Prevention and management of sternal wound infections

Abstract

Although the incidence of sternal wound infections has decreased to 1% to 4% of all cardiac surgery procedures, they continue to be associated with increased morbidity and mortality, and decreased long-term life expectancy. [1][2][3] They prolong hospital length of stay and can raise hospital costs by as much as US$62,000. 4 Sternal wound infections are now publicly reported, and the US Center for Medicare and Medicaid services will no longer reimburse hospital costs incurred in the treatment of deep sternal wound infections (DSWI) following coronary artery bypass graft (CABG) surgery. 5 Despite the significant clinical and economic consequences of sternal wound infections, there are currently no specific guidelines in cardiac surgery for the prevention and treatment of sternal wound infections. What follows are recommendations for the prevention of wound infections during the preoperative, intraoperative, and postoperative periods, as well as principles for the most effective methods and techniques to treat sternal wound infections to achieve the lowest morbidity and mortality as derived from evidence-based recommendations (Tables 1 and 2). METHODSA literature search was performed using PubMed and Google Scholar up to March 2015 using the MeSH headings ''Sternal Wound Infections -Prevention and Treatment,'' ''Treatment of Mediastinitis,'' ''Topical Antibiotics in Cardiac Surgery,'' ''Wound VAC Therapy for Sternal Wound Infections,'' and ''Prevention and Treatment of Sternal Instability.'' Editorials and articles involving prevention and therapy for wound infections in noncardiac, nonsternotomy patients were excluded.The systemic review was reported according to the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines 6 (Figure 1).

Evaluation of the safety and efficacy of a new hemostatic powder using a quantitative surface bleeding severity scale

“…HP may offer advantages in achieving hemostasis with reduced complications on the sternal bone compared to bone wax. The American Association of Thoracic Surgery has a Class III recommendation against the use of bone wax as it may impair bacterial clearance and bone union, and it presents an independent risk factor for sternal dehiscence . For the HP arm of the study, there was only one AE of sternal dehiscence (1 of 83 cardiothoracic patients [1.2%]) which was not attributed to the use of HP by the investigator and the CEC.…”

Deep sternal wound infection after cardiac surgery in the Chinese population: a single-centre 15-year retrospective study

“…For the treatment of DSWI, it is thought that debridement was the most effective treatment after a timely diagnosis, and the use of antibiotics targeting the pathogenic bacterium was better than dilute povidoneiodine irrigation for the treatment of DSWI (23,27). Some studies have reported that an antibiotic-collagen sponge was effective for the prevention of DSWI.…”

Post-sternotomy mediastinitis in the modern era

“…Pre‐operative optimization of nutritional status in patients undergoing cardiac surgery is therefore paramount. The AATS consensus guideline recommends that surgery should be postponed for patients with pre‐operative hypoalbuminemia to receive nutritional nutrition for 7‐10 days if the procedure can be safely delayed . It should be given through the enteral instead of parenteral route, to avoid potential infections and metabolic complications (Class I Recommendation) .…”

“…Despite advances in the perioperative care and infection control practices, deep sternal wound infection (DSWI) or mediastinitis continues to have a considerable impact on not only mortality and morbidity but also length of hospital stay and associated health care expenses. In response to these detrimental effects of DSWI, the American Association for Thoracic Surgery (AATS) has recently published expert consenus review guidelines for the prevention and treatment of sternal wound infections in cardiac surgery . This review will discuss the incidence and risk factors of DSWI in the modern era, and associated morbidity and mortality of this complication.…”