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Antibiotic Management of Mediastinitis

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Antibiotic Management of Mediastinitis Antibiotic management of mediastinitis Olivier Epaulard Infectious Diseases Unit Grenoble University Hospital ESCMID eLibraryFrance by author DOI • Nothing to declare ESCMID eLibrary by author ESCMID eLibrary by author 2001 ESCMID eLibrary by author 2001 Interesting BUT NOT TODAY • How to prevent? • How to diagnose? • How to manage surgically? ESCMID(or only incidentallyeLibrary) by author Vocabulary issues • Mediastinitis • Necrotizing mediastinitis Mediastinal extension • Descending mediastinitis of a cervical sepsis • Sternal infection Mediastinal sepsis • Deep sternal infection after sternotomy • (mostly CABG) ESCMIDDeep sternal wound infection eLibrary by author Tirilomis 2014 ESCMID eLibrary by author Mediastinum • An informal space • A patchwork of spaces • Filled with blood, air, digestive and neural pathways ESCMID eLibraryPatrick J. Lynch, illustrator by author Mediastinitis: why is it so evil? • Type of infected structures – Blood vessels: functional/vital issue – Nerves: functional issue – Cartilage and bone: eradication issues • Topography – Uneasy to reach – Reluctancy to re-perform surgery • Type of infected patients (for post-sternotomy) – Just (trying to) recover(ing) from surgery ESCMID– Pre-existing morbidities eLibrary by author Postoperative mediastinitis ESCMID eLibrary by author ESCMID eLibrary by author ESCMID eLibrary by author ESCMID eLibrary by author cthsurgery.com ESCMID eLibrary by author ESCMIDFrequency eLibrary by author Head 2013 Coronary bypass surgery in Europe ESCMID eLibrary by author ESCMIDEl Oakley 1996eLibrary by author ESCMIDMauermann eLibrary2008 by author Filsoufi 2011 ESCMID eLibrary by author 2004 4004 coronary bypass ESCMID eLibrary by author 2011 • Intraaortic balloon pump • BMI>30kg/m2 • Diabetes with oral therapy • Previous cardiac surgery • Low left Var ejection fraction ESCMID eLibrary5649 surgical procedures by author ESCMID eLibrary by author Post-surgery mediastinitis: Pathogens involved ESCMID eLibrary by author 1995 ESCMID eLibrary by author 2004 30102 heart surgery ESCMID eLibrary by author ESCMID eLibrary2011 by author Combes 2001 ICU for mediastinitis Mediastinitis while in ICU ESCMID eLibrary by author ESCMIDMauermann 2008 eLibrary by author ESCMID eLibrary by author ESCMIDPrognosis eLibrary by author ESCMID eLibrary by author Tang 2004 ESCMID eLibrary by author Filsoufi 2011 ESCMID eLibrary by author ESCMID eLibrary2004 by author ESCMID eLibrary by author Milano 1995 adjusted for age, ejection fraction, extent of coronary artery disease, peripheral vascular disease, cerebrovascular disease, recent myocardial ESCMIDinfarction, angina status, andeLibrary mitral insufficiency by author ESCMID eLibrary2014 by author ESCMID eLibrary by author ESCMIDTherapy eLibrary by author • Vulnerable patients • Agressive pathogens • Nosocomial pathogens • At-risk site of infection • Poor prognosis • Emergency, empiric • Broad spectrum antibacterials • Rapid adaptation to samples ESCMID• Duration eLibrary ? by author Targets of the empiric phase • Staphylococcus aureus • Coagulase negative staphylococci • Enterobacteria ESCMID• Pseudomonas aeruginosa eLibrary by author Staphylococcus spp • Empiric: target MRSA • Vancomycine – Teicoplanin: beware of MIC creeping • Daptomycin • Linezolide ESCMID– bacteriostatic eLibrary by author ESCMID eLibrary by author ESCMID eLibrary by author ESCMID eLibrary by author ESCMID eLibrary by author ESCMID eLibrary by author ESCMID eLibrary by author Gram-negative bacteria (including P. aeruginosa) • Empiric: target Case and Pase producers • Broad-spectrum 3rd G cephalosporins • Piperacillin-tazobactam • Carbapenems? Directed by local ecology (ESBL) • Tigecyclin? Directed by local ecology (oxa48, …) ESCMID• Fluoroquinolones? Better aftereLibrary documentation by author Rapid surgery should always be considered • Purulent effusion removal / drainage • Necrosis removal • Rewiring of sternum if necessary • Microbial samples ESCMID eLibrary by author ESCMID eLibrary by author ESCMID eLibrary by author How long? • Purulent effusion may be incompletely drained • Sternal osteitis • Metal wire in sternum, or other foreign body • 3? 6? 12? weeks No evidence-based guidelines ESCMID eLibrary by author ICU for mediastinitis Mediastinitis while in ICU ESCMIDCombes 2001 eLibrary by author Others causes • Descending cervical abcess – Vulnerable patients (diabetes, alcohol, …) – Through spaces between cervical fascias – Gravity – Negative thoracic pressure / breathing ESCMID eLibrary by author Debnam 2012 ESCMID eLibrary by author ESCMID eLibrary by author ESCMID eLibrary by author Others causes • Descending cervical abcess • Oesophagus perforation • Posterior extension of a sternoclavicular arthritis ESCMID eLibrary by author ESCMID eLibrary by author Empiric antimicrobial therapy • Associated with surgery • Targeting streptococci and anaerobes (+/- GNB) if pharyngeal/odontogenic infection – 3rd G cephalosporin + imidazole – Amoxicillin - clavulanate • Targeting streptococci, anaerobes and GNB if ESCMIDoesophagus perforation eLibrary by author In conclusion • Lack of studies concerning antimicrobials • Severe • Sample • Treat aggressively; initial broad spectrum if post-surgery • Call the surgeon ESCMID eLibrary by author.
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