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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 Abstract
Background: Post-sternotomy mediastinitis is associated with significant mortality and
Correspondence
Siew S.C. Goh MBChB, Department of morbidity. Despite surgical advances in cardiac surgery and improvements in
Cardiothoracic Surgery, Liverpool Hospital,
perioperative care, mediastinitis remains a devastating post-operative complication.
NSW 2170, Australia.
Email: goh.sschristine@gmail.com 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


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

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


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


GOH | 3

the wound is partial or total in relation to its vertical extent and 10% within 6 months and BMI <21 are significantly associated with
position, using as a reference the inclusion of the lower margin of the post-operative infections.26 Potapov et al27 examined over 22,000
pectoralis major muscle. 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
2.2 | Incidence
found a low pre-operative level of albumin increased the risk of DSWI.
The incidence of DSWIs are reported to be between 0.3 and 3.4%, Yu et al29 showed a low pre-operative prealbumin level (<20 mg/dL) is
depending on various factors including the complexity of the surgical associated with 6-fold increase in post-operative infection (28.1% vs.
procedures.8–20 Isolated valvular surgery was reported to have the 5.4%, P = 0.010).29 Several pre-operative screening tools are used to
lowest rate of DSWI at 1.3%, followed by isolated coronary artery identify patients at risk and to provide an opportunity to optimize pre-
bypass grafting (CABG) at 1.8%, isolated thoracic aortic surgery at operative nutritional status to reduce post-operative complications.
1.9%, concomitant CABG with valvular surgery at 2.8%, and The Malnutrition Universal Screening Tool (MUST) includes three
concomitant CABG with thoracic aortic surgery at 3.4%.20 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
2.3 | Risk factors
for malnutrition (MUST = 0), moderate risk for malnutrition
Identification of risk factors for the development of DSWI and the (MUST = 1), or high risk for malnutrition (MUST ≥ 2). Using this
optimization of the patient’s condition perioperatively is paramount to screening tool, Chermesh et al31 identified up to 20% of their studied
reducing post-operative infections. Risk factors are generally catego- population of over 400 patients had at least moderate risk for
rized into patient-related, operative factors, and environmental malnutrition. They also identified a significant increased risk of post-
elements. Patient-related risk factors for the development of DSWI operative infection (12.5% vs. 4.5%, P = 0.02, odds ratio [OR] 3 CI 1.3–
includes age, obesity, diabetes, history of smoking, and COPD, and 7.2) in high-risk MUST patients. Pre-operative optimization of
renal failure.8,11–13,16,17,19 Obesity is a strong risk factor for the nutritional status in patients undergoing cardiac surgery is therefore
development of DSWI.21 Even though Body Mass Index (BMI) does not paramount. The AATS consensus guideline recommends that surgery
correlate closely with body fat, there is a step-wise relationship should be postponed for patients with pre-operative hypoalbuminemia
between BMI and the risk of major surgical infection in cardiac surgery. to receive nutritional nutrition for 7-10 days if the procedure can be
Prabhakar et al22 reviewed a large patient cohort from the STS safely delayed.1 It should be given through the enteral instead of
database and found that the relative risk of deep sternal infections was parenteral route, to avoid potential infections and metabolic
2.22 (95% confidence interval [CI] 2.01-2.45) in moderately obese complications (Class I Recommendation).1 One prospective random-
(BMI 35-39.9) patients and rose to 3.15 (95%CI 2.79-3.55) in ized trial showed that patients received 5 days of oral immune-
extremely obese (BMI ≥ 40) patients. This is related not only to enhancing nutritional supplement containing L-arginine, omega-3
obesity-related technical problems, but also through less effective polyunsaturated fatty acids, and yeast RNA had improved pre-
penetration of antibiotics into the fat tissue.21,22 Another important operative host defenses as measured by serum immunological
risk factor is diabetes. Diabetes is known to impair wound healing and variables and was associated with reduced post-operative infections.32
23
cellular as well as humoral immunity. Perioperative glycemic control Marik et al33 performed a systematic review of 21 studies in more than
12
is important in reducing the development of DSWI. When diabetic 1,000 patients and found that immune-modulating diets of arginine
patients were managed with a continuous insulin infusion initiated and fish oils reduced the risk of wound complications in high-risk
intra-operatively and maintained through the first two post-operative patients. Patient counseling and education involving a registered
days, the rate of DSWI was significantly reduced.24 Matros et al12 dietitian to promptly perform a thorough nutrition assessment and
found a reduction in the incidence of DSWI from 1.57 to 0.88% in the tailor an individualized plan of care is fundamental in optimizing the
last 15 years, and in the diabetic population, from 3.2 to 1.0%, related pre-operative nutritional status of patients undergoing surgery.
to strict perioperative glycemic control. Halkos and colleagues found Furthermore, the cardiac status of these patients must be stable
that pre-operative hemoglobinA1c (HbA1c) as predictor of adverse enough to allow surgery to be postponed during this time of pre-
outcomes after cardiac surgery. They found that pre-operative HbA1c operative nutritional support.
testing allows for more accurate risk stratification of diabetic patients There are a number of surgical factors to be considered in reducing
undergoing cardiac surgery and found a significantly increased risk of DSWI. Internal mammary artery (IMA) harvesting techniques have
DSWI for each unit increase in HbA1c.25 been correlated with the incidence of DSWI. When the IMA is
Poor nutritional status results in a higher risk of post-operative harvested in a pedicled fashion, there is a higher incidence of DSWI in
infections. Nutritional status can be assessed using anthropometric patients undergoing CABG.11,19 This risk becomes greater when
assessments such as unintentional weight loss and BMI, as well as bilateral IMAs are used for revascularization or in the diabetic
biochemical testing such as pre-operative albumin level. Van Venrooij population, but this effect is reduced when both IMAs are taken
and colleagues studied the pre-operative nutritional status in 331 down in a skeletonized fashion, even in diabetics.34,35 Other factor
patients and found that a pre-operative unintentional weight loss of such as re-exploration for bleeding has been reported as an
4 | GOH

independent risk factor for DSWI.14,16,36 This may be related to the risk In addition to increased mortality, DSWI is associated with
of repeated bacteriological wound contamination inherent with a prolonged mechanical ventilation and hemodynamic support, renal
repeat sternotomy, the negative wound healing effect of anemia, and/ impairment, and arrhythmias.47 Predictors of poor outcomes in
36
or concomitant hemodynamic instability. Other factors considered patients with DSWI include length of intensive care unit stay, need
to increase the risk of DSWI include duration of surgery and for late surgical revision, bacteremia, hemodynamic instability, and
cardiopulmonary bypass time, emergency surgery, use of bone wax, prolonged mechanical ventilation.48,49
11–14,18,23,26
and excessive electrocautery. 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
2.4 | Microbiology and routes of infection
no longer reimburse hospital costs incurred in the treatment of DSWI
Gram-positive and gram-negative microorganisms both contribute to after CABG.51 Patients with post-operative mediastinitis are 2-3 times
the pathogenesis of DSWI. Staphylococci, either Staphylococci aureus more expensive to manage compared with patients without this
(S. aureus) or coagulase-negative Staphylococcus (CONS) represent the complication.13,14,52 Hollenbeak et al14 reported that patients with
most common organism of DSWI, accounting for 60-80% of cases.37–39 post-operative DSWI accumulated an average of 20 additional hospital
Mediastinitis caused by CONS is thought to be more commonly stays and cost $20,012 more in the first year. In their study, the 1-year
associated with sternal instability.37 This is because CONS is a common mortality was significantly higher in patients with a post-operative
inhabitant of human skin and it is likely that DSWI caused by CONS DSWI (22% vs. 0.6%, P = 0.0001). The average cost for patients with
develops from a breach of the skin or subcutaneous infection in the DSWI who survived was approximately $20,927 USD, while the
sternal wound which allows the infection to develop when an inoculum average cost for patients who died was $81,474 USD. Therefore, while
of this organism enters the mediastinal space in the setting of a sternal 22% of patients with DSWI died, these patients incurred approxi-
dehiscence. mately 74% of the total excess costs attributable to post-operative
S. aureus infection, unlike CONS, can occur without sternal DSWI.14 Other studies have also demonstrated increased health care
37
dehiscence. The nares of the patient has been suggested to be the costs associated with DSWI related to prolonged length of ICU and
endogenous route of S.aureus infection.40,41 It is also suggested that hospital stay, repeated surgical procedures including debridement, and
the presence of a surgeon who is a carrier and disseminator of S.aureus reconstruction/closure.13,14,52,53
in the operating theater could be a source of infections.42 These data
therefore suggest that S.aureus DSWI is due to perioperative
2.6 | Prevention
contamination and that post-operative infection may occur regardless
of sternal instability. Unlike S.aureus which causes a more aggressive Perioperative prevention strategies entail modifying the patient’s risk
presentation, CONS infection has a more indolent course and is more factors (diabetes, obesity, respiratory insufficiency), preparing the
prone to recurrence.43 patient’s skin (body hair, pre-operative showering, operating site
The other group of pathogens in DSWI are aerobic gram-negative antiseptic treatment), antimicrobial prophylaxis, environmental control
rods. The most common gram-negative microorganisms involved are of the operating room and medical devices, and implementing proper
37
Klebsiella and Enterobacter species. These bacteria are mostly surgical techniques (Table 1).
translocated from other host site infections, such as pneumonia,
urinary, or abdominal infections.37,39,42
2.6.1 | Modification of patient risk factors
Diabetes is a well-known risk factor for all infections. Both long- and
2.5 | Outcomes and cost
short-term controls of blood glucose levels are essential in reducing
Mediastinitis post-cardiac surgery, even with the adoption of modern the risk of DSWI. Zerr et al54 reported the effect of glycemic control on
11,13,14,17–19
treatments, varies between 1.1 and 19%. Hospital the incidence of DSWI and the positive effect of the implementation of
mortality is frequently related to uncontrolled infection, sepsis, and post-operative insulin protocals in diabetic patients on the incidence of
multi-organ failure.10,13,19Post-operative mediastinitis is associated infections. In this study, sternal wound infections increased from 1.3%
with a substantial deceased long-term survival compared with patients in patients with mean glucose values of 100-150 mg/dL to 6.7%
without mediastinitis.8,10,13,16,19 Risnes and colleagues reported that in patients with levels of 250-300 mg/dL. The institution of insulin
patients with mediastinitis had a 59% higher mortality risk compared protocols resulted in a decrease in blood glucose levels for the first two
with those patients without mediastinitis over a 10-year period.10 It is post-operative days and a concomitant decrease in the proportion of
suggested that the chronic inflammatory process associated with patients with deep wound infections, from 2.4 to 1.5% (P < 0.02).54 In
mediastinitis can increase thrombogenesis and thereby negatively the Society of Thoracic Surgeons practice guidelines on blood glucose
reduce the graft patency, contributing to the reduced long-term management during adult cardiac surgery, it is a Class I recommenda-
survival.44 Pericardial and epicardial fibrosis after mediastinitis can also tion that the blood glucose level of patients with diabetes should be
cause constrictive physiology which also reduces long-term maintained at <180 mg/dL during cardiac surgery, with continuous
survival.45,46 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 the routine use of glycopeptides as prophylaxis is controversial. A meta-
showed that a continuous insulin infusion post-operatively to maintain analysis by Saleh et al showed that glycopeptides reduced the risk of
a serum glucose level of 120-150 mg/dL led to a significant decrease in resistant Staphylococcal DSWI by 51% (RR0.49, 95%CI 0.24-0.99,
the incidence of DSWI in diabetics (0.8-2%, P = 0.01) and perioperative P = 0.05) and enterococcal DSWI by 72% (RR0.28; 95%CI 0.10-0.74,
mortality (1.9 vs. 4.5%, P < 0.0001) compared with subcutaneously P = 0.01).58 Beta-Lactams, however, showed superiority in reducing
administered insulin. Lazar et al56 showed that in diabetic CABG superficial chest, deep chest, susceptible Staphylococcal, and respiratory
patients receiving glucose-insulin-potassium infusions had signifi- tract infections.58 Since glycopeptides have no effect on gram-negative
cantly less infections (0% vs. 13%, P = 0.01) compared to patients flora, its usefulness as an exclusive agent in cardiac surgical prophylaxis is
treated with intermittent subcutaneous insulin injections. 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
2.6.2 | Antibiotic prophylaxis
The duration of antibiotic prophylaxis remains controversial. A
Antibiotic prophylaxis and patient decontamination have been proven to number of factors should be taken into consideration when
be effective in reducing DSWI. Since Staphylococcal species are a major determining the duration of effective antibiotic prophylaxis. The
causative pathogen, beta-lactam antibiotics are recommended for prolonged use of antibiotics increase the development of resistant
prophylaxis, particularly first- or second-generation cephalosporins. It is bacterial strains and potential superinfection. This adverse effect was
a Class I recommendation from the STS practice guideline that the demonstrated by Harbarth and colleagues60 in an observational study
antibiotics should be given intravenously within 60 min before the skin of 2,641 patients undergoing CABG. They reported that antibiotic
incision and be continued for no longer than 48 h.57 The dosing of the prophylaxis more than 48 h increased antimicrobial resistance. At the
antibiotics should be weight based and to be repeated for procedures same time, no clinical advantage was demonstrated with administra-
lasting longer than 4 h.57 Given the emergence of resistant Staphylococcus, tion of prophylactic antibiotics for more than 48 h in that study. This
6 | GOH

finding is further supported by others.61–63 Jewell and colleagues61 the emergence of drug-resistant infections or contribute to post-
found no difference in infectious rate when they randomized 200 operative renal toxicity. Another topical agent, the autologous
CABG patients into a group receiving 48 h of intravenous cephalothin platelet-rich plasma, has been reported to reduce the risk of DSWI.
or a group receiving 3 days of oral cephalexin. Saginur et al63 compared The platelet-rich plasma, which is derived from plasmapheresis of the
one dose of teicoplanin versus 2 days of cephazolin in 3,027 patients patient’s own blood, is rich in growth factors and cytokines and is
and found that the 2-day use of cephazolin was associated with lower thought to promote tissue healing and regeneration. Recently a meta-
deep sternal wound infection.63 A meta-analysis performed by Kreter analysis performed by Kirmani et al71 showed that the use of platelet
62
et al demonstrated a significant reduction in surgical infections gel significantly reduced DSWI (OR 2.69 CI 1.20-6.06, P = 0.02). The
associated with the use of prophylactic antibiotics but no clinical use of topical antibiotics on sternal edges is recommended (Class I
benefit was demonstrated with the use of prophylactic antibiotics for Recommendation) in all patients undergoing sternotomy for cardiac
more than 48 h.62 After an extensive review of clinical trials, Ariano and procedures.1
Zhanel recommended the use of prophylactic antibiotics for only
48 h.64 To date there is no evidence to suggest that prophylactic
2.6.3 | Skin and nasal decontamination
antibiotics use of less than 48 h are associated with antimicrobial
resistance. Based on these evidence, the STS practice guideline has In addition to antibiotic prophylaxis, skin, and nasopharyngeal
recommended antibiotic prophylaxis for no more than 48-h for cardiac decontamination have also contributed to decreased DSWI. The use
surgery (Class I Recommendation).57 of chlorhexidine skin wash before surgery showed a significant
The use of topical antibiotics over the sternal edges intra- reduction in the bacterial load.72 The use of mupirocin has been
operatively have been demonstrated to be effective in reducing the demonstrated to be effective in reducing sternal wound infections,
risk of DSWI.65–67 In a large multicenter retrospective analysis of including diabetic patients.73,74
6,960 patients, the topical spraying of antibiotics was found to Nasal carriage of S. aureus is a risk factor for development of DSWI.
significantly reduce the incidence of DSWI (0.46% vs. 1.7%, Several studies have shown a correlation between the colonization
P < 0.0001). In this study, the topical solution was made of 1-g density of S. aureus at the carriage site and the risk for the development
cephazolin and 40-mg gentamicin in 40 mls of normal saline which was of infection.40,75 Kluytmans et al40 confirmed that in patients who
65
sprayed multiple times during the surgery. In another study, 2,000 developed DSWI and had positive pre-operative S. aureus nasal
patients were randomized to routine prophylaxis with intravenous cultures, the phage typing showed that the S. aureus isolates from
antibiotics alone (control group) or intravenous antibiotics combined the nasal swabs and sternal wound cultures were identical.
with application of collagen-gentamicin (260-mg gentamicin) sponges Mupirocin is a self-administered topical antibiotic that is highly
within the sternotomy before wound closure. There was a significant effective in eradicating nasal S. aureus, including MRSA.76,77 It is a
reduction in all sternal wound infections (4.7% vs. 9%, RR0.47 95%CI naturally occurring antibiotic produced by a fermentation of Pseudo-
0.33-0.68, P < 0.001) and DSWI in high-risk patients (Diabetes and monas bacteria mixed in a nonirritating paraffin composition. Its
BMI >25) (2.44% vs. 4.37%, RR0.56 95%CI 0.31-1.00, P < 0.05).66 The specific mechanism of action is to bind to isoleucyl-transfer RNA
positive effect of gentamycin sponge use was further substantiated by synthetase and inhibit protein syntheses.78 Mupirocin is used topically
a meta-analysis performed by Kowalewski et al,68 which included a due to extensive systemic metabolism and is 80-90% effective in
total of 14 studies of 22,135 patients, of which four were randomized eradicating Staphylococcus from the nasopharyngeal mucosa79 but
68
controlled trials with 4,672 patients. They confirmed that the topical only 45-50% for MRSA organisms. Short-term therapy (a 5-day course)
use of a gentamicin sponge significantly reduced the risk of has been shown to be highly effective.76 The STS guidelines
mediastinitis by 36% compared with the control group (RR0.64; recommend beginning treatment after a positive culture beginning
95%CI 0.45-0.91; P = 0.01).68 Vancomycin has also been used to 24 h prior to and for 5 days following surgery.59
69
reduce DSWI. Vander Salm and colleagues, in a prospective, Recently Del Diego Salas et al80 performed an economic analysis
randomized study, demonstrated that topical application of vancomy- of universal mupirocin prophylaxis against surgical site infection for
cin paste to the cut sternal edges resulted in a significant decrease in cardiac surgery. In the study, two protocols were applied: (1) where
DSWI (0.45% vs. 3.6%, P = 0.02).69 Lazar and colleagues70 studied the only patients tested positive to MRSA colonization received muripocin,
effect of topical vancomycin to reduce the incidence of sternal wound twice a day during a two-week period; and (2) where all patients
infections in the presence of peri-operative intravenous antibiotics and received the mupirocin treatment. They concluded that universal use
tight glycemic control. In this study, superficial sternal infections (0% vs of mupirocin as prophylaxis is associated with a lower incidence of
. 1.6%; P < 0.0001), deep sternal infections (0% vs. 0.7%;P = −.005), and infections and cost savings, versus the strategy to treat patients
any type of sternal infection (0% vs. 2.2%; P < 0.0001) were selectively according to the results of their nasal culture.
significantly reduced in patients receiving topical vancomycin. “These Of concern is whether resistance would develop with the use of
beneficial effects were also noted in patients with diabetes (0% vs. mupirocin in all pre-operative patients. The STS Practice Guidelines
3.3%; P = 0.0004).” In another study, Lazar et al67 demonstrated that recommends using a polymerase chain reaction (PCR) rapid analysis
the use of topical vancomycin did not increase levels of serum and treatment of only positive cultures, but in absence of the rapid PCR
vancomycin following cardiac surgical procedures, nor did it potentiate test, the recommendation remains routine prophylaxis for all patients
GOH | 7

with mupirocin.59 Fawley et al81 published the results of a 4-year preferable over simple cerclage technique as it reduces the
prevalence study on the use of short-term, empirical, pre-operative longitudinal motion at the sternotomy site and hence potentially
prophylaxis use of mupirocin at three hospitals. While no mupirocin- reduces sternal dehiscence.1 Moreover, figure-of-eight cables are
resistance isolates was found, they did find that mupirocin was more flexible than the wires and conform more tightly to the
effective in reducing the incidence of nasal carriage of MRSA and S. sternum and thereby providing more stability.1 Traditional standard
aureus at long-term follow-up. sternal wire cerclage, if performed well, is easy and effective.
Effective screening, rapid detection, isolation, and treatment of However, with an increasing number of patients with risk factors
MRSA carriers are important considerations for MRSA control. such as obesity and chronic obstructive pulmonary disease and/or
Screening for MRSA via conventional culture-based detection poor sternal quality in elderly patients, modification in the
methods is time-consuming and often leads to delayed or unnecessary techniques of sternal closure including Robiscek’s parasternal wire
isolation precautions. The time from culture inoculation to identifica- reinforcement has been proposed.90 In 1977, Robicsek et al91
tion of MRSA is typically between 48 and 96 h, and the sensitivity of reported a weaving technique to prevent and treat sternal
any single selective medium method ranges between 65 and 100%.82 dehiscience following sternotomy. They reported satisfactory out-
Real-time PCR, on the other hand, detects the mecA gene which comes in a series of eight patients, of which five had the weave at
mediates methicillin resistance and offers results within 1-2 h with the time of operation, one had sterile sternal dehiscence post-
more than 90% of both sensitivity and specificity.83 The use of this operatively, and two had post-operative sternal infections. The
molecular real-time assay therefore allows a more efficient and procedure involves continuous wire sutures placed parasternally on
effective MRSA control in our surgical patients. The AATS recom- both sides of the sternum, passing alternating anteriorly and
mends that all cardiac surgery patients should have nasal swabs or PCR posteriorly to the costal cartilages down from the manubrium to
testing, if available, before surgery and that routine mupirocin the xiphoid process. The wire suture is then reversed and led
administration is recommended for all cardiac surgery procedures in cranially, passing the cartilages posteriorly where it had been
the absence of PCR testing or nasal cultures positive for staphylococcal anterior and vice versa. The two ends of the wires then are tied
colonization (Class I Recommendation).1 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
2.6.4 | Surgical techniques
mammary vessels. The Robicsek weave has been reported to be an
Surgical technique plays an important role in the risk of DSWI. This effective treatment for post-operative sternal dehiscence as well as
includes meticulous scrubbing practice, careful prepping with skin prophylaxis in high-risk patients to prevent non-infectious dehis-
disinfection agents, mid-line sternotomy, careful handling of soft cence.92,93 In the setting of closing a sternum with multiple fractures,
tissue, checking for glove injury, and leaving the closed wound covered the AATS recommends the use of Robicsek weave technique to
for at least 48 h.84 The use of bone wax should be minimized. Bone wax prevent dehiscence and wound infections (Class IIa Recommenda-
is a well-known topical hemostatic agent composed of beeswax and tion) Other closure systems such as sternal plating, thermoreactive
Vaseline. Its hemostatic effect is based on physical rather than nitinol clips, titanium locked staplers which are designed for
biochemical properties, by sealing the oozing from open bone marrow parasternal fixation, have not been consistently shown to reduce
post-sternotomy. The use of bone wax for hemostasis has been the risk of DSWI.94–96 The application of negative pressure wound
questioned due to the increased risk of sternal infection post-cardiac therapy (NPWT) on clean surgically closed sternal wounds is
surgery. It was shown to inhibit osteoblastic activity, bone healing, and becoming popular especially in obese patients. Prevena® Incision
85
osteogenesis. Bone wax is neither reabsorbed nor metabolized; it Management System (Acelity, San Antonio, TX) is an example of
persists for up to 10 years after application and acts as foreign material NPWT which is commercially available.97 Proposed benefits of this
that results in foreign body reactions and serve as a niche for system include a reduction of skin tension, additional barrier to
microorganism and subsequent infections.86,87 The use of bone wax on external environment, decreased tissue edema, and promotion of
the cut edges of the sternum is not recommended by the AATS microvascular flow.98 Early clinical experience demonstrated no
1
consensus guidelines (Class III Recommendation). wound-healing complications in patients at high risk for sternal
IMAs has been shown to increase the risk of DSWI.11,19,34 The wound infections after cardiac surgery99,100; however, this requires
conventional pedicled IMA harvest dissects the artery along with its further evaluation through randomized trials.
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 3 | MANAGEMENT
88,89
patients. This risk, however, is reduced considerably when the
IMA is taken down in a skeletonized fashion compared to a pedicle Once DSWI is diagnosed, empiric antibiotic therapy is initiated to
34,35,89 include broad-spectrum coverage against methicillin-resistant gram-
graft.
Stable sternal approximation and closure plays an important role positive, gram-negative, and anaerobic organisms. Culture-directed
in preventing DSWI. A figure-of-eight wire closure technique may be therapy should be initiated as soon as microbiological sensitivity is
8 | GOH

available. It should be noted that continuous mediastinal irrigation with VAC therapy. During the initial debridement, it is important to
povidone-iodine solution should be avoided due to potential systemic meticulously remove any sharp bony periosteal fragments and all
absorption with resultant renal failure, electrolyte disturbances, and sternal wires. Mobilization of the RV from the sternal edges on initial
changes in iodine metabolism.1 debridement is beneficial114 but paradoxically can precipitate
Treatment of any DSWI consists of early wound exploration hemorrhage. Interface dressings protect the RV from friction and
followed by reconstruction or direct closure. These include, but are not shearing forces from the raw sternal edges and reduced suction
limited to, vacuum-assisted closure, various flap coverage using pressure on the heart.119,120 The highest mean decrease in pressure
omentum, pectoralis major muscle, the rectus abdominus muscle, occurred with the use of paraffin-impregnated gauze due the pores
the latissimus dorsi muscle, the microsurgical free flap, and various in the foam being blocked. Malmsjo and colleagues120 in an animal
combinations of the above. Sternal fixation with sternal plating study demonstrated that wound contraction seems to be observed
systems has also been reported.101,102 at relatively low levels of pressure −40 to −80 mmHg and additional
Currently, the procedure of choice to treating DSWI is early negative pressure does not further increase wound contraction. In
wound exploration, followed by vacuum-assisted closure (VAC) this study, greater wound contraction was found when foam was
therapy, either as a definitive treatment or as a bridge to reconstruc- used instead of gauze but that there is less damage to the heart
tion and/or closure once the wound is deemed suitable. It is a Class IIa when using gauze than foam. Therefore the use of gauze may be
recommendation by the AATS that NPWT should be initiated more appropriate in addition to the use of interface dressing when
whenever possible in patients in whom delayed sternal closure is the underlying tissue is fragile. In terms of the negative pressure
1
anticipated following DSWI. Vacuum-assisted closure has been setting, it was recommended that the suction be reduced
shown to increase peristernal blood flow by increasing arteriolar from −125 mmHg to −70 mm Hg after 72 h of treatment.114
dilatation, reduce bacterial load, promote granulation tissue formation,
and facilitate approximation of sternal wound edges.103–105 Several
4 | CONCL US IO N
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
Post-sternotomy mediastinitis remains a potentially fatal complication
function and hemodynamics in patients with an open chest,104,106 and
of cardiac surgery despite the advancements in the perioperative care
is associated with improved survival in patients with DSWI.107,108
in the modern era. However, the institution of pre-operative, intra-
Baillot et al106 reported a 15-year review of 25,000 sternotomies,
operative, and post-operative strategies noted in this review, and from
observing that the use of VAC is associated with a significant reduction
the recent AATS practice guidelines summarized in Table 1, have been
in hospital (4.8% vs. 14.1%, P = 0.01) and midterm (61% vs. 88%,
shown to significantly decrease the incidence, morbidity, and mortality
P = 0.02) mortality. In addition to being used as a bridge to
of this dreaded complication.
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, CONFLICT OF I NTEREST
are more likely to be associated with successful single VAC therapy
None declared.
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 ORCID
Complications with VAC use is infrequent but includes a possible
Siew S.C. Goh http://orcid.org/0000-0001-9462-2086
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-
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