eMedicine Specialties > Thoracic Surgery > Infection

Mediastinitis: Treatment

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

Treatment

Medical Therapy

Prevention

  • Strict adherence to perioperative aseptic technique
  • Attention to hemostasis
  • Precise sternal closure
  • Possible prophylactic intranasal mupirocin administered to S aureus carriers (may reduce the rates of overall surgical site infections by S aureus after cardiac surgery)12
  • Possible topical application of bacitracin ointment to sternotomy to decrease risk of mediastinitis after cardiac surgery2
Medical care in the postoperative period

Appropriate, well-directed antibiotic therapy is crucial to successful treatment of mediastinitis.

Most patients have already received prophylactic antibiotics, usually a first-generation cephalosporin. Because up to 20% of organisms cultured from infected sternotomy sites are methicillin-resistant S aureus and because another 20% are gram-negative organisms, institute very broad and deep antibiotic coverage that includes Pseudomonas species. Culture results should then guide antibiotic use, as multiple regimens are available for use with patients who have mediastinitis.

Therapy is usually prolonged, ranging from weeks to months. One study suggests that 4-6 weeks of therapy is adequate for most patients.17

Institute enteral nutritional support immediately, with a duodenal feeding tube, if necessary. Recent data suggest that the use of diets formulated with various anti-inflammatory compounds to include omega-3 long-chain fatty acids and arginine provide clinically important benefits for critically ill patients with sepsis. If enteral feedings are contraindicated, consider hyperalimentation.

Chronic fibrosing mediastinitis

Treat chronic fibrosing mediastinitis, which is often caused by H capsulatum infection, with close observation for signs of superior vena cava compression or other mediastinal organ compromise.18 The role of antifungal therapy is controversial, although amphotericin B has been used.

Surgical Therapy

Surgical options for mediastinitis after cardiac surgery

Effective treatment for simple sternal dehiscence without infection is rewiring the sternum.8 This usually yields reasonable long-term results. Cultures should be taken to exclude active infection in the cases of sternal dehiscence.

Failure to adequately debride and sterilize the mediastinum during the first reoperation is the most common cause of repeat postoperative mediastinitis. Options for mediastinitis after cardiac surgery are immediate closure after sternal debridement, delayed closure after sternal debridement, and sternal irrigation after sternal debridement. Each has its advantages and disadvantages. The best strategy for accomplishing this depends on the duration of the infection, the condition of the mediastinal structures, and the experience of the surgeon.

Most surgeons prefer to leave the wound open or treat with vacuum-assisted closure for subsequent debridement efforts after initial sternal reexploration.1,13,14 In this case, the wound is packed daily until it appears clean with adequate granulation tissue. At this point, muscle flap closure is achieved. Usually, bilateral pectoralis muscle flaps are used. Occasionally, the rectus abdominus muscle, which is opposite the internal mammary artery used for bypass, is used for coverage.

Both the surgeon's experience and patient factors influence the type of flap procedure used. If a large anterior retrosternal dead space exists, it must be obliterated in order to achieve cure. Although often achieved with a muscle flap, the omentum provides lymphocytes and angiogenesis factors that may prove beneficial.19,20 Disadvantages of this delayed approach are the altered thoracic mechanics, which may lead to ventilator dependence, and a risk of bleeding from the exposed heart and vessels, with muscle flap closure for mediastinitis in an attempt to decrease the incidence of this bleeding.

Some surgeons uniformly perform muscle flap closure at the initial debridement with good results.21 Other surgeons elect to close the wound site primarily in less-advanced cases of mediastinitis and use large-bore drainage and irrigation tubes to infuse various antibiotic or antiseptic solutions for many days. Although the most commonly used solution in the past has been povidone iodine, this should be used with caution. Case reports have indicated the development of serious iodine toxicity manifesting as seizures and renal failure.22

The lack of a bony anterior sternal wall may be unacceptable to some patients and has prompted some surgeons to attempt sternum-sparing procedures, even in more advanced cases. This is often a difficult decision, requiring excellent surgical judgment. Clearly advanced cases of sternal osteomyelitis are extremely difficult to cure, and most patients with muscle or omental flaps do very well from a functional standpoint.

Chronic fibrosing mediastinitis

Surgery is seldom recommended for cases of chronic fibrosing mediastinitis unless compression of major mediastinal structures has occurred. Whether surgical debulking early in the process minimizes the development of superior vena cava syndrome or cardiac compression has not been adequately studied.

Oropharyngeal descending infections

In cases of descending mediastinitis due to infections that began in the oropharynx, some surgeons attempt to limit drainage and debridement to the cervical region. In a more advanced infection, often the best plan to offer a maximal chance of cure is to proceed with formal thoracic drainage and debridement.

Complications

Systemic sepsis is a major complication of mediastinitis and manifests with tachycardia, hypotension, poor urine output, and other signs of poor systemic perfusion. The aim of early aggressive therapy, both surgical and medical, is to prevent this often lethal complication.

Pneumoperitoneum and pneumothorax can produce serious local problems and eventual hemodynamic compromise.

If pleural effusions become infected and develop into empyema, systemic sepsis may occur.

Severe and life-threatening bleeding from ruptured vessels or the heart itself can occur when the chest is packed and left open to await definitive closure.

Superior vena cava syndrome and compression of critical mediastinal structures is sometimes observed with chronic fibrosing mediastinitis.

More on Mediastinitis

Overview: Mediastinitis
Workup: Mediastinitis
Treatment: Mediastinitis
Follow-up: Mediastinitis
Multimedia: Mediastinitis
References
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References

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Further Reading

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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

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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.

 
 
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