Key result
In diabetic patients undergoing CABG, bilateral IMA grafting was associated with higher odds of bloodstream infection compared to single IMA grafting (OR 1.446; 95% CI 1.22-1.71; p<0.0001).
Why the study?
Does bilateral internal mammary artery (BIMA) grafting compared to single internal mammary artery (SIMA) grafting affect the risk of nosocomial infections in diabetic patients undergoing CABG?
Cohort (n=286,487)
Yes
Does bilateral internal mammary artery (BIMA) grafting compared to single internal mammary artery (SIMA) grafting affect the risk of nosocomial infections in diabetic patients undergoing CABG?
Odds Ratio: 1.446 (95% CI 1.22–1.71)
p-value: p=<.0001
While diabetes was generally associated with lower overall nosocomial infections post-CABG, BIMA grafting in diabetics increased bloodstream infection risk, and uncontrolled hyperglycemia drastically increased surgical site and urinary tract infections, suggesting BIMA should be avoided in uncontrolled diabetics.
BACKGROUND: There is a conflict evidence about the association of using bilateral internal mammary artery (BIMA) grafting in diabetics undergoing coronary artery bypass grafting (CABG) surgery and increased risk of contracting surgical site infection. The direct impact of the diabetics glycemic control status and using the optimal grafting method on surgical site infection is still not conclusive in literature. The aim of the study is to evaluate the impact of Bilateral internal mammary artery grafting in diabetic patients, the diagnosis of diabetes mellitus, and its glycemic control status on different kinds of nosocomial infections. The assumption was made that those exposures associated with higher risk of surgical site infection, urinary tract infection, blood stream infection and pneumonia. METHOD: A retrospective cohort is conducted by utilizing Nationwide Inpatient Sample (NIS) data from the Agency of Healthcare Research and Quality (AHRQ). All patients who were admitted to coronary artery bypass grafting (CABG) surgery were retrieved from 2007 to 2012 and grouped based on the exposures of the study. RESULTS: The total sample of the study was 286,487 patients underwent CABG surgery. There were 122,642 (42.81%) patients diagnosed with Diabetes Mellitus, of whom 18,065 (14.73%) had uncontrolled hyperglycemia, 3,700 (3.01%) received Bilateral (IMA) and 103,577 (84.45%) unilateral or single (IMA) grafting method. The study population was predominantly white (79.78%) and male (72.08%) with an average age of 66 (SD ±10.89) old. About 215,740 (75.31%) of patients had developed nosocomial pneumonia, 16,667 (5.82%) urinary tract infections (UTIs), 9,442 (3.3%) sepsis or bloodstream infection (BSIs), and 5,302 (1.85%) surgical site infection (SSIs in overall sample population.Among diabetic patients, there was no significant difference in comparing BIMA versus SIMA for surgical site infection (SSI) (p-value=0.2491) and blood stream infections (BSI) (p-value=0.6630). The results have also indicated that UTIs (4.2% vs. 5.5%; p-value=0.0005) was significantly lower with BIMA grafting method. However, results did not meet the hypothesis assumption regarding Pneumonias rate (76.8% vs. 70.5%; p-value < 0.0001) and was significantly higher with BIMA compared to SIMA grafting method. Multivariable analysis showed inconsistent result and confirmed that BIMA grafting predicts higher odd of BSI by 44.6% in diabetic, compared to SIMA grafting (OR: 1.446; 95% CI: 1.22-1.71; p<.0001). The cross unadjusted baseline results for all nosocomial infections were significantly lower in diabetic patients compared to non-diabetic; Except for UTI was significantly higher by the presence of diabetes in BIMA grafting population (n=10,223) (4.2% vs. 3.39%; p-value= 0.0393). Multivariable analysis has confirmed that Diabetes Miletus increase the risk of UTI by 21.7% in BIMA population (OR: 1.217; 95% CI: 1.21-1.22; p<.0001). The bivariate analysis results indicated that nosocomial infections were significantly higher in a diabetic with uncontrolled HbA1c compared to those with controlled diabetes. Except for nosocomial pneumonia. Adjusted results showed that uncontrolled hyperglycemia in a diabetic increase risk of UTI by 20% in overall and SIMA population. Uncontrolled hyperglycemia increase risk of SSI by 52% and UTI by 104% in diabetic undergoing BIMA grafting (SSI: OR 1.52; CI 1.50-1.53; p<.0001) (UTI: OR 2.049; CI 1.45-2.89; p<.0001). CONCLUSION: In patients who underwent CABG surgery, Diabetes Mellitus (DM) was associated with significantly lower nosocomial infections. This may imply a better trend in nosocomial infections complications for diabetics compared to the total population of CABG. However, in diabetic patient’s population, those stated with uncontrolled hyperglycemia have significantly higher risk of surgical site infection and urinary tract infection. Continuous insulin infusion protocol and intensive glycemic control monitoring are highly recommended for patients with uncontrolled diabetes during admission for CABG surgery. In diabetic patients who underwent CABG with Bilateral versus Single internal mammary (IMA), grafting, Bilateral IMA grafting was significantly associated with only higher odds of bloodstream infection in the diabetic patient and overall CABG population. BIMA grafting should be encouraged in diabetic patients. Expect in the case of uncontrolled hyperglycemia; it should be avoided due to the high risk of both SSI and UTI as it has been emphasized in other studies.
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Al Zayer (2017) conducted a cohort in Diabetes Mellitus in patients undergoing CABG surgery (n=286,487). Bilateral internal mammary artery (BIMA) grafting vs. Unilateral or single internal mammary artery (SIMA) grafting was evaluated on Bloodstream infection (BSI) (OR 1.446, 95% CI 1.22-1.71, p=<.0001). In diabetic patients undergoing CABG, bilateral IMA grafting was associated with higher odds of bloodstream infection compared to single IMA grafting (OR 1.446; 95% CI 1.22-1.71; p<0.0001).
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