eMedicine Specialties > Thoracic Surgery > Infection

Mediastinitis: Follow-up

Author: Dale K Mueller, MD, Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois at Peoria; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC
Coauthor(s): Michael J Dacey, MD, Consulting Staff, Department of Internal Medicine, Division of Critical Care, Kent County Hospital
Contributor Information and Disclosures

Updated: Jun 4, 2009

Outcome and Prognosis

The development of mediastinitis dramatically raises the chance of mortality and lengthens the hospital stay. One study showed that postoperatively, a patient's chance of dying doubled to 12% when mediastinitis developed compared with 6% for those without the condition. Some studies report death rates as high as 47%. Mediastinitis also raises the 2-year mortality rate from 2% to 8% following coronary bypass grafting. Patients with postoperative mediastinitis stay in the hospital 6-7 times longer than those without the condition, and total costs may triple.23

Future and Controversies

Fortunately, mediastinitis is fairly uncommon in relation to the hundreds of thousands of cardiac surgeries performed each year in the United States. However, when it occurs, the results are often devastating and the costs of care increase substantially.

Future directions for research should focus on prevention, including timely antibiotic administration, sterile technique, prophylactic measures such as topical bacitracin, and meticulous hemostasis. Focus should also include more accurate methods of diagnosis during the first 14 days after surgery, when CT scan findings are not reliable. However, the key to successful management remains early recognition and aggressive treatment, including sternal reopening and debridement.

Further research should also focus on the optimal timing and method of wound closure and the duration of antibiotic therapy required for optimal treatment.

 


More on Mediastinitis

Overview: Mediastinitis
Workup: Mediastinitis
Treatment: Mediastinitis
Follow-up: Mediastinitis
Multimedia: Mediastinitis
References
[ CLOSE WINDOW ]

References

  1. Luckraz H, Murphy F, Bryant S, Charman SC, Ritchie AJ. Vacuum-assisted closure as a treatment modality for infections after cardiac surgery. J Thorac Cardiovasc Surg. Feb 2003;125(2):301-5. [Medline].

  2. MacIver RH, Stewart R, Frederiksen JW, Fullerton DA, Horvath KA. Topical application of bacitracin ointment is associated with decreased risk of mediastinitis after median sternotomy. Heart Surg Forum. 2006;9(5):E750-3. [Medline].

  3. Athanassiadi KA. Infections of the mediastinum. Thorac Surg Clin. Feb 2009;19(1):37-45, vi. [Medline].

  4. Jayakrishnan AG, Allan A, Forsyth AT, Desai JB. Sternal wound infections and internal mammary artery grafts. J Thorac Cardiovasc Surg. Jul 1993;106(1):181-2. [Medline].

  5. Ioannis K. Toumpoulisa, Nikolaos Theakosb and Joel Dunningc. Does bilateral internal thoracic artery harvest increase the risk of mediastinitis?. Interact CardioVasc Thorac Surg. 2007;6:787-791. [Medline].

  6. Farinas MC, Gald Peralta F, Bernal JM, et al. Suppurative mediastinitis after open-heart surgery: a case-control study covering a seven-year period in Santander, Spain. Clin Infect Dis. Feb 1995;20(2):272-9. [Medline].

  7. Milano CA, Kesler K, Archibald N, et al. Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival. Circulation. Oct 15 1995;92(8):2245-51. [Medline].

  8. Baldwin RT, Radovancevic B, Sweeney MS, et al. Bacterial mediastinitis after heart transplantation. J Heart Lung Transplant. May-Jun 1992;11(3 Pt 1):545-9. [Medline].

  9. Shaffer HA, Valenzuela G, Mittal RK. Esophageal perforation. A reassessment of the criteria for choosing medical or surgical therapy. Arch Intern Med. Apr 1992;152(4):757-61. [Medline].

  10. Sancho LM, Minamoto H, Fernandez A, et al. Descending necrotizing mediastinitis: a retrospective surgical experience. Eur J Cardiothorac Surg. Aug 1999;16(2):200-5. [Medline].

  11. Loyd JE, Tillman BF, Atkinson JB, Des Prez RM. Mediastinal fibrosis complicating histoplasmosis. Medicine (Baltimore). Sep 1988;67(5):295-310. [Medline].

  12. Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect. Oct 2006;64(2):162-8. [Medline].

  13. Saiki Y, Tabayashi K. [Use of a vacuum-assisted closure system for the treatment of mediastinitis after cardiac and aortic surgery]. Nippon Geka Gakkai Zasshi. Jan 2009;110(1):21-6. [Medline].

  14. Noji S, Yuda A, Tatebayashi T, Kuroda M. Vacuum-assisted closure for postcardiac surgery mediastinitis in a patient on hemodialysis. Gen Thorac Cardiovasc Surg. Apr 2009;57(4):217-20. [Medline].

  15. Maroto LC, Aguado JM, Carrascal Y, et al. Role of epicardial pacing wire cultures in the diagnosis of poststernotomy mediastinitis. Clin Infect Dis. Mar 1997;24(3):419-21. [Medline].

  16. Jolles H, Henry DA, Roberson JP, et al. Mediastinitis following median sternotomy: CT findings. Radiology. Nov 1996;201(2):463-6. [Medline].

  17. El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg. Mar 1996;61(3):1030-6. [Medline].

  18. Kalweit G, Huwer H, Straub U, Gams E. Mediastinal compression syndromes due to idiopathic fibrosing mediastinitis--report of three cases and review of the literature. Thorac Cardiovasc Surg. Apr 1996;44(2):105-9. [Medline].

  19. Weinzweig N, Yetman R. Transposition of the greater omentum for recalcitrant median sternotomy wound infections. Ann Plast Surg. May 1995;34(5):471-7. [Medline].

  20. Hountis P, Dedeilias P, Bolos K. The role of omental transposition for the management of postoperative mediastinitis: a case series. Cases J. Feb 23 2009;2(1):142. [Medline].

  21. Chase CW, Franklin JD, Guest DP, Barker DE. Internal fixation of the sternum in median sternotomy dehiscence. Plast Reconstr Surg. May 1999;103(6):1667-73. [Medline].

  22. Zec N, Donovan JW, Aufiero TX, et al. Seizures in a patient treated with continuous povidone-iodine mediastinal irrigation. N Engl J Med. Jun 25 1992;326(26):1784. [Medline].

  23. Loop FD, Lytle BW, Cosgrove DM, et al. J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg. Feb 1990;49(2):179-86; discussion 186-7. [Medline].

  24. Gadek JE, DeMichele SJ, Karlstad MD, et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral Nutrition in ARDS Study Group. Crit Care Med. Aug 1999;27(8):1409-20. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

mediastinitis, cardiac surgery, heart transplant, surgical complication, operative complication, surgery, postoperative complications, esophageal perforation, postoperative infection, tracheobronchial perforation, progressive odontogenic infection, Ludwig angina, lung infection, chronic fibrosing mediastinitis, granulomatous infections, Staphylococcus aureus, S aureus, Staphylococcus epidermidis, S epidermidis, Candida, Histoplasma capsulatum, H capsulatum, Mycobacterium tuberculosis, M tuberculosis, gram-positive cocci, mediastinal disease, mediastinum disease, open heart surgery, open heart operations, open-heart surgery, open-heart operations

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Dale K Mueller, MD, Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois at Peoria; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC
Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, American Medical Writers Association, Chicago Medical Society, Illinois State Medical Society, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Dacey, MD, Consulting Staff, Department of Internal Medicine, Division of Critical Care, Kent County Hospital
Disclosure: Nothing to disclose.

Medical Editor

Benson B Roe, MD, Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center
Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shreekanth V Karwande, MBBS, Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center
Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.