eMedicine Specialties > Emergency Medicine > Infectious Diseases
Mediastinitis: Treatment & Medication
Updated: Apr 2, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
Mediastinitis may result in airway compromise. Protection of the airway is vital. Since patients may present in septic shock, adequate volume resuscitation is essential.
Emergency Department Care
- Ensure an adequate airway.
- Do not allow a patient who is potentially unstable to be placed into the CT scanner without ensuring that the airway is adequately protected.
- Intubation may be difficult because of soft tissue swelling. Fiberoptic assistance may be required and the patient may need an emergent cricothyrotomy or tracheostomy.
- In addition to the usual complications of intubation, it may be further complicated by trauma to the retropharyngeal wall, laryngospasm, or aspiration of purulent material.
- Antibiotic therapy should be initiated without delay.
- Fluid resuscitation and management of sepsis are essential.
Consultations
- Immediately make arrangements for surgical consultation.
- Extensive and aggressive debridement of necrotic tissues with exploration of all mediastinal fascial spaces may be required.
- Controversy exists about whether the cervical approach or the transthoracic approach is best. Some physicians support a combination of the two approaches. In some case series, the combination approach has been associated with a lower mortality rate.
- Depending upon the resources available, consultations may include otorhinolaryngology, cardiothoracic surgery, and general surgery.
- The necessity for extensive drainage may mandate the transfer of some patients to a tertiary referral center.
Medication
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.
Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting.
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.
Adult
1-2 g IV qd; not to exceed 4 g/d
Pediatric
50-75 mg/kg/d IV divided bid
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin
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.
Adult
600-1200 mg/d IV divided bid/tid/qid
For very severe infections, dose range may be 1200-2700 mg/d IV
Doses as high as 4800 mg/d have been given in exceptional circumstances
Pediatric
<1 month: 15-20 mg/kg/d IV divided tid/qid
1 month to 16 years: 20-40 mg/kg/d IV divided tid/qid
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis: ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
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.
Adult
500-1000 mg IV q6h
Patients with impaired renal function need lower doses
Pediatric
50 mg/kg/d IV divided tid/qid
Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency; avoid use in children <12 years because they may be prone to neurotoxicity of drug
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.
Adult
15 mg/kg IV over 1 h initially, followed by 7.5 mg/kg q6h IV infusion; not to exceed 4 g/d
Pediatric
15-30 mg/kg/d IV divided bid/tid for 7 d, or 40 mg/kg PO once; not to exceed 2 g/d
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
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.
Adult
3 mg/kg/d IV divided tid
Pediatric
>1 week: 6-7.5 mg/kg/d IV divided tid
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
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.
Adult
3.375 g IV q6h; adjust to 2.25 g IV q6h for creatinine clearance <20
Pediatric
<6 months: Not established
>6 months: 240-400 mg/kg/d IV divided q6h
Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high-dose parenteral penicillins may result in increased risk of bleeding
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions; caution when administering medication to patients on heparin or warfarin
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.
Adult
1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
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.
Adult
500 mg to 1 g (ie, 10 mg/kg DBW) IV q8-24h (based on CrCl)
Pediatric
40 mg/kg/d IV divided q6h
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
More on Mediastinitis |
| Overview: Mediastinitis |
| Differential Diagnoses & Workup: Mediastinitis |
 Treatment & Medication: Mediastinitis |
| Follow-up: Mediastinitis |
| Multimedia: Mediastinitis |
| References |
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References
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Further Reading
Keywords
descending necrotizing mediastinitis, oropharynx, oropharyngeal infection, mediastinum, mediastinitis, infection of the mediastinum, head and neck infection, head infection, neck infection
