Mediastinitis

Mediastinitis

No Results

No Results

processing….

Mediastinitis is a life-threatening condition that carries an extremely high mortality if recognized late or treated improperly. [1, 2, 3, 4] Although long recognized as a complication of certain infectious diseases, most cases of mediastinitis are associated with cardiac surgery (>300,000 cases per year in the United States). [4, 5] This complication affects approximately 1-2% of these patients. Although small in proportional terms, the actual number of patients affected by mediastinitis is substantial. This significantly increases mortality and cost.

After years of evolution, optimal therapy for mediastinitis is more clearly understood. Future directions for research should focus on prevention, including timely antibiotic administration, sterile technique, prophylactic measures such as topical bacitracin, and meticulous hemostasis. The focus should also include more accurate methods of diagnosis during the first 14 days after surgery, when computed tomography (CT) findings are not reliable.

However, the keys to successful management remain early recognition and aggressive treatment, including sternal reopening and debridement. Further research should also focus on the optimal timing and method of wound closure and the duration of antibiotic therapy required for optimal treatment.

The portion of the thorax defined as the mediastinum extends from the posterior aspect of the sternum to the anterior surface of the vertebral bodies and includes the paravertebral sulci when the locations of specific mediastinal masses are defined. It is limited bilaterally by the mediastinal parietal pleura and extends from the diaphragm inferiorly to the level of the thoracic inlet superiorly.

Traditionally, the mediastinum is artificially subdivided into three compartments (anterior, middle, and posterior) for better descriptive localization of specific lesions. When the location or origin of specific masses or neoplasms is discussed, the compartments or spaces are most commonly defined as follows:

Infection from either bacterial pathogens or more atypical organisms can inflame any of the mediastinal structures, causing physiologic compromise by compression, bleeding, systemic sepsis, or a combination of these.

The origin of infection following open heart operations is not known in most patients. Some believe that the process begins as an isolated area of sternal osteomyelitis that eventually leads to sternal separation. Others hold that sternal instability is the inciting event, and bacteria then migrate into deeper tissues. Inadequate mediastinal drainage in the operating room may also contribute to the development of a deeper chest infection.

The patient’s own skin flora and the bacteria in the local surgical environment are possible sources of infection as well. Because some bacterial contamination of surgical wounds is inevitable, host risk factors are likely critical in promoting an active infection.

Most cases of mediastinitis in the United States occur following cardiovascular surgery. Risk factors for the development of mediastinitis in this setting include the following:

A study by Perrault et al found that higher body mass index, higher creatinine level, the presence of peripheral vascular disease, preoperative corticosteroid use, and ventricular assist device or transplant surgery were all associated with an increased risk of mediastinal infection; in nondiabetic patients, postoperative hyperglycemia was associated with an increased infection risk. [13]

Additional causes include the following:

Most mediastinitis cases involve gram-positive cocci, [9] with Staphylococcus aureus [19] and Staphylococcus epidermidis accounting for 70-80% of cases (see the image below). [12] Mixed gram-positive and gram-negative infections account for approximately 40% of cases. Isolated gram-negative infections are rare causes.

Fibrosing mediastinitis is most commonly associated with Histoplasma capsulatum and Mycobacterium tuberculosis, though mediastinitis is an extremely rare complication of these infections. [16]

Acute mediastinitis has also been reported as a complication of Epstein-Barr virus infection. [20]

In the United States, mediastinitis most commonly occurs in the postoperative setting following CABG. [4]  The reported incidence of mediastinitis after cardiac surgery has ranged from 0.3% to 3.4%. [5]  At most large surgical centers, the incidence is in the range of 1-2%; however, certain subsets of patients, such as patients who have undergone a heart transplant, are at much higher risk.

The development of mediastinitis dramatically increases mortality. One study showed that postoperatively, a patient’s chance of dying was twice as high when mediastinitis developed as it was when mediastinitis was absent (12% vs 6%). In a review by Goh, in-hospital mortality for poststernotomy mediastinitis ranged from 1.1% to 19%. [5]  Some studies have reported death rates as high as 47%. Mediastinitis also raises the 2-year mortality from 2% to 8% following CABG.

Mediastinitis substantially lengthens the hospital stay as well. Patients with postoperative mediastinitis stay in the hospital six to seven times longer than those without the condition, and total costs may triple. [21]

Wiesemann S, Schmid S, Haager B, Passlick B. [Mediastinitis: Clinical Presentation and Therapy]. Zentralbl Chir. 2015 Oct. 140 Suppl 1:S8-15. [Medline].

Luckraz H, Murphy F, Bryant S, Charman SC, Ritchie AJ. Vacuum-assisted closure as a treatment modality for infections after cardiac surgery. J Thorac Cardiovasc Surg. 2003 Feb. 125(2):301-5. [Medline].

MacIver RH, Stewart R, Frederiksen JW, Fullerton DA, Horvath KA. Topical application of bacitracin ointment is associated with decreased risk of mediastinitis after median sternotomy. Heart Surg Forum. 2006. 9 (5):E750-3. [Medline].

Athanassiadi KA. Infections of the mediastinum. Thorac Surg Clin. 2009 Feb. 19(1):37-45, vi. [Medline].

Goh SSC. Post-sternotomy mediastinitis in the modern era. J Card Surg. 2017 Sep. 32 (9):556-566. [Medline].

Jayakrishnan AG, Allan A, Forsyth AT, Desai JB. Sternal wound infections and internal mammary artery grafts. J Thorac Cardiovasc Surg. 1993 Jul. 106(1):181-2. [Medline].

Toumpoulis IK, Theakos N, Dunning J. Does bilateral internal thoracic artery harvest increase the risk of mediastinitis?. Interact Cardiovasc Thorac Surg. 2007 Dec. 6 (6):787-91. [Medline].

Iribarne A, Westbrook BM, Malenka DJ, Schmoker JD, McCullough JN, Leavitt BJ, et al. Should Diabetes be a Contraindication to Bilateral Internal Mammary Artery Grafting?. Ann Thorac Surg. 2017 Dec 6. [Medline].

Farinas 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 Feb. 20(2):272-9. [Medline].

Milano CA, Kesler K, Archibald N, et al. Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival. Circulation. 1995 Oct 15. 92(8):2245-51. [Medline].

Ang LB, Veloria EN, Evanina EY, Smaldone A. Mediastinitis and blood transfusion in cardiac surgery: a systematic review. Heart Lung. 2012 May. 41 (3):255-63. [Medline].

Baldwin RT, Radovancevic B, Sweeney MS, et al. Bacterial mediastinitis after heart transplantation. J Heart Lung Transplant. 1992 May-Jun. 11(3 Pt 1):545-9. [Medline].

Perrault LP, Kirkwood KA, Chang HL, Mullen JC, Gulack BC, Argenziano M, et al. A Prospective Multi-Institutional Cohort Study of Mediastinal Infections After Cardiac Operations. Ann Thorac Surg. 2018 Feb. 105 (2):461-468. [Medline].

Shaffer HA, Valenzuela G, Mittal RK. Esophageal perforation. A reassessment of the criteria for choosing medical or surgical therapy. Arch Intern Med. 1992 Apr. 152(4):757-61. [Medline].

Sancho LM, Minamoto H, Fernandez A, et al. Descending necrotizing mediastinitis: a retrospective surgical experience. Eur J Cardiothorac Surg. 1999 Aug. 16(2):200-5. [Medline].

Loyd JE, Tillman BF, Atkinson JB, Des Prez RM. Mediastinal fibrosis complicating histoplasmosis. Medicine (Baltimore). 1988 Sep. 67(5):295-310. [Medline].

Voldby N, Folkersen BH, Rasmussen TR. Mediastinitis: A Serious Complication of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration. J Bronchology Interv Pulmonol. 2017 Jan. 24 (1):75-79. [Medline].

Jahoor A, Ghamande S, Jones S, Boethel C, White HD. Mediastinitis Following Endobronchial Ultrasound-guided Transbronchial Needle Aspiration. J Bronchology Interv Pulmonol. 2017 Oct. 24 (4):323-329. [Medline].

Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect. 2006 Oct. 64(2):162-8. [Medline].

Lloyd T, Tran VK. Acute Mediastinitis as a Complication of Epstein-Barr Virus. CJEM. 2016 Mar. 18 (2):149-51. [Medline].

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 Feb. 49(2):179-86; discussion 186-7. [Medline].

Maroto LC, Aguado JM, Carrascal Y, et al. Role of epicardial pacing wire cultures in the diagnosis of poststernotomy mediastinitis. Clin Infect Dis. 1997 Mar. 24(3):419-21. [Medline].

Jolles H, Henry DA, Roberson JP, et al. Mediastinitis following median sternotomy: CT findings. Radiology. 1996 Nov. 201(2):463-6. [Medline].

Peikert T, Colby TV, Midthun DE, Pairolero PC, Edell ES, Schroeder DR, et al. Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response. Medicine (Baltimore). 2011 Nov. 90(6):412-23. [Medline].

Saiki Y, Tabayashi K. [Use of a vacuum-assisted closure system for the treatment of mediastinitis after cardiac and aortic surgery]. Nippon Geka Gakkai Zasshi. 2009 Jan. 110(1):21-6. [Medline].

Noji S, Yuda A, Tatebayashi T, Kuroda M. Vacuum-assisted closure for postcardiac surgery mediastinitis in a patient on hemodialysis. Gen Thorac Cardiovasc Surg. 2009 Apr. 57(4):217-20. [Medline].

El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg. 1996 Mar. 61(3):1030-6. [Medline].

Kalweit G, Huwer H, Straub U, Gams E. Mediastinal compression syndromes due to idiopathic fibrosing mediastinitis–report of three cases and review of the literature. Thorac Cardiovasc Surg. 1996 Apr. 44(2):105-9. [Medline].

Vos RJ, Yilmaz A, Sonker U, Kelder JC, Kloppenburg GT. Vacuum-assisted closure of post-sternotomy mediastinitis as compared to open packing. Interact Cardiovasc Thorac Surg. 2012 Jan. 14 (1):17-21. [Medline].

Weinzweig N, Yetman R. Transposition of the greater omentum for recalcitrant median sternotomy wound infections. Ann Plast Surg. 1995 May. 34(5):471-7. [Medline].

Hountis P, Dedeilias P, Bolos K. The role of omental transposition for the management of postoperative mediastinitis: a case series. Cases J. 2009 Feb 23. 2(1):142. [Medline].

Chase CW, Franklin JD, Guest DP, Barker DE. Internal fixation of the sternum in median sternotomy dehiscence. Plast Reconstr Surg. 1999 May. 103(6):1667-73. [Medline].

Zec N, Donovan JW, Aufiero TX, et al. Seizures in a patient treated with continuous povidone-iodine mediastinal irrigation. N Engl J Med. 1992 Jun 25. 326(26):1784. [Medline].

Seferian A, Steriade A, Jaïs X, Planché O, Savale L, Parent F, et al. Pulmonary Hypertension Complicating Fibrosing Mediastinitis. Medicine (Baltimore). 2015 Nov. 94 (44):e1800. [Medline].

Gadek JE, DeMichele SJ, Karlstad MD, et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral Nutrition in ARDS Study Group. Crit Care Med. 1999 Aug. 27(8):1409-20. [Medline].

Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society

Disclosure: Received consulting fee from Provation Medical for writing.

Michael J Dacey, MD Consulting Staff, Department of Internal Medicine, Division of Critical Care, Kent County Hospital

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Mary C Mancini, MD, PhD, MMM Surgeon-in-Chief and Director of Cardiothoracic Surgery, Christus Highland

Mary C Mancini, MD, PhD, MMM 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

Disclosure: Nothing to disclose.

Benson B Roe, MD 

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, Society of University Surgeons

Disclosure: Nothing to disclose.

Mediastinitis

Research & References of Mediastinitis|A&C Accounting And Tax Services
Source