Postoperative mediastinitis after cardiac surgery
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Prior to the development of modern cardiovascular surgery, most cases of mediastinitis arose from either esophageal perforation or from contiguous spread of odontogenic or retropharyngeal infections. Rarely, primary infections of the mediastinum developed as a result of penetrating trauma or hematogenous spread of infection. However, in modern practice, most cases of mediastinitis are a postoperative complication of cardiovascular or other thoracic surgical procedures.
The medical management of sternal wound infection will be reviewed here. The surgical management of sternal wound complications is discussed in detail separately. (See "Surgical management of sternal wound complications".)
The pathogenesis of postoperative mediastinitis is complex and multifactorial. The most important factor is intraoperative wound contamination. Such contamination probably occurs in virtually all patients during the long time interval that large sternotomy wounds are open during cardiac surgery. It is therefore likely that the degree and type of contamination interact with host factors, such as the adequacy of local blood supply, nutrition, and immunologic status, to result in infection in small numbers of patients even if meticulous care is exercised by the surgical team.
A number of other preoperative and operative factors occasionally play a role in the pathogenesis of postoperative mediastinitis. These include preoperative skin colonization with potentially pathogenic or highly resistant organisms, disruption of the blood supply to the sternum during surgery, tissue trauma due to electrocautery, and early postoperative wound disruption (eg, from coughing).
Microbiology — The majority of patients with postoperative mediastinitis have monomicrobial infections. In two reviews with a total of 350 patients with postoperative mediastinitis, 290 (83 percent) had a single pathogen isolated from their mediastinum or blood [1,2].
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