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Elena Blasco-Colmenares, MD, PhD; Trish M. Perl, MD, MSc; Eliseo Guallar, MD, DrPH; William A. Baumgartner, MD; John V. Conte, MD; Diane Alejo, BA; Roberto Pastor-Barriuso, PhD; A. Richey Sharrett, MD, DrPH; Nauder Faraday, MD

Arch Intern Med. 2009;169(8):788-795.

Background  The risks associated with the use of the combination of aspirin and clopidogrel before surgery are incompletely understood. Pharmacologic suppression of platelet function may increase the risk of postoperative infection by inhibiting hemostasis, immunity, or both.

Methods  We performed a retrospective cohort study of 1677 patients undergoing coronary artery bypass surgery to determine the relationship of the preoperative use of aspirin plus clopidogrel vs aspirin alone to the 30-day incidence of postoperative surgical site infection and bacteremia.

Results  The cumulative incidence of infection at 30 days was 23.1% and 16.1% in patients who were receiving dual antiplatelet therapy and aspirin monotherapy, respectively (unadjusted hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.09-2.08). The risk of infection remained higher among patients who were receiving dual antiplatelet therapy after adjustment for demographic, socioeconomic, preoperative, and intraoperative risk factors (HR, 1.42; 95% CI, 1.01-2.00) and propensity score (HR, 1.43; 95% CI, 1.01-2.01]). Transfusion rates were also higher among patients who were receiving dual antiplatelet therapy than among patients who were receiving aspirin monotherapy (68.4% vs 60.4%, P = .04), but transfusion played a modest role in mediating the risk of infection (adjusted HR, 1.37; 95% CI, 0.96-1.93]). Mortality rates at 30 days were 5.2% and 3.1% in patients who were receiving dual antiplatelet and aspirin monotherapy, respectively (adjusted HR, 1.44; 95% CI, 0.70-2.99]).

Conclusions  Preoperative use of aspirin plus clopidogrel is associated with an increased risk of infection after coronary artery bypass surgery. These findings merit additional work to clarify the risks and benefits of uninterrupted dual antiplatelet therapy in surgical patients and the impact of platelet inhibition on infectious outcomes in populations that are at heightened infectious risk.

Author Affiliations: Department of Anesthesiology, Division of Cardiac Surgical Intensive Care (Drs Blasco-Colmenares and Faraday), Department of Medicine, Division of Infectious Diseases (Dr Perl), and Department of Surgery, Division of Cardiac Surgery (Drs Baumgartner and Conte and Ms Alejo), Johns Hopkins University School of Medicine, and Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health (Drs Blasco-Colmenares, Perl, Guallar, and Sharrett), Baltimore, Maryland; and Department of Cardiovascular Epidemiology and Population Genetics, Centro Nacional de Investigaciones Cardiovasculares, Madrid (Dr Guallar), National Center for Epidemiology, Instituto de Salud Carlos III, Madrid (Dr Pastor-Barriuso), and El Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública, Barcelona (Dr Pastor-Barriuso), Spain.

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BMJ 2009;338:b1712-b1712.
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