Treatment of Acute Mediastinitis in Deep Sternal Wound Infection Following Median Sternotomy with Purulent Drainage

Deep sternal wound infection (DSWI) with purulent mediastinitis is a life-threatening complication of median sternotomy. When local wound signs and systemic inflammation are present, a structured, multi-modal treatment approach is required.

Clinical scenario

Deep sternal wound infection following median sternotomy
Purulent drainage from the sternal wound
Sternal instability
Fever

Treatment approach

Management centres on intravenous antibiotic therapy initiated promptly, with agent selection guided by antimicrobial susceptibility testing once results are available. Surgical intervention — including wound debridement — is considered necessary, combined with negative pressure wound therapy.

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References

DOI: 10.1093/ejcts/ezw326

Mediastinitis and deep sternal wound infection (DSWI) are devastating and life-threatening complications after median sternotomy.

Signs and symptoms of mediastinitis typically present within 30 days of cardiac surgery.

Local signs include purulent drainage from the sternal wound and sternal instability.

Sternal SSI is therefore initially treated with IV antibiotics.

As Coagulase-negative Staphylococcus (CoNS) is often multiresistant and MRSA is common in some centres, first-line antibiotic treatment is commonly IV vancomycin, until results from antimicrobial susceptibility tests become available.

Cloxacillin and other beta-lactamase-resistant staphylococcal antibiotics are commonly used when infection with either S. aureus or CoNS has been established.

Although the most appropriate surgical approach for the treatment of sternal SSI is still debated, there is a consensus that at least wound debridement is necessary.

Negative pressure wound therapy is recommended either as a destination or as a bridge prior to final surgical closure in cases of post-sternotomy mediastinitis.

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