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].
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: Nov 21, 2016.References
- Fariñas 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 1995; 20:272.
- Trouillet JL, Vuagnat A, Combes A, et al. Acute poststernotomy mediastinitis managed with debridement and closed-drainage aspiration: factors associated with death in the intensive care unit. J Thorac Cardiovasc Surg 2005; 129:518.
- San Juan R, Chaves F, López Gude MJ, et al. Staphylococcus aureus poststernotomy mediastinitis: description of two distinct acquisition pathways with different potential preventive approaches. J Thorac Cardiovasc Surg 2007; 134:670.
- Pertowski CA, Baron RC, Lasker BA, et al. Nosocomial outbreak of Candida albicans sternal wound infections following cardiac surgery traced to a scrub nurse. J Infect Dis 1995; 172:817.
- Glower DD, Douglas JM Jr, Gaynor JW, et al. Candida mediastinitis after a cardiac operation. Ann Thorac Surg 1990; 49:157.
- Lowry PW, Blankenship RJ, Gridley W, et al. A cluster of legionella sternal-wound infections due to postoperative topical exposure to contaminated tap water. N Engl J Med 1991; 324:109.
- Sielaff TD, Everett JE, Shumway SJ, et al. Mycoplasma hominis infections occurring in cardiovascular surgical patients. Ann Thorac Surg 1996; 61:99.
- Wenger PN, Brown JM, McNeil MM, Jarvis WR. Nocardia farcinica sternotomy site infections in patients following open heart surgery. J Infect Dis 1998; 178:1539.
- Wang TK, Wong CF, Au WK, et al. Mycobacterium tuberculosis sternal wound infection after open heart surgery: a case report and review of the literature. Diagn Microbiol Infect Dis 2007; 58:245.
- El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996; 61:1030.
- 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 1990; 49:179.
- Risnes I, Abdelnoor M, Almdahl SM, Svennevig JL. Mediastinitis after coronary artery bypass grafting risk factors and long-term survival. Ann Thorac Surg 2010; 89:1502.
- Baldwin RT, Radovancevic B, Sweeney MS, et al. Bacterial mediastinitis after heart transplantation. J Heart Lung Transplant 1992; 11:545.
- Griffith BP, Kormos RL, Hardesty RL, et al. The artificial heart: infection-related morbidity and its effect on transplantation. Ann Thorac Surg 1988; 45:409.
- Calderwood MS, Kleinman K, Soumerai SB, et al. Impact of Medicare's payment policy on mediastinitis following coronary artery bypass graft surgery in US hospitals. Infect Control Hosp Epidemiol 2014; 35:144.
- Kohli M, Yuan L, Escobar M, et al. A risk index for sternal surgical wound infection after cardiovascular surgery. Infect Control Hosp Epidemiol 2003; 24:17.
- Russo PL, Spelman DW. A new surgical-site infection risk index using risk factors identified by multivariate analysis for patients undergoing coronary artery bypass graft surgery. Infect Control Hosp Epidemiol 2002; 23:372.
- Milano CA, Kesler K, Archibald N, et al. Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival. Circulation 1995; 92:2245.
- Farrington M, Webster M, Fenn A, Phillips I. Study of cardiothoracic wound infection at St. Thomas' Hospital. Br J Surg 1985; 72:759.
- Ottino G, De Paulis R, Pansini S, et al. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987; 44:173.
- Nagachinta T, Stephens M, Reitz B, Polk BF. Risk factors for surgical-wound infection following cardiac surgery. J Infect Dis 1987; 156:967.
- Koshal A, Hendry P, Raman SV, Keon WJ. Should obese patients not undergo coronary artery surgery? Can J Surg 1985; 28:331.
- Gaynes R, Marosok R, Mowry-Hanley J, et al. Mediastinitis following coronary artery bypass surgery: a 3-year review. J Infect Dis 1991; 163:117.
- Wouters R, Wellens F, Vanermen H, et al. Sternitis and mediastinitis after coronary artery bypass grafting. Analysis of risk factors. Tex Heart Inst J 1994; 21:183.
- Bor DH, Rose RM, Modlin JF, et al. Mediastinitis after cardiovascular surgery. Rev Infect Dis 1983; 5:885.
- Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 1991; 91:152S.
- Lilienfeld DE, Vlahov D, Tenney JH, McLaughlin JS. Obesity and diabetes as risk factors for postoperative wound infections after cardiac surgery. Am J Infect Control 1988; 16:3.
- Friedman ND, Bull AL, Russo PL, et al. An alternative scoring system to predict risk for surgical site infection complicating coronary artery bypass graft surgery. Infect Control Hosp Epidemiol 2007; 28:1162.
- Zerr KJ, Furnary AP, Grunkemeier GL, et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg 1997; 63:356.
- Trick WE, Scheckler WE, Tokars JI, et al. Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000; 119:108.
- Wilson SJ, Sexton DJ. Elevated preoperative fasting serum glucose levels increase the risk of postoperative mediastinitis in patients undergoing open heart surgery. Infect Control Hosp Epidemiol 2003; 24:776.
- Latham R, Lancaster AD, Covington JF, et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol 2001; 22:607.
- Kouchoukos NT, Wareing TH, Murphy SF, et al. Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg 1990; 49:210.
- Grossi EA, Esposito R, Harris LJ, et al. Sternal wound infections and use of internal mammary artery grafts. J Thorac Cardiovasc Surg 1991; 102:342.
- Seyfer AE, Shriver CD, Miller TR, Graeber GM. Sternal blood flow after median sternotomy and mobilization of the internal mammary arteries. Surgery 1988; 104:899.
- Dodds Ashley ES, Carroll DN, Engemann JJ, et al. Risk factors for postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2004; 38:1555.
- Costello JM, Graham DA, Morrow DF, et al. Risk factors for surgical site infection after cardiac surgery in children. Ann Thorac Surg 2010; 89:1833.
- Kagen J, Lautenbach E, Bilker WB, et al. Risk factors for mediastinitis following median sternotomy in children. Pediatr Infect Dis J 2007; 26:613.
- Nishida H, Grooters RK, Soltanzadeh H, et al. Discriminate use of electrocautery on the median sternotomy incision. A 0.16% wound infection rate. J Thorac Cardiovasc Surg 1991; 101:488.
- Roy MC, Herwaldt LA, Embrey R, et al. Does the Centers for Disease Control's NNIS system risk index stratify patients undergoing cardiothoracic operations by their risk of surgical-site infection? Infect Control Hosp Epidemiol 2000; 21:186.
- Chen L, Anderson D, Kaye K, Sexton DJ. Validating a new predictive instrument for surgical site infections following cardiac bypass surgery. Presented at the Annual IDSA Meeting. San Diego, CA. October 4-7, 2007.
- Kohman LJ, Coleman MJ, Parker FB Jr. Bacteremia and sternal infection after coronary artery bypass grafting. Ann Thorac Surg 1990; 49:454.
- Jolles H, Henry DA, Roberson JP, et al. Mediastinitis following median sternotomy: CT findings. Radiology 1996; 201:463.
- Benlolo S, Matéo J, Raskine L, et al. Sternal puncture allows an early diagnosis of poststernotomy mediastinitis. J Thorac Cardiovasc Surg 2003; 125:611.
- Fowler VG Jr, Kaye KS, Simel DL, et al. Staphylococcus aureus bacteremia after median sternotomy: clinical utility of blood culture results in the identification of postoperative mediastinitis. Circulation 2003; 108:73.
- Maroto LC, Aguado JM, Carrascal Y, et al. Role of epicardial pacing wire cultures in the diagnosis of poststernotomy mediastinitis. Clin Infect Dis 1997; 24:419.
- Yu AW, Rippel RA, Smock E, Jarral OA. In patients with post-sternotomy mediastinitis is vacuum-assisted closure superior to conventional therapy? Interact Cardiovasc Thorac Surg 2013; 17:861.
- Deniz H, Gokaslan G, Arslanoglu Y, et al. Treatment outcomes of postoperative mediastinitis in cardiac surgery; negative pressure wound therapy versus conventional treatment. J Cardiothorac Surg 2012; 7:67.
- Segers P, Speekenbrink RG, Ubbink DT, et al. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA 2006; 296:2460.
- Bennett-Guerrero E, Ferguson TB Jr, Lin M, et al. Effect of an implantable gentamicin-collagen sponge on sternal wound infections following cardiac surgery: a randomized trial. JAMA 2010; 304:755.
- Braxton JH, Marrin CA, McGrath PD, et al. Mediastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg 2000; 70:2004.
- Karra R, McDermott L, Connelly S, et al. Risk factors for 1-year mortality after postoperative mediastinitis. J Thorac Cardiovasc Surg 2006; 132:537.
- Mekontso-Dessap A, Kirsch M, Brun-Buisson C, Loisance D. Poststernotomy mediastinitis due to Staphylococcus aureus: comparison of methicillin-resistant and methicillin-susceptible cases. Clin Infect Dis 2001; 32:877.
- Engemann JJ, Carmeli Y, Cosgrove SE, et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003; 36:592.
- Reddy SL, Grayson AD, Smith G, et al. Methicillin resistant Staphylococcus aureus infections following cardiac surgery: incidence, impact and identifying adverse outcome traits. Eur J Cardiothorac Surg 2007; 32:113.