Mediastinitis in Emergency Medicine Medication

  • Author: Ethan S Brandler, MD, MPH; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 14, 2010
 

Medication Summary

Because mediastinitis usually is a mixed growth infection, wide antimicrobial coverage is required. The cause of infection should be determined. Extension of a Staphylococcus aureus osteomyelitis should be managed differently from an esophageal rupture; however, in the absence of a source and definitive microbiological data, broad-spectrum therapy is indicated. Combinations such as piperacillin-tazobactam with vancomycin or ceftazidime with vancomycin or vancomycin with a fluoroquinolone and clindamycin should be used. An aminoglycoside may be added to broaden gram-negative coverage.

Next

Antibiotics

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

View full drug information

Ceftriaxone (Rocephin)

 

Third-generation cephalosporin that has broad-spectrum gram-negative activity, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to one or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.

View full drug information

Clindamycin (Cleocin)

 

Lincosamide that is useful treatment of serious skin and soft tissue infections caused by most staphylococcal strains. Effective against aerobic and anaerobic streptococci, except enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.

View full drug information

Imipenem-cilastatin (Primaxin)

 

Used for treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated because of their potential for toxicity.

View full drug information

Metronidazole (Flagyl)

 

Active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells and the intermediate metabolized compounds that bind DNA are then formed and inhibit synthesis, causing cell death.

View full drug information

Gentamicin (Garamycin)

 

An aminoglycoside antibiotic effective against Pseudomonas aeruginosa,Escherichia coli,Proteus,Klebsiella, and Staphylococcus species.

Numerous dosing regimens are available, and they are adjusted based on creatinine clearance and changes in the volume of distribution. The dose of gentamicin may be given IV or IM.

View full drug information

Piperacillin and tazobactam sodium (Zosyn)

 

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication. This medication has a broad antimicrobial spectrum that is effective again most oral, respiratory, and GI bacterial pathogens. Used in concert with gentamicin, strong anti-gram-negative activity occurs.

View full drug information

Ampicillin and sulbactam (Unasyn)

 

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

View full drug information

Vancomycin (Vancocin)

 

Inhibits cell wall synthesis. Accomplished by binding to carboxyl units on peptide subunits containing free D-alanyl-D-alanine.

Effective against methicillin-resistant S aureus.

Previous
Proceed to Follow-up
 
 
Contributor Information and Disclosures
Author

Ethan S Brandler, MD, MPH  Clinical Assistant Professor, Attending Physician, Departments of Emergency Medicine and Internal Medicine, University Hospital of Brooklyn, Kings County Hospital

Ethan S Brandler, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Miller B Pearsall, MD  Resident Physician and Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate School of Medicine, Kings County Hospital Center, University Hospital of Brooklyn

Miller B Pearsall, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric M Kardon, MD, FACEP  Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Ridder GJ, Maier W, Kinzer S, Teszler CB, Boedeker CC, Pfeiffer J. Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome. Ann Surg. Mar 2010;251(3):528-34. [Medline].

  2. Scaglione M, Pezzullo MG, Pinto A, Sica G, Bocchini G, Rotondo A. Usefulness of multidetector row computed tomography in the assessment of the pathways of spreading of neck infections to the mediastinum. Semin Ultrasound CT MR. Jun 2009;30(3):221-30. [Medline].

  3. Mihos P, Potaris K, Gakidis I, Papadakis D, Rallis G. Management of descending necrotizing mediastinitis. J Oral Maxillofac Surg. Aug 2004;62(8):966-72. [Medline].

  4. Cirino LM, Elias FM, Almeida JL. Descending mediastinitis: a review. Sao Paulo Med J. Sep 7 2006;124(5):285-90. [Medline].

  5. Akman C, Kantarci F, Cetinkaya S. Imaging in mediastinitis: a systematic review based on aetiology. Clin Radiol. Jul 2004;59(7):573-85. [Medline].

  6. Allotey J, Duncan H, Williams H. Mediastinitis and retropharyngeal abscess following delayed diagnosis of glass ingestion. Emerg Med J. Feb 2006;23(2):e12. [Medline].

  7. Becker M, Zbaren P, Hermans R, et al. Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management. Radiology. Feb 1997;202(2):471-6. [Medline].

  8. Brook I, Frazier EH. Microbiology of mediastinitis. Arch Intern Med. Feb 12 1996;156(3):333-6. [Medline].

  9. Brunelli A, Sabbatini A, Catalini G, Fianchini A. Descending necrotizing mediastinitis. Surgical drainage and tracheostomy. Arch Otolaryngol Head Neck Surg. Dec 1996;122(12):1326-9. [Medline].

  10. Bulut M, Balci V, Akkose S, Armagan E. Fatal descending necrotising mediastinitis. Emerg Med J. Jan 2004;21(1):122-3. [Medline]. [Full Text].

  11. Clancy CJ, Nguyen MH, Morris AJ. Candidal mediastinitis: an emerging clinical entity. Clin Infect Dis. Sep 1997;25(3):608-13. [Medline].

  12. Corsten MJ, Shamji FM, Odell PF, et al. Optimal treatment of descending necrotising mediastinitis. Thorax. Aug 1997;52(8):702-8. [Medline].

  13. Diez C, Koch D, Kuss O, Silber RE, Friedrich I, Boergermann J. Risk factors for mediastinitis after cardiac surgery - a retrospective analysis of 1700 patients. J Cardiothorac Surg. May 20 2007;2:23. [Medline].

  14. Estrera AS, Landay MJ, Grisham JM, Sinn DP, Platt MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet. Dec 1983;157(6):545-52. [Medline].

  15. Gamlin F, Caldicott LD, Shah MV. Mediastinitis and sepsis syndrome following intubation. Anaesthesia. Oct 1994;49(10):883-5. [Medline].

  16. Haraden BM, Zwemer FL Jr. Descending necrotizing mediastinitis: complication of a simple dental infection. Ann Emerg Med. May 1997;29(5):683-6. [Medline].

  17. Isaacs LM, Kotton B, Peralta MM Jr, Shekar R, Meden G, Brown LA, et al. Fatal mediastinal abscess from upper respiratory infection. Ear Nose Throat J. Sep 1993;72(9):620-2, 624-6, 631. [Medline].

  18. Iwama S, Kato Y, Nakayama S. Acute suppurative thyroiditis extending to descending necrotizing mediastinitis and pericarditis. Thyroid. Mar 2007;17(3):281-2. [Medline].

  19. Kaira K, Yasuoka H, Ichikawa T, et al. Descending necrotizing mediastinitis after upper gastrointestinal endoscopy. Endoscopy. Feb 2007;39 Suppl 1:E29. [Medline].

  20. Kiernan PD, Hernandez A, Byrne WD, et al. Descending cervical mediastinitis. Ann Thorac Surg. May 1998;65(5):1483-8. [Medline].

  21. Makeieff M, Gresillon N, Berthet JP, Garrel R, Crampette L, Marty-Ane C. Management of descending necrotizing mediastinitis. Laryngoscope. Apr 2004;114(4):772-5. [Medline].

  22. Marty-Ane CH, Alauzen M, Alric P, Serres-Cousine O, Mary H. Descending necrotizing mediastinitis. Advantage of mediastinal drainage with thoracotomy. J Thorac Cardiovasc Surg. Jan 1994;107(1):55-61. [Medline].

  23. Marty-Ane CH, Berthet JP, Alric P, Pegis JD, Rouviere P, Mary H. Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease. Ann Thorac Surg. Jul 1999;68(1):212-7. [Medline].

  24. Mathisen DJ, Grillo HC. Clinical manifestation of mediastinal fibrosis and histoplasmosis. Ann Thorac Surg. Dec 1992;54(6):1053-7; discussion 1057-8. [Medline].

  25. Misthos P, Katsaragakis S, Kakaris S, Theodorou D, Skottis I. Descending necrotizing anterior mediastinitis: analysis of survival and surgical treatment modalities. J Oral Maxillofac Surg. Apr 2007;65(4):635-9. [Medline].

  26. Nielsen TR, Clement F, Andreassen UK. Mediastinitis-a rare complication of a peritonsillar abscess. J Laryngol Otol. Feb 1996;110(2):175-6. [Medline].

  27. Nomori H, Horio H, Kobayashi R. Descending necrotizing mediastinitis secondary to pharyngitis. A case report. Scand Cardiovasc J. 1997;31(4):233-5. [Medline].

  28. Pasaoglu I, Arsan S, Yorgancioglu AC, Yüksel Bozer A. A simple management of mediastinitis. Int Surg. Jul-Sep 1995;80(3):239-41. [Medline].

  29. Reddy SL, Grayson AD, Smith G, Warwick R, Chalmers JA. Methicillin resistant Staphylococcus aureus infections following cardiac surgery: incidence, impact and identifying adverse outcome traits. Eur J Cardiothorac Surg. Jul 2007;32(1):113-7. [Medline].

  30. Savides TJ, Margolis D, Richman KM, Singh V. Gemella morbillorum mediastinitis and osteomyelitis following transesophageal endoscopic ultrasound-guided fine-needle aspiration of a posterior mediastinal lymph node. Endoscopy. Feb 2007;39 Suppl 1:E123-4. [Medline].

  31. Scaglione M, Pinto A, Giovine S, Di Nuzzo L, Giuliano V, Romano L. CT features of descending necrotizing mediastinitis--a pictorial essay. Emerg Radiol. Jun 2007;14(2):77-81. [Medline].

  32. Sugata T, Fujita Y, Myoken Y, Fujioka Y. Cervical cellulitis with mediastinitis from an odontogenic infection complicated by diabetes mellitus: report of a case. J Oral Maxillofac Surg. Aug 1997;55(8):864-9. [Medline].

  33. Watanabe M, Ohshika Y, Aoki T, Takagi K, Tanaka S, Ogata T. Empyema and mediastinitis complicating retropharyngeal abscess. Thorax. Nov 1994;49(11):1179-80. [Medline].

  34. Wheatley MJ, Stirling MC, Kirsh MM, Gago O, Orringer MB. Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg. May 1990;49(5):780-4. [Medline].

 
Previous
Next
 
Chest radiograph of a patient presenting with mediastinitis secondary to esophageal perforation by a chicken bone. Image courtesy of Mark Silverberg, MD, FACEP, and Rafi Israeli, MD.
Chest CT of same patient showing gas-filled mediastinal abscess and widened esophagus. Image courtesy of Mark Silverberg, MD, FACEP, and Rafi Israeli, MD.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
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.