DOI: 10.1111/jocs.

13189

REVIEW ARTICLE

Post-sternotomy mediastinitis in the modern era

Siew S.C. Goh MBChB

Department of Cardiothoracic Surgery,

Liverpool Hospital, NSW, Australia
Correspondence
Siew S.C. Goh MBChB, Department of
Cardiothoracic Surgery, Liverpool Hospital,
NSW 2170, Australia.
Email: goh.sschristine@gmail.com
Abstract
Background: Post-sternotomy mediastinitis is associated with significant mortality and
morbidity. Despite surgical advances in cardiac surgery and improvements in
perioperative care, mediastinitis remains a devastating post-operative complication.
This study provides a comprehension review of post-sternotomy mediastinitis in the
modern era, and discusses the incidence, risk factors, microbiology, prevention, and
management of this complication.
Methods: This review was based on a PubMed/MEDLINE literature search up
until 9th March 2017 for publications relevant to mediastinitis post-cardiac
surgery.
Results: The incidence of mediastinitis post-cardiac surgery varies between 0.3 and
3.4%, and is associated with an in-hospital mortality ranging from from 1.1 to 19%. The
risk of developing post-operative mediastinitis is dependent on the patients’ co-
morbidities (diabetes, obesity, smoking, renal failure) and surgical techniques (bilateral
pedicled internal mammary harvest, excessive cautery, long duration of surgery).
Preventative measures including skin and nasal decontamination, antibiotic prophy-
laxis, strict glycemic control, and meticulous surgical techniques are crucial in reducing
the risk. Treatment of post-operative mediastinitis include culture-directed antibiotic
therapy, early wound exploration, and debridement followed by sternal reconstruc-
tion/closure. Vacuum-assisted therapy can be used as a single line therapy or as a
bridge to eventual sternal reconstruction/closure.
Conclusion: Post-sternotomy mediastinitis remains a potentially fatal complication of
cardiac surgery despite the advancements in the perioperative care in the modern era.
Management on preventative measures, prompt diagnosis, and managements are
crucial in reducing associated mortality and morbidity.

KEYWORDS
cardiac surgery, mediastinitis, sternal wound infections

1 | INTRODUCTION American Association for Thoracic Surgery (AATS) has recently

Despite advances in the perioperative care and infection control
practices, deep sternal wound infection (DSWI) or mediastinitis
continues to have a considerable impact on not only mortality and
morbidity but also length of hospital stay and associated health care
expenses. In response to these detrimental effects of DSWI, the
published expert consenus review guidelines for the prevention and
treatment of sternal wound infections in cardiac surgery.1 This review
will discuss the incidence and risk factors of DSWI in the modern era,
and associated morbidity and mortality of this complication. The
microbiology, preventative measures, and managements will also be
reviewed.

J Card Surg. 2017;1–11. wileyonlinelibrary.com/journal/jocs © 2017 Wiley Periodicals, Inc. | 1

2 | GOH

2 | M ATERIA LS AN D METH ODS
Available PubMed/MEDLINE literature was searched up until 9th
March 2017 using the terms “deep sternal wound infection” or
“mediastinitis,” “cardiac surgery,” “definition,” “risk factors,” “microbi-
ology,” “prevention,” and “management.” Titles and abstracts were
screened, and reference lists checked for relevant articles. Topics not
related to cardiac surgery and post-sternotomy were not included. This
review was reported according to the Preferred Reporting Items for
2
Systemic Reviews and Meta-Analyses (PRISMA) guidelines (Figure 1).
2.1 | Definition and classification
According to the definition by the hospital infection control practices
advisory committee, Centers for Disease Control and Prevention
(CDC), and the list of criteria for organ or space surgical-site infection
used by the National Nosocomial Infection Surveillance system of
CDC,3 DSWI must meet at least one of the following criteria: 1.
Organisms identified from culture of mediastinal tissue or fluid. 2.
Evidence of mediastinitis on gross anatomic or histopathologic
exam. 3. Patient has at least one of the following signs or symptoms:
fever (>38.0 °C), chest pain, or sternal instability with either purulent
drainage from the mediastinal area or mediastinal widening on imaging
studies.
There have been several classifications for DSWI. The first
classification was described by Pairolero and Arnold in 1984,4 based on
the length of time from surgery that the infection occurred,
subsequently El Oakley in 19965 used the same criteria, but added
factors for the establishment and treatment of the initial infection.
According to the CDC, the infection in surgical wounds after
sternotomy should be classified into three types: (A) surface when
only the skin and subcutaneous are involved; (B) superficial when the
infection reaches the sternum, but not directly involving the bone; and
(C) deep when there is sternum osteomyelitis and/or when there is
involvement of the mediastinum.6 These definitions clarify the site of
infection, but do not correlate with the extension beyond the sternum,
which is important in determining the variety of surgical techniques for
sternal closure and/or reconstruction. Anger and colleagues7 created a
classification based on the depth and anatomical extent of the wounds,
in recognition of the additional difficulty of reconstructing the lower
portion of the sternal wound when it extends below the insertion of
the lower border of the pectoralis major muscle. They also defined if

Records idenfied through Addional records idenfied

database searching through other sources

(n=146) (n=0)

Records aer duplicates removed

(n=146)

Records screened Records excluded

(n=146) (n=26)

Full-text arcles assessed for Full-text arcles excluded, with

eligibility reasons

(n=120) (n=26)

12 had majority of non-cardiac

paents
Studies included in qualitave
synthesis 14 were review arcles

(n=120)

Studies included in quantave

synthesis

(n=120)

FIGURE 1 PRISMA flow diagram

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the wound is partial or total in relation to its vertical extent and
position, using as a reference the inclusion of the lower margin of the
pectoralis major muscle.
2.2 | Incidence
The incidence of DSWIs are reported to be between 0.3 and 3.4%,
depending on various factors including the complexity of the surgical
procedures.8–20 Isolated valvular surgery was reported to have the
lowest rate of DSWI at 1.3%, followed by isolated coronary artery
bypass grafting (CABG) at 1.8%, isolated thoracic aortic surgery at
1.9%, concomitant CABG with valvular surgery at 2.8%, and
concomitant CABG with thoracic aortic surgery at 3.4%.20
2.3 | Risk factors
Identification of risk factors for the development of DSWI and the
optimization of the patient’s condition perioperatively is paramount to
reducing post-operative infections. Risk factors are generally catego-
rized into patient-related, operative factors, and environmental
elements. Patient-related risk factors for the development of DSWI
includes age, obesity, diabetes, history of smoking, and COPD, and
renal failure.8,11–13,16,17,19 Obesity is a strong risk factor for the
development of DSWI.21 Even though Body Mass Index (BMI) does not
correlate closely with body fat, there is a step-wise relationship
between BMI and the risk of major surgical infection in cardiac surgery.
Prabhakar et al22 reviewed a large patient cohort from the STS
database and found that the relative risk of deep sternal infections was
2.22 (95% confidence interval [CI] 2.01-2.45) in moderately obese
(BMI 35-39.9) patients and rose to 3.15 (95%CI 2.79-3.55) in
extremely obese (BMI ≥ 40) patients. This is related not only to
obesity-related technical problems, but also through less effective
penetration of antibiotics into the fat tissue.21,22 Another important
risk factor is diabetes. Diabetes is known to impair wound healing and
23
cellular as well as humoral immunity. Perioperative glycemic control
12
is important in reducing the development of DSWI. When diabetic
patients were managed with a continuous insulin infusion initiated
intra-operatively and maintained through the first two post-operative
days, the rate of DSWI was significantly reduced.24 Matros et al12
found a reduction in the incidence of DSWI from 1.57 to 0.88% in the
last 15 years, and in the diabetic population, from 3.2 to 1.0%, related
to strict perioperative glycemic control. Halkos and colleagues found
that pre-operative hemoglobinA1c (HbA1c) as predictor of adverse
outcomes after cardiac surgery. They found that pre-operative HbA1c
testing allows for more accurate risk stratification of diabetic patients
undergoing cardiac surgery and found a significantly increased risk of
DSWI for each unit increase in HbA1c.25
Poor nutritional status results in a higher risk of post-operative
infections. Nutritional status can be assessed using anthropometric
assessments such as unintentional weight loss and BMI, as well as
biochemical testing such as pre-operative albumin level. Van Venrooij
and colleagues studied the pre-operative nutritional status in 331
patients and found that a pre-operative unintentional weight loss of
| 3
10% within 6 months and BMI <21 are significantly associated with
post-operative infections.26 Potapov et al27 examined over 22,000
patients and found that post-operative infections was more common
among patients with a BMI below 20. Rapp-Kesek and colleagues28
studied 886 consecutive patients undergoing cardiac surgery and
found a low pre-operative level of albumin increased the risk of DSWI.
Yu et al29 showed a low pre-operative prealbumin level (<20 mg/dL) is
associated with 6-fold increase in post-operative infection (28.1% vs.
5.4%, P = 0.010).29 Several pre-operative screening tools are used to
identify patients at risk and to provide an opportunity to optimize pre-
operative nutritional status to reduce post-operative complications.
The Malnutrition Universal Screening Tool (MUST) includes three
components: BMI, unintended weight loss, and the expectation that
the presence of an acute disease will result in an absence of nutritional
intake for 5 days or more.30 The patient is defined as being at low risk
for malnutrition (MUST = 0), moderate risk for malnutrition
(MUST = 1), or high risk for malnutrition (MUST ≥ 2). Using this
screening tool, Chermesh et al31 identified up to 20% of their studied
population of over 400 patients had at least moderate risk for
malnutrition. They also identified a significant increased risk of post-
operative infection (12.5% vs. 4.5%, P = 0.02, odds ratio [OR] 3 CI 1.3–
7.2) in high-risk MUST patients. Pre-operative optimization of
nutritional status in patients undergoing cardiac surgery is therefore
paramount. The AATS consensus guideline recommends that surgery
should be postponed for patients with pre-operative hypoalbuminemia
to receive nutritional nutrition for 7-10 days if the procedure can be
safely delayed.1 It should be given through the enteral instead of
parenteral route, to avoid potential infections and metabolic
complications (Class I Recommendation).1 One prospective random-
ized trial showed that patients received 5 days of oral immune-
enhancing nutritional supplement containing L-arginine, omega-3
polyunsaturated fatty acids, and yeast RNA had improved pre-
operative host defenses as measured by serum immunological
variables and was associated with reduced post-operative infections.32
Marik et al33 performed a systematic review of 21 studies in more than
1,000 patients and found that immune-modulating diets of arginine
and fish oils reduced the risk of wound complications in high-risk
patients. Patient counseling and education involving a registered
dietitian to promptly perform a thorough nutrition assessment and
tailor an individualized plan of care is fundamental in optimizing the
pre-operative nutritional status of patients undergoing surgery.
Furthermore, the cardiac status of these patients must be stable
enough to allow surgery to be postponed during this time of pre-
operative nutritional support.
There are a number of surgical factors to be considered in reducing
DSWI. Internal mammary artery (IMA) harvesting techniques have
been correlated with the incidence of DSWI. When the IMA is
harvested in a pedicled fashion, there is a higher incidence of DSWI in
patients undergoing CABG.11,19 This risk becomes greater when
bilateral IMAs are used for revascularization or in the diabetic
population, but this effect is reduced when both IMAs are taken
down in a skeletonized fashion, even in diabetics.34,35 Other factor
such as re-exploration for bleeding has been reported as an
4 |
independent risk factor for DSWI.14,16,36 This may be related to the risk
of repeated bacteriological wound contamination inherent with a
repeat sternotomy, the negative wound healing effect of anemia, and/
36
or concomitant hemodynamic instability. Other factors considered
to increase the risk of DSWI include duration of surgery and
cardiopulmonary bypass time, emergency surgery, use of bone wax,
11–14,18,23,26
and excessive electrocautery.
2.4 | Microbiology and routes of infection
Gram-positive and gram-negative microorganisms both contribute to
the pathogenesis of DSWI. Staphylococci, either Staphylococci aureus
(S. aureus) or coagulase-negative Staphylococcus (CONS) represent the
most common organism of DSWI, accounting for 60-80% of cases.37–39
Mediastinitis caused by CONS is thought to be more commonly
associated with sternal instability.37 This is because CONS is a common
inhabitant of human skin and it is likely that DSWI caused by CONS
develops from a breach of the skin or subcutaneous infection in the
sternal wound which allows the infection to develop when an inoculum
of this organism enters the mediastinal space in the setting of a sternal
dehiscence.
S. aureus infection, unlike CONS, can occur without sternal
37
dehiscence. The nares of the patient has been suggested to be the
endogenous route of S.aureus infection.40,41 It is also suggested that
the presence of a surgeon who is a carrier and disseminator of S.aureus
in the operating theater could be a source of infections.42 These data
therefore suggest that S.aureus DSWI is due to perioperative
contamination and that post-operative infection may occur regardless
of sternal instability. Unlike S.aureus which causes a more aggressive
presentation, CONS infection has a more indolent course and is more
prone to recurrence.43
The other group of pathogens in DSWI are aerobic gram-negative
rods. The most common gram-negative microorganisms involved are
37
Klebsiella and Enterobacter species. These bacteria are mostly
translocated from other host site infections, such as pneumonia,
urinary, or abdominal infections.37,39,42
2.5 | Outcomes and cost
Mediastinitis post-cardiac surgery, even with the adoption of modern
11,13,14,17–19
treatments, varies between 1.1 and 19%. Hospital
mortality is frequently related to uncontrolled infection, sepsis, and
multi-organ failure.10,13,19Post-operative mediastinitis is associated
with a substantial deceased long-term survival compared with patients
without mediastinitis.8,10,13,16,19 Risnes and colleagues reported that
patients with mediastinitis had a 59% higher mortality risk compared
with those patients without mediastinitis over a 10-year period.10 It is
suggested that the chronic inflammatory process associated with
mediastinitis can increase thrombogenesis and thereby negatively
reduce the graft patency, contributing to the reduced long-term
survival.44 Pericardial and epicardial fibrosis after mediastinitis can also
cause constrictive physiology which also reduces long-term
survival.45,46
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In addition to increased mortality, DSWI is associated with
prolonged mechanical ventilation and hemodynamic support, renal
impairment, and arrhythmias.47 Predictors of poor outcomes in
patients with DSWI include length of intensive care unit stay, need
for late surgical revision, bacteremia, hemodynamic instability, and
prolonged mechanical ventilation.48,49
Post-operative DSWI is one of the most expensive complications.
In the US, the incidence of post-sternotomy mediastinitis is publicly
reported50 and the US Center for Medicine and Medicaid services will
no longer reimburse hospital costs incurred in the treatment of DSWI
after CABG.51 Patients with post-operative mediastinitis are 2-3 times
more expensive to manage compared with patients without this
complication.13,14,52 Hollenbeak et al14 reported that patients with
post-operative DSWI accumulated an average of 20 additional hospital
stays and cost $20,012 more in the first year. In their study, the 1-year
mortality was significantly higher in patients with a post-operative
DSWI (22% vs. 0.6%, P = 0.0001). The average cost for patients with
DSWI who survived was approximately $20,927 USD, while the
average cost for patients who died was $81,474 USD. Therefore, while
22% of patients with DSWI died, these patients incurred approxi-
mately 74% of the total excess costs attributable to post-operative
DSWI.14 Other studies have also demonstrated increased health care
costs associated with DSWI related to prolonged length of ICU and
hospital stay, repeated surgical procedures including debridement, and
reconstruction/closure.13,14,52,53
2.6 | Prevention
Perioperative prevention strategies entail modifying the patient’s risk
factors (diabetes, obesity, respiratory insufficiency), preparing the
patient’s skin (body hair, pre-operative showering, operating site
antiseptic treatment), antimicrobial prophylaxis, environmental control
of the operating room and medical devices, and implementing proper
surgical techniques (Table 1).
2.6.1 | Modification of patient risk factors
Diabetes is a well-known risk factor for all infections. Both long- and
short-term controls of blood glucose levels are essential in reducing
the risk of DSWI. Zerr et al54 reported the effect of glycemic control on
the incidence of DSWI and the positive effect of the implementation of
post-operative insulin protocals in diabetic patients on the incidence of
infections. In this study, sternal wound infections increased from 1.3%
in patients with mean glucose values of 100-150 mg/dL to 6.7%
in patients with levels of 250-300 mg/dL. The institution of insulin
protocols resulted in a decrease in blood glucose levels for the first two
post-operative days and a concomitant decrease in the proportion of
patients with deep wound infections, from 2.4 to 1.5% (P < 0.02).54 In
the Society of Thoracic Surgeons practice guidelines on blood glucose
management during adult cardiac surgery, it is a Class I recommenda-
tion that the blood glucose level of patients with diabetes should be
maintained at <180 mg/dL during cardiac surgery, with continuous
insulin infusions rather than intermittent subcutaneous or intravenous
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TABLE 1 Summary of pre-operative, intra-operative, and post-operative strategies to prevent and manage sternal wound infections
Prevention
Pre-operative
Nasal swabs or PCR testing if available should be done on all cardiac surgery patients
Administer intranasal mupirocin within 24 h of surgery and continue for 5 days in all patients in the absence of negative PCR testing or a negative
nasal swab for staphylococcal organisms
Perform a chlorhexidine bath or shower on the evening before surgery
Patients with preoperative hypoalbuminemia should have their surgery postponed to receive enteral nutrition for 7-10 days if the procedure can be
safely delayed
Patients with increased HbA1c levels (≥7%) and serum glucose levels >180 mg/dL should have their blood glucose level optimized prior to surgery
using intravenous insulin infusions
Intraoperative and post-operative
Intravenous antibiotics should be given within 60 min before the skin incision and be continued for no longer than 48 h. The dosing of the antibiotics
should be weight based and to be repeated for procedures longer than 4 h.
Vancomycin should not be used as the sole prophylactic antibiotic for cardiac surgical procedures. An aminoglycoside should be added for gram-
negative coverage when vancomycin is the primary prophylactic antibiotic.
Topical antibiotics should be applied to the cut edges of the in all patients undergoing sternotomy for cardiac procedures
Bone wax should not be applied to the cut edges of the sternum at any time
Closing a sternum with multiple fractures using the Robicsek weave technique may prevent sternal dehiscence and wound infection
Meticulous scrubbing, careful prepping with skin disinfection agents, mid-line sternotomy, careful handling of soft tissue, checking for glove injury,
and leaving the closed wound covered for at least 48 h
Consider skeletonized IMA harvest if bilateral IMAs are used as conduits, especially in diabetic patients
The blood glucose level of patients with diabetes should be maintained at 180 mg/dL during cardiac surgery, with continuous insulin infusions rather
than intermittent subcutaneous or intravenous insulin injections, for at least 24 h post-operatively
Management
Negative pressure wound therapy should be initiated whenever possible in patients when delayed sternal closure is anticipated following deep sternal
wound infections
A dressing barrier between the sponge and heart and great vessels is useful when using negative pressure wound therapy to prevent fatal
hemorrhage

insulin injections, for at least 24 h post-operatively.55 Furnary et al24
showed that a continuous insulin infusion post-operatively to maintain
a serum glucose level of 120-150 mg/dL led to a significant decrease in
the incidence of DSWI in diabetics (0.8-2%, P = 0.01) and perioperative
mortality (1.9 vs. 4.5%, P < 0.0001) compared with subcutaneously
administered insulin. Lazar et al56 showed that in diabetic CABG
patients receiving glucose-insulin-potassium infusions had signifi-
cantly less infections (0% vs. 13%, P = 0.01) compared to patients
treated with intermittent subcutaneous insulin injections.
2.6.2 | Antibiotic prophylaxis
Antibiotic prophylaxis and patient decontamination have been proven to
be effective in reducing DSWI. Since Staphylococcal species are a major
causative pathogen, beta-lactam antibiotics are recommended for
prophylaxis, particularly first- or second-generation cephalosporins. It is
a Class I recommendation from the STS practice guideline that the
antibiotics should be given intravenously within 60 min before the skin
incision and be continued for no longer than 48 h.57 The dosing of the
antibiotics should be weight based and to be repeated for procedures
lasting longer than 4 h.57 Given the emergence of resistant Staphylococcus,
the routine use of glycopeptides as prophylaxis is controversial. A meta-
analysis by Saleh et al showed that glycopeptides reduced the risk of
resistant Staphylococcal DSWI by 51% (RR0.49, 95%CI 0.24-0.99,
P = 0.05) and enterococcal DSWI by 72% (RR0.28; 95%CI 0.10-0.74,
P = 0.01).58 Beta-Lactams, however, showed superiority in reducing
superficial chest, deep chest, susceptible Staphylococcal, and respiratory
tract infections.58 Since glycopeptides have no effect on gram-negative
flora, its usefulness as an exclusive agent in cardiac surgical prophylaxis is
not recommended and should only be used as an adjuvant agent.59 The
STS practice guideline recommends that aminoglycosides should be added
when vancomycin is the primary prophylactic antibiotic.57
The duration of antibiotic prophylaxis remains controversial. A
number of factors should be taken into consideration when
determining the duration of effective antibiotic prophylaxis. The
prolonged use of antibiotics increase the development of resistant
bacterial strains and potential superinfection. This adverse effect was
demonstrated by Harbarth and colleagues60 in an observational study
of 2,641 patients undergoing CABG. They reported that antibiotic
prophylaxis more than 48 h increased antimicrobial resistance. At the
same time, no clinical advantage was demonstrated with administra-
tion of prophylactic antibiotics for more than 48 h in that study. This
6 |
finding is further supported by others.61–63 Jewell and colleagues61
found no difference in infectious rate when they randomized 200
CABG patients into a group receiving 48 h of intravenous cephalothin
or a group receiving 3 days of oral cephalexin. Saginur et al63 compared
one dose of teicoplanin versus 2 days of cephazolin in 3,027 patients
and found that the 2-day use of cephazolin was associated with lower
deep sternal wound infection.63 A meta-analysis performed by Kreter
62
et al demonstrated a significant reduction in surgical infections
associated with the use of prophylactic antibiotics but no clinical
benefit was demonstrated with the use of prophylactic antibiotics for
more than 48 h.62 After an extensive review of clinical trials, Ariano and
Zhanel recommended the use of prophylactic antibiotics for only
48 h.64 To date there is no evidence to suggest that prophylactic
antibiotics use of less than 48 h are associated with antimicrobial
resistance. Based on these evidence, the STS practice guideline has
recommended antibiotic prophylaxis for no more than 48-h for cardiac
surgery (Class I Recommendation).57
The use of topical antibiotics over the sternal edges intra-
operatively have been demonstrated to be effective in reducing the
risk of DSWI.65–67 In a large multicenter retrospective analysis of
6,960 patients, the topical spraying of antibiotics was found to
significantly reduce the incidence of DSWI (0.46% vs. 1.7%,
P < 0.0001). In this study, the topical solution was made of 1-g
cephazolin and 40-mg gentamicin in 40 mls of normal saline which was
65
sprayed multiple times during the surgery. In another study, 2,000
patients were randomized to routine prophylaxis with intravenous
antibiotics alone (control group) or intravenous antibiotics combined
with application of collagen-gentamicin (260-mg gentamicin) sponges
within the sternotomy before wound closure. There was a significant
reduction in all sternal wound infections (4.7% vs. 9%, RR0.47 95%CI
0.33-0.68, P < 0.001) and DSWI in high-risk patients (Diabetes and
BMI >25) (2.44% vs. 4.37%, RR0.56 95%CI 0.31-1.00, P < 0.05).66 The
positive effect of gentamycin sponge use was further substantiated by
a meta-analysis performed by Kowalewski et al,68 which included a
total of 14 studies of 22,135 patients, of which four were randomized
68
controlled trials with 4,672 patients. They confirmed that the topical
use of a gentamicin sponge significantly reduced the risk of
mediastinitis by 36% compared with the control group (RR0.64;
95%CI 0.45-0.91; P = 0.01).68 Vancomycin has also been used to
69
reduce DSWI. Vander Salm and colleagues, in a prospective,
randomized study, demonstrated that topical application of vancomy-
cin paste to the cut sternal edges resulted in a significant decrease in
DSWI (0.45% vs. 3.6%, P = 0.02).69 Lazar and colleagues70 studied the
effect of topical vancomycin to reduce the incidence of sternal wound
infections in the presence of peri-operative intravenous antibiotics and
tight glycemic control. In this study, superficial sternal infections (0% vs
. 1.6%; P < 0.0001), deep sternal infections (0% vs. 0.7%;P = −.005), and
any type of sternal infection (0% vs. 2.2%; P < 0.0001) were
significantly reduced in patients receiving topical vancomycin. “These
beneficial effects were also noted in patients with diabetes (0% vs.
3.3%; P = 0.0004).” In another study, Lazar et al67 demonstrated that
the use of topical vancomycin did not increase levels of serum
vancomycin following cardiac surgical procedures, nor did it potentiate
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the emergence of drug-resistant infections or contribute to post-
operative renal toxicity. Another topical agent, the autologous
platelet-rich plasma, has been reported to reduce the risk of DSWI.
The platelet-rich plasma, which is derived from plasmapheresis of the
patient’s own blood, is rich in growth factors and cytokines and is
thought to promote tissue healing and regeneration. Recently a meta-
analysis performed by Kirmani et al71 showed that the use of platelet
gel significantly reduced DSWI (OR 2.69 CI 1.20-6.06, P = 0.02). The
use of topical antibiotics on sternal edges is recommended (Class I
Recommendation) in all patients undergoing sternotomy for cardiac
procedures.1
2.6.3 | Skin and nasal decontamination
In addition to antibiotic prophylaxis, skin, and nasopharyngeal
decontamination have also contributed to decreased DSWI. The use
of chlorhexidine skin wash before surgery showed a significant
reduction in the bacterial load.72 The use of mupirocin has been
demonstrated to be effective in reducing sternal wound infections,
including diabetic patients.73,74
Nasal carriage of S. aureus is a risk factor for development of DSWI.
Several studies have shown a correlation between the colonization
density of S. aureus at the carriage site and the risk for the development
of infection.40,75 Kluytmans et al40 confirmed that in patients who
developed DSWI and had positive pre-operative S. aureus nasal
cultures, the phage typing showed that the S. aureus isolates from
the nasal swabs and sternal wound cultures were identical.
Mupirocin is a self-administered topical antibiotic that is highly
effective in eradicating nasal S. aureus, including MRSA.76,77 It is a
naturally occurring antibiotic produced by a fermentation of Pseudo-
monas bacteria mixed in a nonirritating paraffin composition. Its
specific mechanism of action is to bind to isoleucyl-transfer RNA
synthetase and inhibit protein syntheses.78 Mupirocin is used topically
due to extensive systemic metabolism and is 80-90% effective in
eradicating Staphylococcus from the nasopharyngeal mucosa79 but
only 45-50% for MRSA organisms. Short-term therapy (a 5-day course)
has been shown to be highly effective.76 The STS guidelines
recommend beginning treatment after a positive culture beginning
24 h prior to and for 5 days following surgery.59
Recently Del Diego Salas et al80 performed an economic analysis
of universal mupirocin prophylaxis against surgical site infection for
cardiac surgery. In the study, two protocols were applied: (1) where
only patients tested positive to MRSA colonization received muripocin,
twice a day during a two-week period; and (2) where all patients
received the mupirocin treatment. They concluded that universal use
of mupirocin as prophylaxis is associated with a lower incidence of
infections and cost savings, versus the strategy to treat patients
selectively according to the results of their nasal culture.
Of concern is whether resistance would develop with the use of
mupirocin in all pre-operative patients. The STS Practice Guidelines
recommends using a polymerase chain reaction (PCR) rapid analysis
and treatment of only positive cultures, but in absence of the rapid PCR
test, the recommendation remains routine prophylaxis for all patients
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with mupirocin.59 Fawley et al81 published the results of a 4-year
prevalence study on the use of short-term, empirical, pre-operative
prophylaxis use of mupirocin at three hospitals. While no mupirocin-
resistance isolates was found, they did find that mupirocin was
effective in reducing the incidence of nasal carriage of MRSA and S.
aureus at long-term follow-up.
Effective screening, rapid detection, isolation, and treatment of
MRSA carriers are important considerations for MRSA control.
Screening for MRSA via conventional culture-based detection
methods is time-consuming and often leads to delayed or unnecessary
isolation precautions. The time from culture inoculation to identifica-
tion of MRSA is typically between 48 and 96 h, and the sensitivity of
any single selective medium method ranges between 65 and 100%.82
Real-time PCR, on the other hand, detects the mecA gene which
mediates methicillin resistance and offers results within 1-2 h with
more than 90% of both sensitivity and specificity.83 The use of this
molecular real-time assay therefore allows a more efficient and
effective MRSA control in our surgical patients. The AATS recom-
mends that all cardiac surgery patients should have nasal swabs or PCR
testing, if available, before surgery and that routine mupirocin
administration is recommended for all cardiac surgery procedures in
the absence of PCR testing or nasal cultures positive for staphylococcal
colonization (Class I Recommendation).1
2.6.4 | Surgical techniques
Surgical technique plays an important role in the risk of DSWI. This
includes meticulous scrubbing practice, careful prepping with skin
disinfection agents, mid-line sternotomy, careful handling of soft
tissue, checking for glove injury, and leaving the closed wound covered
for at least 48 h.84 The use of bone wax should be minimized. Bone wax
is a well-known topical hemostatic agent composed of beeswax and
Vaseline. Its hemostatic effect is based on physical rather than
biochemical properties, by sealing the oozing from open bone marrow
post-sternotomy. The use of bone wax for hemostasis has been
questioned due to the increased risk of sternal infection post-cardiac
surgery. It was shown to inhibit osteoblastic activity, bone healing, and
85
osteogenesis. Bone wax is neither reabsorbed nor metabolized; it
persists for up to 10 years after application and acts as foreign material
that results in foreign body reactions and serve as a niche for
microorganism and subsequent infections.86,87 The use of bone wax on
the cut edges of the sternum is not recommended by the AATS
1
consensus guidelines (Class III Recommendation).
IMAs has been shown to increase the risk of DSWI.11,19,34 The
conventional pedicled IMA harvest dissects the artery along with its
accompanying veins, fascia, adipose tissue, and lymphatics from the
sternum and has been shown to decrease sternal blood flow by up to
90% and significantly increase the risk of DSWI, especially in diabetic
88,89
patients. This risk, however, is reduced considerably when the
IMA is taken down in a skeletonized fashion compared to a pedicle
34,35,89
graft.
Stable sternal approximation and closure plays an important role
in preventing DSWI. A figure-of-eight wire closure technique may be
| 7
preferable over simple cerclage technique as it reduces the
longitudinal motion at the sternotomy site and hence potentially
reduces sternal dehiscence.1 Moreover, figure-of-eight cables are
more flexible than the wires and conform more tightly to the
sternum and thereby providing more stability.1 Traditional standard
sternal wire cerclage, if performed well, is easy and effective.
However, with an increasing number of patients with risk factors
such as obesity and chronic obstructive pulmonary disease and/or
poor sternal quality in elderly patients, modification in the
techniques of sternal closure including Robiscek’s parasternal wire
reinforcement has been proposed.90 In 1977, Robicsek et al91
reported a weaving technique to prevent and treat sternal
dehiscience following sternotomy. They reported satisfactory out-
comes in a series of eight patients, of which five had the weave at
the time of operation, one had sterile sternal dehiscence post-
operatively, and two had post-operative sternal infections. The
procedure involves continuous wire sutures placed parasternally on
both sides of the sternum, passing alternating anteriorly and
posteriorly to the costal cartilages down from the manubrium to
the xiphoid process. The wire suture is then reversed and led
cranially, passing the cartilages posteriorly where it had been
anterior and vice versa. The two ends of the wires then are tied
together at the upper end. This weave is done bilaterally, followed by
a number of peristernal wires in the routine manner, passing lateral
to the continuous parasternal wire sutures but medial to the internal
mammary vessels. The Robicsek weave has been reported to be an
effective treatment for post-operative sternal dehiscence as well as
prophylaxis in high-risk patients to prevent non-infectious dehis-
cence.92,93 In the setting of closing a sternum with multiple fractures,
the AATS recommends the use of Robicsek weave technique to
prevent dehiscence and wound infections (Class IIa Recommenda-
tion) Other closure systems such as sternal plating, thermoreactive
nitinol clips, titanium locked staplers which are designed for
parasternal fixation, have not been consistently shown to reduce
the risk of DSWI.94–96 The application of negative pressure wound
therapy (NPWT) on clean surgically closed sternal wounds is
becoming popular especially in obese patients. Prevena® Incision
Management System (Acelity, San Antonio, TX) is an example of
NPWT which is commercially available.97 Proposed benefits of this
system include a reduction of skin tension, additional barrier to
external environment, decreased tissue edema, and promotion of
microvascular flow.98 Early clinical experience demonstrated no
wound-healing complications in patients at high risk for sternal
wound infections after cardiac surgery99,100; however, this requires
further evaluation through randomized trials.
3 | MANAGEMENT
Once DSWI is diagnosed, empiric antibiotic therapy is initiated to
include broad-spectrum coverage against methicillin-resistant gram-
positive, gram-negative, and anaerobic organisms. Culture-directed
therapy should be initiated as soon as microbiological sensitivity is
8 |
available. It should be noted that continuous mediastinal irrigation with
povidone-iodine solution should be avoided due to potential systemic
absorption with resultant renal failure, electrolyte disturbances, and
changes in iodine metabolism.1
Treatment of any DSWI consists of early wound exploration
followed by reconstruction or direct closure. These include, but are not
limited to, vacuum-assisted closure, various flap coverage using
omentum, pectoralis major muscle, the rectus abdominus muscle,
the latissimus dorsi muscle, the microsurgical free flap, and various
combinations of the above. Sternal fixation with sternal plating
systems has also been reported.101,102
Currently, the procedure of choice to treating DSWI is early
wound exploration, followed by vacuum-assisted closure (VAC)
therapy, either as a definitive treatment or as a bridge to reconstruc-
tion and/or closure once the wound is deemed suitable. It is a Class IIa
recommendation by the AATS that NPWT should be initiated
whenever possible in patients in whom delayed sternal closure is
1
anticipated following DSWI. Vacuum-assisted closure has been
shown to increase peristernal blood flow by increasing arteriolar
dilatation, reduce bacterial load, promote granulation tissue formation,
and facilitate approximation of sternal wound edges.103–105 Several
studies report excellent outcomes with the use of VAC in DSWI. The
use of VAC has been shown to be beneficial in terms of respiratory
function and hemodynamics in patients with an open chest,104,106 and
is associated with improved survival in patients with DSWI.107,108
Baillot et al106 reported a 15-year review of 25,000 sternotomies,
observing that the use of VAC is associated with a significant reduction
in hospital (4.8% vs. 14.1%, P = 0.01) and midterm (61% vs. 88%,
P = 0.02) mortality. In addition to being used as a bridge to
reconstruction or closure, complete sternal wound healing with VAC
use has been reported.109 Negative blood cultures, wound depth less
than 4 cm, and a low degree of bony exposure and sternal instability,
are more likely to be associated with successful single VAC therapy
alone.110 The duration of VAC therapy is uncertain. Short-term use of
VAC (<3 weeks) followed by early direct sternal closure has been
recommended.9
Complications with VAC use is infrequent but includes a possible
increased risk of bleeding and damage to underlying tissues, in
particular the potentially fatal complication of right ventricular (RV)
rupture.111 The proposed mechanisms for bleeding include infec-
tious erosion of vessels112 or a combination of mechanical trauma
and compromised RV wall integrity in the case of right ventricular
rupture.113,114 Conditions that promote a compromised integrity of
the RV wall include RV ischemia/infarction with thinning/dilatation
of the RV wall, inflammation in the setting of mediastinitis, and
surgical trauma.115 When the anterior RV wall is adherent to the
dehisced sternum, the outward and inward movement of the
adherent and relatively fixed RV wall can rupture during ventila-
tion.116 This is especially noted with the sudden increases in the
intrathoracic pressure during coughing and vomiting.117 Dislodge-
ment and penetration of bony fragments and sharp sternal edges can
also contribute to bleeding and RV rupture.118 Several measures
have been suggested to reduce these complications associated with
GOH
VAC therapy. During the initial debridement, it is important to
meticulously remove any sharp bony periosteal fragments and all
sternal wires. Mobilization of the RV from the sternal edges on initial
debridement is beneficial114 but paradoxically can precipitate
hemorrhage. Interface dressings protect the RV from friction and
shearing forces from the raw sternal edges and reduced suction
pressure on the heart.119,120 The highest mean decrease in pressure
occurred with the use of paraffin-impregnated gauze due the pores
in the foam being blocked. Malmsjo and colleagues120 in an animal
study demonstrated that wound contraction seems to be observed
at relatively low levels of pressure −40 to −80 mmHg and additional
negative pressure does not further increase wound contraction. In
this study, greater wound contraction was found when foam was
used instead of gauze but that there is less damage to the heart
when using gauze than foam. Therefore the use of gauze may be
more appropriate in addition to the use of interface dressing when
the underlying tissue is fragile. In terms of the negative pressure
setting, it was recommended that the suction be reduced
from −125 mmHg to −70 mm Hg after 72 h of treatment.114
4 | CONCL US IO N
Post-sternotomy mediastinitis remains a potentially fatal complication
of cardiac surgery despite the advancements in the perioperative care
in the modern era. However, the institution of pre-operative, intra-
operative, and post-operative strategies noted in this review, and from
the recent AATS practice guidelines summarized in Table 1, have been
shown to significantly decrease the incidence, morbidity, and mortality
of this dreaded complication.
CONFLICT OF I NTEREST
None declared.
ORCID
Siew S.C. Goh http://orcid.org/0000-0001-9462-2086
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How to cite this article: Goh SS. Post-sternotomy
mediastinitis in the modern era. J Card Surg. 2017;1–11.
https://doi.org/10.1111/jocs.13189