Mediastinitis medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Mediastinitis}} | {{Mediastinitis}} | ||
{{CMG}} | {{CMG}} {{AE}} {{AG}} | ||
==Overview== | ==Overview== | ||
The mainstay of therapy in acute mediastinitis includes [[ | The mainstay of therapy in acute mediastinitis secondary to cardiothoracic surgery includes [[clindamycin]] and [[ceftriaxone]]. The preferred regimen for preoperative [[prophylaxis]] against acute mediastinitis includes either a second generation [[cephalosporin]] or [[vancomycin]]. Descending necrotizing mediastinitis is a very serious complication of [[oropharyngeal]] infections that should be treated promptly with early and aggressive surgical debridement and broad spectrum antibiotics that provide coverage against [[Methicillin-resistant staphylococcus aureus|MRSA]], beta-lactamase producing [[gram-negative bacteria|gram-negative organisms]], and [[anaerobes]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
===Antimicrobial | ===Antimicrobial Regimens=== | ||
* ''' | * '''1. Post-cardiothoracic surgery mediastinitis'''<ref name="pmid22070836">{{cite journal| author=Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG et al.| title=2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 24 | pages= e123-210 | pmid=22070836 | doi=10.1016/j.jacc.2011.08.009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22070836 }} </ref> | ||
:* Preferred regimen: [[Clindamycin]] 450 mg IV q6h {{and}} [[Ceftriaxone]] 2 g IV q24h | :* '''1.1 Treatment''' | ||
* '''Prophylaxis''' | ::* Preferred regimen: [[Clindamycin]] 450 mg IV q6h {{and}} [[Ceftriaxone]] 2 g IV q24h for > 2 weeks | ||
:* '''Methicillin susceptible staphylococcus aureus | :::* Note: A deep sternal wound [[infection]] should be treated with aggressive surgical [[debridement]] in the absence of complicating circumstances. | ||
::* Preferred regimen: | :* '''1.2 Prophylaxis''' | ||
:* '''Methicillin | ::* '''1.2.1 Methicillin susceptible staphylococcus aureus''' | ||
::* Preferred regimen: [[Vancomycin]] | :::* Preferred regimen: [[Cefazolin]] 2 g IV single dose {{or}} [[Cefoxitin]] 2 g IV single dose {{or}} [[Cefuroxime]] 1.5 g IV single dose | ||
::* Note (1): Preoperative [[antibiotics]] should be administered to all patients to reduce the risk of [[mediastinitis]] in cardiac surgery. | ::* '''1.2.2 Methicillin resistant staphylococcus aureus''' | ||
::* Note (2): | :::* Preferred regimen: [[Vancomycin]] 15 mg/kg IV single dose | ||
:::* Note (1): Preoperative [[antibiotics]] should be administered to all patients to reduce the risk of [[mediastinitis]] in cardiac surgery. | |||
:::* Note (2): The use of intranasal [[mupirocin]] is reasonable in nasal carriers of [[S. aureus]]. | |||
* '''2. Descending necrotizing mediastinitis''' | |||
:*Preferred regimen (1): [[Vancomycin]] 2 g/day IV q6-12h (trough levels 15-20 mg/L) {{and}} [[Imipenem]] 500 mg IV q6h | |||
:*Preferred regimen (2): [[Vancomycin]] 2 g/day IV q6-12h (trough levels 15-20 mg/L) {{and}} [[Meropenem]] 1 g IV q8h | |||
:*Preferred regimen (3): [[Vancomycin]] 2 g/day IV q6-12h (trough levels 15-20 mg/L) {{and}} [[Piperacillin-Tazobactam]] 3.375 g IV q6h | |||
:*Note: The mainstay of therapy for descending necrotizing mediastinitis is surgical debridement. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Pulmonology]] | |||
{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
{{WikiDoc Sources}} | {{WikiDoc Sources}} | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anthony Gallo, B.S. [2]
Overview
The mainstay of therapy in acute mediastinitis secondary to cardiothoracic surgery includes clindamycin and ceftriaxone. The preferred regimen for preoperative prophylaxis against acute mediastinitis includes either a second generation cephalosporin or vancomycin. Descending necrotizing mediastinitis is a very serious complication of oropharyngeal infections that should be treated promptly with early and aggressive surgical debridement and broad spectrum antibiotics that provide coverage against MRSA, beta-lactamase producing gram-negative organisms, and anaerobes.
Medical Therapy
Antimicrobial Regimens
- 1. Post-cardiothoracic surgery mediastinitis[1]
- 1.1 Treatment
- Preferred regimen: Clindamycin 450 mg IV q6h AND Ceftriaxone 2 g IV q24h for > 2 weeks
- Note: A deep sternal wound infection should be treated with aggressive surgical debridement in the absence of complicating circumstances.
- 1.2 Prophylaxis
- 1.2.1 Methicillin susceptible staphylococcus aureus
- Preferred regimen: Cefazolin 2 g IV single dose OR Cefoxitin 2 g IV single dose OR Cefuroxime 1.5 g IV single dose
- 1.2.2 Methicillin resistant staphylococcus aureus
- Preferred regimen: Vancomycin 15 mg/kg IV single dose
- Note (1): Preoperative antibiotics should be administered to all patients to reduce the risk of mediastinitis in cardiac surgery.
- Note (2): The use of intranasal mupirocin is reasonable in nasal carriers of S. aureus.
- 2. Descending necrotizing mediastinitis
- Preferred regimen (1): Vancomycin 2 g/day IV q6-12h (trough levels 15-20 mg/L) AND Imipenem 500 mg IV q6h
- Preferred regimen (2): Vancomycin 2 g/day IV q6-12h (trough levels 15-20 mg/L) AND Meropenem 1 g IV q8h
- Preferred regimen (3): Vancomycin 2 g/day IV q6-12h (trough levels 15-20 mg/L) AND Piperacillin-Tazobactam 3.375 g IV q6h
- Note: The mainstay of therapy for descending necrotizing mediastinitis is surgical debridement.
References
- ↑ Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG; et al. (2011). "2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons". J Am Coll Cardiol. 58 (24): e123–210. doi:10.1016/j.jacc.2011.08.009. PMID 22070836.