Mediastinitis medical therapy
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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.