58 (53,4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0,181\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMV\u0026thinsp;\u0026gt;\u0026thinsp;5 days\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57/138 (41,3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34/58 (58,6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0,136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRACHS-1 Score\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(Between 5\u0026ndash;6 points)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46/138 (33,3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22/58 (37,9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0,703\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eECC\u003c/b\u003e: Extracorporeal circulation; \u003cb\u003eMV\u003c/b\u003e: mechanical ventilation.\u003c/p\u003e\u003cp\u003eAdditionally, a significant decrease in the use of DSC was observed in patients with transposition of the great arteries (D-TGA) during the current period. Between 2015 and 2020, 19% of DSC cases corresponded to this pathology, compared with 36% during the 2009\u0026ndash;2010 period (p\u0026thinsp;=\u0026thinsp;0.038), a difference that was statistically significant. This change is accompanied by a greater predominance of other diagnoses in the current study, such as tetralogy of Fallot, ventricular septal defect, aortic coarctation, atrioventricular canal, anomalous pulmonary venous drainage, anomalous origin of the left coronary artery from the pulmonary artery and Ebstein's anomaly. In contrast, the previous study showed a more homogeneous distribution of heart disease among patients with DSC (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUse of CED in congenital heart disease between the current and previous study.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCurrent study\u003c/p\u003e\u003cp\u003e(2015\u0026ndash;2020)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrevious study. (2009\u0026ndash;2010)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eD-TGa\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27/138 (19%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21/58 (36%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLVH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41/138 (29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16/58 (27%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOthers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70/138 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21/58 (36%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eD-TGA\u003c/b\u003e: Transposition of the great arteries; \u003cb\u003eLVH\u003c/b\u003e: Left ventricular hypoplasia syndrome.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study determined the SSI rate in patients with congenital heart disease who underwent CCS with DSC between January 2015 and December 2020 and compared it with the results obtained during the 2009\u0026ndash;2010 period at the same center, also considering exposure to previously identified risk factors.\u003c/p\u003e\u003cp\u003eCompared to the study published in 2016 by Retamal et al., which reported a 22% SSI rate in patients with EDC, the present analysis shows a significant reduction to 4.3%. This decrease corresponds to a fivefold relative reduction in the infection rate (rate ratio: 5.16; 95% CI 1.83\u0026ndash;16.54; p\u0026thinsp;=\u0026thinsp;0.001). This result is consistent with findings from other centers. Von Stumm et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] reported an SSI rate of 7.3% in a study of 358 patients undergoing DSC between 2013 and 2017. In their analysis, risk factors such as younger age, greater surgical complexity, and longer DSC duration were associated with SSI; however, in the multivariate analysis, DSC itself was the only independent predictor (p\u0026thinsp;=\u0026thinsp;0.013; OR\u0026thinsp;=\u0026thinsp;8.6).\u003c/p\u003e\u003cp\u003eIn our cohort, previously identified risk factors, such as ECC time greater than 200 minutes and MV for more than 5 days, were comparable between the two study periods, although with a slight decrease in the prevalence of these factors in the more recent period. This could contribute, in part, to the observed reduction in SSI incidence. Other authors, such as Harder et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], have also described higher morbidity and mortality in younger patients with elevated RACHS-1 scores and prolonged ECC durations, without finding any association with acidosis, inotropic support, or postoperative shock.\u003c/p\u003e\u003cp\u003eAlthough the number of SSI cases in the present study was small, certain clinical patterns are relevant. Patients who died shared characteristics such as ECC\u0026thinsp;\u0026ge;\u0026thinsp;200 minutes, open chest for more than 2 days, and prolonged MV, in addition to presenting concomitant infections (such as UTI, bacteremia, or tracheitis). This suggests that a more complicated postoperative course may predispose to secondary infections or reflect a more severe clinical condition from the outset.\u003c/p\u003e\u003cp\u003eThe optimal duration of DSC remains controversial, and there is no clear consensus [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Some studies, such as the retrospective analysis by the American Society of Thoracic Surgeons in 2023 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], found no significant differences between primary closure and DSC performed on the third postoperative day in terms of complications. Recently, predictive algorithms applied to the pediatric population have been proposed as tools for the early identification of patients at higher risk of developing SSI after DSC [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Their implementation could optimize clinical decision-making and reduce associated complications.\u003c/p\u003e\u003cp\u003e At our center, the reduction in the SSI rate could be attributed to multiple factors: progressive implementation of multidisciplinary measures led by the Healthcare-Associated Infections Committee (HAIC), decreased exposure to risk factors, lower use of the DSC in certain patient subgroups (such as those with transposition of the great arteries), and optimization of postoperative care.\u003c/p\u003e\u003cp\u003eAs described in the literature, a more restrictive and rational use of the EDC could be linked to a lower incidence of SSI, as well as a reduction in complications related to ICU stay and mortality. However, additional causal studies are needed to more precisely determine the relationship between the measures implemented and the reduction of postoperative infections in patients with DSC.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe SSI rate in patients with congenital heart disease undergoing cardiac surgery with a DSC was 4.3% during the 2015\u0026ndash;2020 period. This figure represents a statistically significant decrease compared to the 2009\u0026ndash;2010 period. This improvement could be explained by the strengthening of perioperative cardiovascular care, greater experience of the clinical team, and the preventive measures implemented by the HAI Committee.\u003c/p\u003e\u003cp\u003eDespite the risks that could be associated with the use of a DSC, it continues to be a useful measure in reducing operative mortality. Therefore, strategies focused on preventing infectious complications in CCS are vitally important.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eD.J., C.C., P.V. and N.C. wrote the main manuscript text with help of diferent experts in the area: J.C (epidemiologist prepared the estadistics); M.I.R as part of the Healthcare-Associated Infections Committee provited information and guideence; P.B. and R.G. as cardiadic surgeons provited information and guideence and C.S. as Pediatric Intensivist provited information and guideence. All authors reviewed the manuscript and sugested upgrades.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e Dr. Mar\u0026iacute;a In\u0026eacute;s Cer\u0026oacute;n, internist and head of the Healthcare-Associated Infections Committee at the Hospital of Pontifical Catholic University of Chile, for her valuable support and contributions to the development of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRiahi M, Tomatis LA, Schlosser RJ, Bertolozzi E, Johnston DW. Cardiac compression due to closure of the median sternotomy in open heart surgery. Chest. 1975 Jan;67(1):113-4. doi: 10.1378/chest.67.1.113. \u003c/li\u003e\n\u003cli\u003eOtt DA, Cooley DA, Norman JC, Sandiford FM. Delayed sternal closure: a useful technique to prevent tamponade or compression of the heart. Cardiovasc Dis. 1978 Mar;5(1):15-18. \u003c/li\u003e\n\u003cli\u003eYabrodi M, Hermann JL, Brown JW, Rodefeld MD, Turrentine MW, Mastropietro CW. Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg. 2019 Jul;10(4):400-406. doi: 10.1177/2150135119846040. \u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zker E, Saritaş B, Vuran C, Y\u0026ouml;r\u0026uuml;ker U, Ulug\u0026ouml;l H, T\u0026uuml;rk\u0026ouml;z R. Delayed sternal closure after pediatric cardiac operations; single center experience: a retrospective study. J Cardiothorac Surg. 2012 Oct 2;7:102. doi: 10.1186/1749-8090-7-102. \u003cbr\u003e \u003c/li\u003e\n\u003cli\u003eHarder EE, Gaies MG, Yu S, Donohue JE, Hanauer DA, Goldberg CS, Hirsch JC. Risk factors for surgical site infection in pediatric cardiac surgery patients undergoing delayed sternal closure. J Thorac Cardiovasc Surg. 2013 Aug;146(2):326-33. doi: 10.1016/j.jtcvs.2012.09.062. \u003c/li\u003e\n\u003cli\u003eNelson-McMillan K, Hornik CP, He X, Vricella LA, Jacobs JP, Hill KD, Pasquali SK, Alejo DE, Cameron DE, Jacobs ML. Delayed Sternal Closure in Infant Heart Surgery-The Importance of Where and When: An Analysis of the STS Congenital Heart Surgery Database. Ann Thorac Surg. 2016 Nov;102(5):1565-1572. doi: 10.1016/j.athoracsur.2016.08.081. \u003c/li\u003e\n\u003cli\u003eYasa H, Laf\u0026ccedil;i B, Yilik L, Bademci M, Sahin A, Kestelli M, Yeşil M, G\u0026uuml;rb\u0026uuml;z A. Delayed sternal closure: an effective procedure for life-saving in open-heart surgery. Anadolu Kardiyol Derg. 2010 Apr;10(2):163-7. doi: 10.5152/akd.2010.043. \u003c/li\u003e\n\u003cli\u003eWoodward CS, Son M, Calhoon J, Michalek J, Husain SA. Sternal wound infections in pediatric congenital cardiac surgery: a survey of incidence and preventative practice. Ann Thorac Surg. 2011 Mar;91(3):799-804. doi: 10.1016/j.athoracsur.2010.10.030. \u003c/li\u003e\n\u003cli\u003eJo T, Hur J, Kim EK. Treatment of Pediatric Sternotomy Wound Complications: A Minimally Invasive Approach. Thorac Cardiovasc Surg. 2022 Jan;70(1):56-64. doi: 10.1055/s-0040-1722733. \u003c/li\u003e\n\u003cli\u003eWoodward C, Taylor R, Son M, Taeed R, Jacobs ML, Kane L, Jacobs JP, Husain SA. Multicenter Quality Improvement Project to Prevent Sternal Wound Infections in Pediatric Cardiac Surgery Patients. World J Pediatr Congenit Heart Surg. 2017 Jul;8(4):453-459. doi: 10.1177/2150135117713741. \u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zker E, Saritaş B, Vuran C, Y\u0026ouml;r\u0026uuml;ker U, Ulug\u0026ouml;l H, T\u0026uuml;rk\u0026ouml;z R. Delayed sternal closure after pediatric cardiac operations; single center experience: a retrospective study. J Cardiothorac Surg. 2012 Oct 2;7:102. doi: 10.1186/1749-8090-7-102. \u003c/li\u003e\n\u003cli\u003eBen-Ami E, Levy I, Katz J, Dagan O, Shalit I. Risk factors for sternal wound infection in children undergoing cardiac surgery: a case-control study. J Hosp Infect. 2008 Dec;70(4):335-40. doi: 10.1016/j.jhin.2008.08.010. \u003c/li\u003e\n\u003cli\u003eRetamal J, Becker P, Gonz\u0026aacute;lez R, Ferr\u0026eacute;s M, Cerda J, Riquelme MI, P\u0026eacute;rez R, Claver\u0026iacute;a C. Surgical site infections in children undergoing cardiac surgery with delayed sternal closure: Case-control study. Rev Chilena Infectol. 2016 Oct;33(5):495-500. Spanish. doi: 10.4067/S0716-10182016000500001. \u003c/li\u003e\n\u003cli\u003eCircular C37, Update of definitions and reporting criteria for healthcare-associated infections (HAIs) for epidemiological surveillance. \u003cbr\u003e https://eydsalacrisis9.cl/situacion-covid19/mantenedor/contenidos/contenido_vigilancia_epidemiologica/documentos/CIRCULAR%20C37%20N%C2%BA%2002%20ACTUALIZA%20%20NORMA%20IAAS.pdf \u003c/li\u003e\n\u003cli\u003evon Stumm M, Leps Y, Jochheim L, van R\u0026uuml;th V, Gottschalk U, Mueller G, Kozlik-Feldmann R, Hazekamp MG, Sachweh JS, Biermann D. Impact of delayed sternal closure on wound infections following neonatal and infant cardiac surgery. PLoS One. 2022 May 23;17(5):e0267985. doi: 10.1371/journal.pone.0267985. \u003c/li\u003e\n\u003cli\u003eHarder EE, Gaies MG, Yu S, Donohue JE, Hanauer DA, Goldberg CS, Hirsch JC. Risk factors for surgical site infection in pediatric cardiac surgery patients undergoing delayed sternal closure. J Thorac Cardiovasc Surg. 2013 Aug;146(2):326-33. doi: 10.1016/j.jtcvs.2012.09.062. \u003c/li\u003e\n\u003cli\u003eIguidbashian J, Feng Z, Colborn KL, Barrett CS, Newman SR, Harris M, Campbell DN, Mitchell MB, Jaggers J, Stone ML. Open Chest Duration Following Congenital Cardiac Surgery Increases Risk for Surgical Site Infection. Pediatr Cardiol. 2024 Aug;45(6):1284-1288. doi: 10.1007/s00246-022-03088-4. \u003c/li\u003e\n\u003cli\u003eAsfari A, Jacobs JP, Byrnes JW, Borasino S, Prodhan P, Zaccagni H, Dabal RJ, Sorabella RA, Hammel JM, Smith-Parrish M, Zhang W, Banerjee M, Schumacher KR, Tabbutt S. Norwood Operation: Immediate vs Delayed Sternal Closure. Ann Thorac Surg. 2023 Mar;115(3):649-654. doi: 10.1016/j.athoracsur.2022.06.046. \u003c/li\u003e\n\u003cli\u003eSuvorov VV, Zaitsev VV, Gvozd EM. Efficiency of an algorithm for the prevention of sternal infection after cardiac surgery in children under 1 year of age: A single-center retrospective study. Heliyon. 2024 Apr 2010(9):e29991. doi: 10.1016/j.heliyon.2024.e29991. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Surgical site infection, delayed sternal closure, pediatric cardiac surgery","lastPublishedDoi":"10.21203/rs.3.rs-7115282/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7115282/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction :\u003c/strong\u003eDelayed sternal closure (DSC) is a technique used in complex cardiac surgery (CCS) and is associated with an increased risk of surgical site infection (SSI). SSI increases hospital stay and healthcare costs, with an incidence ranging from 1.5% to 34%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e To determine the SSI rate and associated risk factors in patients with congenital heart disease (CHD) undergoing CCS with DSC between January 2015 and December 2020, and to compare them with previous results, before the implementation of measures by the Healthcare-Associated Infections Committee (HAIC).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods: \u003c/strong\u003eA descriptive study was conducted in patients under 18 years of age who required DSC between 2015 and 2020 at the Hospital of Pontifical Catholic University of Chile, meeting the Chilean Ministry of Health's definition of SSI. SSI rates were compared between the periods 2009-2010 and 2015-2020 using the Poisson rate ratio.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 1,471 surgeries were performed, of which 138 (9.3%) required DSC and 6 (4.3%) presented SSI. 67% were males older than 7 days, with one patient premature. 66.7% had extracorporeal circulation (ECC) \u0026gt;200 minutes and 83.3% required mechanical ventilation (MV) \u0026gt;5 days. Several SSI-causing microorganisms were identified. Comparing both studies, a decrease in the prevalence of SSI in DSC was found from 22% to 4.3%, with a rate ratio of 5.16 (95% IC 1.83-16.54, p = 0.001), with no significant differences in the risk factors identified in the initial study (ECC \u0026gt; 200 min and MV \u0026gt; 5 days).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The SSI rate was 4.3%, a significant decrease compared to the previous study, attributed to improvements in cardiovascular management and IAAS Committee measures.\u003c/p\u003e","manuscriptTitle":"Surgical site infection in pediatric patients undergoing cardiac surgery with delayed sternal closure: experience from a center in Chile, South America (2015–2020)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 17:08:26","doi":"10.21203/rs.3.rs-7115282/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-29T13:11:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-08T21:06:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21599830817557697185825187175927985127","date":"2025-08-19T10:18:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82616281029714428375355220263078143304","date":"2025-08-17T21:38:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-05T02:10:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-14T16:10:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-14T07:10:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Cardiology","date":"2025-07-13T19:56:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bb4bff87-d2a9-4dc6-b72a-b1fe041b812b","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T16:04:39+00:00","versionOfRecord":{"articleIdentity":"rs-7115282","link":"https://doi.org/10.1007/s00246-025-04080-4","journal":{"identity":"pediatric-cardiology","isVorOnly":false,"title":"Pediatric Cardiology"},"publishedOn":"2025-10-31 15:57:46","publishedOnDateReadable":"October 31st, 2025"},"versionCreatedAt":"2025-08-06 17:08:26","video":"","vorDoi":"10.1007/s00246-025-04080-4","vorDoiUrl":"https://doi.org/10.1007/s00246-025-04080-4","workflowStages":[]},"version":"v1","identity":"rs-7115282","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7115282","identity":"rs-7115282","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}