Mediastinitis - Revision history

Aidan: /* Clinical Manifestations */

2022-09-01T01:10:51Z

Clinical Manifestations

← Older revision		Revision as of 01:10, 1 September 2022
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	**[[Staphylococcus aureus]] and [[coagulase-negative staphylococci]] are the most common		**[[Staphylococcus aureus]] and [[coagulase-negative staphylococci]] are the most common
	**Can also involve other [[Gram-positive cocci]] and [[Gram-negative bacilli]] (including [[SPICE organisms]] and [[Pseudomonas aeruginosa]])		**Can also involve other [[Gram-positive cocci]] and [[Gram-negative bacilli]] (including [[SPICE organisms]] and [[Pseudomonas aeruginosa]])
	*Esophageal rupture: ~~polymicrobial,~~ ~~with~~ ~~oropharyngeal~~ ~~and~~ ~~gastrointestinal~~ ~~flora including~~ ~~anaerobes~~		*Esophageal rupture: [[Viridans group streptococci]], [[Neisseria]], [[Haemophilus]], [[Prevotella]], [[Fusobacterium]]
			*Descending head and neck infections: [[streptococci]], [[Staphylococcus aureus]], [[Peptostreptococcus]], [[Haemophilus influenzae]], [[Pseudomonas aeruginosa]], [[Escherichia coli]], [[Moraxella catarrhalis]], [[Fusobacterium]], [[Prevotella]], [[Actinomyces]]
	*Can also occur from contiguous extension of [[pneumonia]], [[pancreatitis]], [[subphrenic abscess]], or [[epidural abscess]], with the microbiology determined by the source of infection		*Can also occur from contiguous extension of [[pneumonia]], [[pancreatitis]], [[subphrenic abscess]], or [[epidural abscess]], with the microbiology determined by the source of infection

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	* Acute (discussed herein)		* Acute (discussed herein)
	** Complication of cardiovascular or thoracic surgery with median sternotomy		** Complication of cardiovascular or thoracic surgery with median sternotomy (deep sternal wound infection [DSWI])
	** Esophageal perforation		** Esophageal perforation
	*** Iatrogenic, from a procedure		*** Iatrogenic, from a procedure
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	==Clinical Manifestations==		==Clinical Manifestations==

			=== Deep Sternal Wound Infection ===
	*Usually presents within 30 days of surgery		*Usually presents within 30 days of surgery involving thoracotomy
	*Fever, chest pain, drainage from surgical site		*Fever, chest pain, drainage from surgical site
	*See CDC definition, ~~above~~		*See CDC definition, below

	=== Prognosis ===		==== Prognosis ====
		⚫	* Mortality is about 15% in the short term, but is also higher than those without infection in the years following surgery

		⚫	* Mortality is higher when Gram-negatives are isolated
	* For deep sternal wound infections after cardiac surgery
⚫	** Mortality is about 15% in the short term, but is also higher than those without infection in the years following surgery
⚫	** Mortality is higher when Gram-negatives are isolated

	==Investigations==		==Investigations==
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	== Diagnosis ==		== Diagnosis ==

	=== CDC Definition ===		=== CDC Definition of DSWI ===
	*One of the following:		*One of the following:
	**Organisms cultured from mediastinal tissue or fluid		**Organisms cultured from mediastinal tissue or fluid
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	==Management==		==Management==

			=== DSWI ===
	*In general, surgical exploration with debridement should always be performed as quickly as possible		*In general, surgical exploration with debridement should always be performed as quickly as possible
	*Empiric antibiotics should be broad, including coverage for ~~MRSA~~ and resistant Gram-negatives		*Empiric antibiotics should be broad, including coverage for [[Staphylococcus aureus]], [[coagulase-negative staphylococci]], and resistant Gram-negatives
			**[[Piperacillin-tazobactam]] plus [[vancomycin]] is a reasonable choice
	**Antimicrobials directed by culture results
	*Duration of therapy unclear but depends on adequacy of source control, presence of sternal osteitis, and presence of metal or other foreign bodies		*Duration of therapy unclear but depends on adequacy of source control, presence of sternal osteitis, and presence of metal or other foreign bodies
	**Probably somewhere between 3 and 12 weeks		**Probably somewhere between 3 and 12 weeks
			***Usual duration 14 to 21 days
			***As long as 6 weeks when foreign bodies (such as sternotomy wires) are present
	**Following sternal resection and pectoral flap: maybe 2 to 3 weeks		**Following sternal resection and pectoral flap: maybe 2 to 3 weeks
	**After debridement without resection, or with residual bone infection: probably 4 to 6 weeks		**After debridement without resection, or with residual bone infection: probably 4 to 6 weeks

			=== Esophageal Perforation ===

			* Empiric antibiotics should target upper GI pathogens, including anaerobes
			** [[Piperacillin-tazobactam]] or [[ceftriaxone]] plus [[metronidazole]]
			** Consider empiric antifungals for more complicated infections
			*** Risk factors include septic shock, female, prior upper GI surgery, and recent antimicrobials
			* Continue for at least 7 days after drainage

			=== Descending Head and Neck Infections ===

			* Empiric antibiotics to cover oropharyngeal pathogens including anaerobes
			** [[Ceftriaxone]] plus [[metronidazole]]

			== Further Reading ==

			* Pastene B, Cassir N, Tankel J, Einav S, Fournier P-E, Thomas P, Leone M. Mediastinitis in the intensive care unit patient: a narrative review. ''Clin Microbiol Infect''. 2020;26(1):26-34. doi: [https://doi.org/10.1016/j.cmi.2019.07.005 10.1016/j.cmi.2019.07.005]

	[[Category:Respiratory infections]]		[[Category:Respiratory infections]]

Aidan at 20:07, 31 August 2022

2022-08-31T20:07:31Z

← Older revision		Revision as of 20:07, 31 August 2022
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	*Infection of the structures in the mediastinum		*Infection of the structures in the mediastinum
	**The mediastinum refers to the space between the lungs which contains the heart, thymus, esophagus, and trachea		**The mediastinum refers to the space in the chest between the lungs, which contains the heart, thymus, esophagus, and trachea
	*Confusing nomenclature, and includes mediastinal infections caused by extension of a cervical infection (necrotizing mediastinitis or descending mediastinitis) and mediastinal infection after sternotomy (sternal infection or deep sternal wound infection)		*Confusing nomenclature, and includes mediastinal infections caused by extension of a cervical infection (necrotizing mediastinitis or descending mediastinitis) and mediastinal infection after sternotomy (sternal infection or deep sternal wound infection)

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	*Post-cardiac surgery: often mixed		*Post-cardiac surgery: often mixed
	**[[Staphylococcus aureus]] ~~is by far most common, followed by~~ [[coagulase-negative staphylococci]]		**[[Staphylococcus aureus]] and [[coagulase-negative staphylococci]] are the most common
	**Can also involve other [[Gram-positive cocci]] and [[Gram-negative bacilli]] (including [[SPICE organisms]] and [[Pseudomonas aeruginosa]])		**Can also involve other [[Gram-positive cocci]] and [[Gram-negative bacilli]] (including [[SPICE organisms]] and [[Pseudomonas aeruginosa]])
	*Esophageal rupture: polymicrobial, with oropharyngeal and gastrointestinal flora including anaerobes		*Esophageal rupture: polymicrobial, with oropharyngeal and gastrointestinal flora including anaerobes
	*Can also occur from contiguous extension of [[pneumonia]], [[pancreatitis]], [[subphrenic abscess]], or [[epidural abscess]], with the microbiology determined by the source of infection		*Can also occur from contiguous extension of [[pneumonia]], [[pancreatitis]], [[subphrenic abscess]], or [[epidural abscess]], with the microbiology determined by the source of infection

			=== Etiologies ===

			* Acute (discussed herein)
			** Complication of cardiovascular or thoracic surgery with median sternotomy
			** Esophageal perforation
			*** Iatrogenic, from a procedure
			*** Swallowed foreign body
			*** Trauma (penetration or blunt)
			*** Other, including esophageal carcinoma, emesis (Boerhaave syndrome), cricoid pressure from induction, heavy lifting, defecation, parturition, ingestion of caustic or corrosive liquids
			** Continguous spread of infection
			*** Head and neck infections, including odontogenic infections, [[Ludwig angina]], [[pharyngitis]], [[tonsillitis]], [[parotitis]], [[epiglottitis]], [[Lemierre syndrome]]
			*** Lymph nodes, from [[anthrax]] or [[tuberculosis]]
			*** [[Pneumonia]], [[empyema]], [[subphrenic abscess]], [[pancreatitis]], [[cellulitis]], [[osteomyelitis]], or hematogenous spread
			* Chronic (fibrosing/sclerosing/granulomatous), caused by [[Histoplasma capsulatum]]

	=== Epidemiology ===		=== Epidemiology ===
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	** Incidence increases with the complexity of the operation, and is highest with CABG = valve replacement or aortic surgery		** Incidence increases with the complexity of the operation, and is highest with CABG = valve replacement or aortic surgery
	** Risk increases with BMI, diabetes, and number of platelet transfusions		** Risk increases with BMI, diabetes, and number of platelet transfusions
			* Complicates less than 0.5% of upper endoscopies

	==Clinical Manifestations==		==Clinical Manifestations==

Aidan at 19:45, 31 August 2022

2022-08-31T19:45:08Z

@@ Line 4: / Line 4: @@
 **The mediastinum refers to the space between the lungs which contains the heart, thymus, esophagus, and trachea
 *Confusing nomenclature, and includes mediastinal infections caused by extension of a cervical infection (necrotizing mediastinitis or descending mediastinitis) and mediastinal infection after sternotomy (sternal infection or deep sternal wound infection)
 ===Microbiology===
@@ Line 29: / Line 19: @@
 ** Risk increases with BMI, diabetes, and number of platelet transfusions
-==Clinical Manfestation==
+==Clinical Manifestations==
 *Usually presents within 30 days of surgery
@@ Line 45: / Line 35: @@
 *CT chest can show evidence, including sternal wire displacement, sternal disruption, free gas, or fluid collections
 *Surgical exploration, with fluid sent for culture
 ==Management==

Aidan at 14:12, 7 February 2021

2021-02-07T14:12:44Z

← Older revision		Revision as of 14:12, 7 February 2021
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	== Background ==		==Background==

	* Infection of the structures in the mediastinum		*Infection of the structures in the mediastinum
			**The mediastinum refers to the space between the lungs which contains the heart, thymus, esophagus, and trachea
			*Confusing nomenclature, and includes mediastinal infections caused by extension of a cervical infection (necrotizing mediastinitis or descending mediastinitis) and mediastinal infection after sternotomy (sternal infection or deep sternal wound infection)

	=== CDC Definition ===		===CDC Definition===

	* One of the following:		*One of the following:
	** Organisms cultured from mediastinal tissue or fluid		**Organisms cultured from mediastinal tissue or fluid
	** Gross anatomical or histopathologic evidence of mediastinitis		**Gross anatomical or histopathologic evidence of mediastinitis
	** Fever, chest pain, or sternal instability		**Fever, chest pain, or sternal instability
	* Plus one of the following:		*Plus one of the following:
	** Purulence from the mediastinal area		**Purulence from the mediastinal area
	** Mediastinal widening on imaging		**Mediastinal widening on imaging

	=== Microbiology ===		===Microbiology===

	* Post-cardiac surgery: ~~[[coagulase-negative staphylococci]], [[Staphylococcus~~ ~~aureus]]~~		*Post-cardiac surgery: often mixed
			**[[Staphylococcus aureus]] is by far most common, followed by [[coagulase-negative staphylococci]]
⚫	* Esophageal rupture: polymicrobial, with oropharyngeal and gastrointestinal flora including anaerobes
			**Can also involve other [[Gram-positive cocci]] and [[Gram-negative bacilli]] (including [[SPICE organisms]] and [[Pseudomonas aeruginosa]])
⚫	* Can also occur from contiguous extension of [[pneumonia]], [[pancreatitis]], [[subphrenic abscess]], or [[epidural abscess]], with the microbiology determined by the source of infection
		⚫	*Esophageal rupture: polymicrobial, with oropharyngeal and gastrointestinal flora including anaerobes
		⚫	*Can also occur from contiguous extension of [[pneumonia]], [[pancreatitis]], [[subphrenic abscess]], or [[epidural abscess]], with the microbiology determined by the source of infection

	== ~~Clinical Manfestation~~ ==		=== Epidemiology ===

			* Post-surgical deep sternal wound infections occur after about 1% of cardiac surgeries
⚫	* Usually presents within 30 days of surgery
			** Incidence increases with the complexity of the operation, and is highest with CABG = valve replacement or aortic surgery
⚫	* Fever, chest pain, drainage from surgical site
			** Risk increases with BMI, diabetes, and number of platelet transfusions
⚫	* See CDC definition, above

			==Clinical Manfestation==
⚫	== Investigations ==

		⚫	*Usually presents within 30 days of surgery
⚫	* CT chest can show evidence, including sternal wire displacement, sternal disruption, free gas, or fluid collections
		⚫	*Fever, chest pain, drainage from surgical site
⚫	* Surgical exploration, with fluid sent for culture
		⚫	*See CDC definition, above

	== ~~Management~~ ==		=== Prognosis ===

			* For deep sternal wound infections after cardiac surgery
	* Surgical exploration with debridement
			** Mortality is about 15% in the short term, but is also higher than those without infection in the years following surgery
⚫	* Antimicrobials directed by culture results
			** Mortality is higher when Gram-negatives are isolated

		⚫	==Investigations==

		⚫	*CT chest can show evidence, including sternal wire displacement, sternal disruption, free gas, or fluid collections
		⚫	*Surgical exploration, with fluid sent for culture

			==Management==

			*In general, surgical exploration with debridement should always be performed as quickly as possible
			*Empiric antibiotics should be broad, including coverage for MRSA and resistant Gram-negatives
		⚫	**Antimicrobials directed by culture results
			*Duration of therapy unclear but depends on adequacy of source control, presence of sternal osteitis, and presence of metal or other foreign bodies
			**Probably somewhere between 3 and 12 weeks
			**Following sternal resection and pectoral flap: maybe 2 to 3 weeks
			**After debridement without resection, or with residual bone infection: probably 4 to 6 weeks

	[[Category:Respiratory infections]]		[[Category:Respiratory infections]]

Aidan: Created page with "== Background == * Infection of the structures in the mediastinum === CDC Definition === * One of the following: Organisms cultured from mediastinal tissue or fluid G..."

2020-08-22T21:38:20Z

Created page with "== Background == * Infection of the structures in the mediastinum === CDC Definition === * One of the following: ** Organisms cultured from mediastinal tissue or fluid ** G..."

New page

== Background ==

* Infection of the structures in the mediastinum

=== CDC Definition ===

* One of the following:
** Organisms cultured from mediastinal tissue or fluid
** Gross anatomical or histopathologic evidence of mediastinitis
** Fever, chest pain, or sternal instability
* Plus one of the following:
** Purulence from the mediastinal area
** Mediastinal widening on imaging

=== Microbiology ===

* Post-cardiac surgery: [[coagulase-negative staphylococci]], [[Staphylococcus aureus]]
* Esophageal rupture: polymicrobial, with oropharyngeal and gastrointestinal flora including anaerobes
* Can also occur from contiguous extension of [[pneumonia]], [[pancreatitis]], [[subphrenic abscess]], or [[epidural abscess]], with the microbiology determined by the source of infection

== Clinical Manfestation ==

* Usually presents within 30 days of surgery
* Fever, chest pain, drainage from surgical site
* See CDC definition, above

== Investigations ==

* CT chest can show evidence, including sternal wire displacement, sternal disruption, free gas, or fluid collections
* Surgical exploration, with fluid sent for culture

== Management ==

* Surgical exploration with debridement
* Antimicrobials directed by culture results

[[Category:Respiratory infections]]
[[Category:Cardiac infections]]
[[Category:Trauma and surgical patients]]

Mediastinitis - Revision history

Aidan: /* Clinical Manifestations */

Aidan at 20:07, 31 August 2022

Aidan at 19:45, 31 August 2022

Aidan at 14:12, 7 February 2021

Aidan: Created page with "== Background == * Infection of the structures in the mediastinum === CDC Definition === * One of the following: ** Organisms cultured from mediastinal tissue or fluid ** G..."

Aidan: Created page with "== Background == * Infection of the structures in the mediastinum === CDC Definition === * One of the following: Organisms cultured from mediastinal tissue or fluid G..."