Infectious Complications After Surgical Stabilization of Rib Fractures: A National Analysis

Authors:
Hadi Hamdan, Ahmad El Nouiri, Camden Gardner, Tarek Araji, Michael Bock, Jeffrey Johnson

Body of Abstract:
Background: Surgical stabilization of rib fractures (SSRF) has gained increasing traction for the management of severe chest wall injuries. Prior national studies have focused on mortality and pulmonary outcomes, while infectious complications are only reported as secondary endpoints. Thus, the relationship between SSRF and nosocomial infections are poorly understood. We aimed to evaluate the association between SSRF and major hospital-acquired infections using a contemporary national trauma cohort.

Methods: A retrospective analysis of adult trauma patients with ≥1 rib fracture was conducted using ACS-TQIP (2019–2023). ICD-10 diagnosis and procedure codes identified rib fractures and SSRF cases. Patients were categorized as to whether they underwent SSRF vs. non-operative management (NOM). Multivariable logistic regression evaluated associations of both interventions with severe sepsis, catheter-associated urinary tract infection (CAUTI), and central line–associated bloodstream infection (CLABSI). Adjustment for demographics, comorbidities, physiology, injury severity (ISS, GCS, shock index), antibiotic therapy, hospital length of stay, ICU length of stay, ventilator days, and hospital characteristics was done. A planned sub-analysis—restricted to mechanically ventilated, ICU-admitted patients—assessed ventilator-associated pneumonia (VAP).

Results: Among 595,375 eligible patients, 18,140 (3.0%) underwent SSRF. Median time to surgery was 4 days (IQR 3–8). SSRF patients had greater critical-care exposure, including longer ICU stay (7 days, IQR 4–13 vs. 4 days, IQR 2–7) and ventilator duration (7 days, IQR 3–13 vs. 4 days, IQR 2–10). Unadjusted rates of severe sepsis (1.66% vs. 0.53%), CAUTI (0.41% vs. 0.21%), CLABSI (0.14% vs. 0.06%), and VAP (3.34% vs. 0.86%) were all higher among SSRF patients. After full adjustment, SSRF remained independently associated with severe sepsis (aOR 1.87, p<0.001). SSRF was not independently associated with CAUTI (aOR 1.25, p=0.067) or CLABSI (aOR 1.50, p=0.063). In the ventilated ICU sub-analysis (94,842 patients), SSRF remained independently associated with increased VAP risk (aOR 1.44, p<0.001) after adjustment. Conclusion: In a large national cohort, SSRF was associated with increased odds of severe sepsis and VAP despite adjustment for comorbidities, physiology, injury severity, and critical-care exposure. SSRF was not independently associated with an increase in CAUTI or CLABSI risk. The persistence of the VAP association suggests that factors intrinsic to patients selected for SSRF—such as injury complexity or clinical trajectory—may contribute to this elevated vulnerability. Further work is needed to clarify whether these risks reflect operative factors, patient selection, or underlying injury patterns.