Mediastinitis – ABC CARDIOL

ABC

Original Article

Clinical and Microbiology Predictors for Therapeutic Failure in Sternal Surgical Site Infections – A Retrospective Cohort Study

Jaqueline Fabiano Palazzo et al. Diego Augusto Medeiros Santos Bruno Adler Maccagnan Pinheiro Besen Caio Sambo … Gabriel Fialkovitz da Costa Leite Samuel Terra Gallafrio Danielle Menosi Gualandro Lani Paola Bonilla Cuello Marcus Vinicius Barbosa Santos Tania Mara Varejão Strabelli Pablo Maria Alberto Pomerantzeff Fabio Biscegli Jatene Rinaldo Siciliano

Abstract

Background

Although sternal surgical site infections (SSI) are an important complication after cardiac surgeries, predictors of treatment failure are poorly studied.

Objectives

The aim of this study is to assess the clinical and microbiology predictors of a sternal SSI therapeutic failure.

Methods

Patients who presented a sternal SSI were retrospectively analyzed. Data regarding demographic characteristics, clinical findings, initial laboratory and radiologic findings and treatment of index sternal SSI were evaluated. Primary outcome was treatment failure, comprising infection relapse (clinical sternal SSI after complete treatment) or infection persistence (outpatient antimicrobial treatment failure). The microbiology was assessed at the index infection and in the outcome. P-values < 0.05 were considered statistically significant.

Results

Among 489 included patients, mean age was 58 years, 265 (55%) were female, 185 (38%) had diabetes mellitus. The overall prevalence of therapeutic failure was 14% (67), occurring in a median of 174 days (±41) after index cardiac surgery. Most frequent etiologies were cocci Gram-positive and Klebsiella pneumoniae. None of laboratory or thoracic tomographic findings presented during the index sternal SSI was related to outcome. After multivariate analysis, Staphylococcus aureus, carbapenem-resistant Gram-negative bacilli (GNB), fungi, diabetes mellitus and presence of mediastinitis/osteomyelitis were positive predictors of therapeutic failure.

Conclusions

Emerging carbapenem-resistant GNB, fungi and S. aureus were etiologies associated with higher risk of therapeutic failure in sternal SSI. DM and deep sternal wound infections were also contributing factors. Its clinical implications and the exact role of multi-resistant microorganism itself are subject for more studies.

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ABCIC

Case Report

Cardiac Tamponade: Initial Clinical Presentation of Fibrosing Mediastinitis

Aluísio José de O. Monteiro Neto et al. Vitor Medeiros Delgado Filipe Melo A. Leite Álvaro Braga Dutra Marcelo Dantas Tavares de Melo

Introduction

Fibrosing mediastinitis (FM) is a rare condition characterized by the proliferation of fibrotic tissue in the mediastinum, presenting as a concentrated mass or diffuse infiltration.^, Clinical conditions can range from benignity to obstruction of critical mediastinal structures, such as vessels, airways, and the esophagus. Common complaints are cough, dyspnea, recurrent pulmonary infection, hemoptysis, and pleuritic pain. Pericardial involvement is not frequently reported in the literature. In this article, we describe a rare case of major pericardial effusion with cardiac tamponade as an initial presentation of FM in a patient with cancer.

[…]

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IJCS

Original Article

Factors Associated with Post-Sternotomy Mediastinitis. Case-Control Study

Débora Cristine Gomes Pinto et al. Antônio Fernandino de Castro Bahia Neto Flávia Lage Gonçalves Isabel Cristina Gomes … Eduardo Back Sternick Alessandra Maciel Almeida Nulma Souto Jentzsch

Abstract

Background:

Mediastinitis is a severe post-median sternotomy infection with poor prognosis, even with early diagnosis and treatment.

Objectives:

To evaluate the profile of patients submitted to sternotomy, identify the risk factors for the development of mediastinitis and evaluate the bacteriological diagnosis of patients with this infection.

Methods:

Case-control study carried out in a large hospital in Belo Horizonte (MG, Brazil) in patients submitted to median sternotomy, from January 2015 to January 2018. The sample consisted of 65 patients, of which 13 were cases and 52, controls (1:4). For the statistical analysis, Student’s t test, Mann-Whitney test and Fisher exact test were used, in addition to logistic regression, with a level of significance of 5%.

Results:

There was a predominance of males (63.1%), and the mean age was 58.8 ± 10.3 years. Evolution to death occurred in 9.2% of the patients and in 23.1% of those with mediastinitis. Myocardial revascularization was performed in 75.4% of the cases. Predominance of male gender, longer hospitalization time, post-surgical fever and death, and a greater number of risk factors were more frequent characteristics in patients who developed mediastinitis. The most common microorganism found in patients with mediastinal infection was Staphylococcus aureus (30.7%), in addition to a high occurrence of Gram-negative bacteria (46,2%).

Conclusion:

The results are in accordance with the literature. Efforts should be focused on the control of risk factors prior to the procedure, in addition to improving measures that can decrease or eliminate the onset of mediastinitis, aiming at infection prevention and control.

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ABC

Original Article

Predictors of Mediastinitis Risk after Coronary Artery Bypass Surgery: Applicability of Score in 1.322 Cases

Fabiana dos Santos Oliveira et al. Letícia Delfino Oliveira de Freitas Eneida Rejane Rabelo-Silva Laura Maggi da Costa … Renato Abdala Karam Kalil Maria Antonieta Pereira de Moraes

Abstract

Background:

Mediastinitis is a severe surgical complication of low incidence, but high lethality. Scores used in the preoperative period to stratify the risk of postoperative mediastinitis may contribute to improve the results.

Objective:

To test the applicability of the MagedanzSCORE in predicting the risk factors for mediastinitis in patients undergoing coronary artery bypass grafting at a cardiology reference hospital.

Methods:

Historical cohort study with adult patients who underwent coronary artery bypass grafting. The analyzed variables were contemplated in the MagedanzSCORE: reoperation, chronic obstructive pulmonary disease (COPD), obesity, class IV unstable angina, polytransfusion therapy, mediastinitis and death as outcome variables.

Results:

Of the 1.322 patients examined, 56 (4.2%) developed mediastinitis. Of these, 26 (46.4%) were classified as high risk for mediastinitis and 15 (26.8%) at very high risk for mediastinitis. Three of the five variables of the Magendanz Score showed statistically significant differences: reoperation, COPD and obesity. Class IV unstable angina and postoperative polytransfusion were not associated with mediastinitis after coronary artery by-pass grafting. The area under the ROC curve was 0.80 (CI 95% 0.73 – 0.86), indicating the model’s satisfactory ability to predict the occurrence of mediastinitis.

Conclusion:

The tool was useful in the preoperative assessment demonstrating the risk for mediastinitis in this population of intensive care patients. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

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ABC

Original Article

Mediastinitis after cardiac transplantation

Noedir A. G. Stolf et al. Alfredo I. Fiorelli Fernando Bacal Luiz F. Camargo … Edimar A. Bocchi Andréa Freitas André Nicoletti Daniela Meira

OBJECTIVE: Assessment of incidence and behavior of mediastinitis after cardiac transplantation. METHODS: From 1985 to 1999, 214 cardiac transplantations were performed, 12 (5.6%) of the transplanted patients developed confirmed mediastinitis. Patient’s ages ranged from 42 to 66 years (mean of 52.3±10.0 years) and 10 (83.3%) patients were males. Seven (58.3%) patients showed sternal stability on palpation, 4 (33.3%) patients had pleural empyema, and 2 (16.7%) patients did not show purulent secretion draining through the wound. RESULTS: Staphylococcus aureus was the infectious agent identified in the wound secretion or in the mediastinum, or both, in 8 (66.7%) patients. Staphylococcus epidermidis was identified in 2 (16.7%) patients, Enterococcus faecalis in 1 (8.3%) patient, and the cause of mediastinitis could not be determined in 1 (8.3%) patient. Surgical treatment was performed on an emergency basis, and the extension of the débridement varied with local conditions. In 2 (16.7%) patients, we chose to leave the surgical wound open and performed daily dressings with granulated sugar. Total sternal resection was performed in only 1 (8.3%) patient. Out of this series, 5 (41.7%) patients died, and the causes of death were related to the infection. Autopsy revealed persistence of mediastinitis in 1 (8.3%) patient. CONCLUSION: Promptness in diagnosing mediastinitis and precocious surgical drainage have changed the natural evolution of this disease. Nevertheless, observance of the basic precepts of prophylaxis of infection is still the best way to treat mediastinitis.

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