Antibiotic therapy in reconstructive surgery of deep sternal wound infections.

BACKGROUND: The choice of antibiotics and length of administration in the treatment of deep sternal wound infections (DSWI) is unclear. The reason for this is the lack of studies and local differences in resistance. An increase in resistance can be observed in gram-positive cocci, which are the most frequently detected in deep sternal infections. The duration of administration is often 2- 6 weeks or longer, although the benefit of prolonged antibiotic administration has not been confirmed by studies. We evaluated the antibiotic treatment during surgical treatment, consisting of surgical wound debridement and plastic chest reconstruction. METHODS: Retrospective analysis of patients (n = 260) who underwent reconstructive surgery in the Department of Plastic Surgery at Leipzig University Hospital from 01.05.2012 - 31.12.2020. The duration of intake, results of microbiological swabs and resistance were investigated. RESULTS: At the time of discharge, closed wound conditions were noted in 177 of 260 cases (68.1%). The largest proportion of patients (n = 238) was treated with a latissimus dorsi flap (91.5%).Antibiotic treatment was conducted in 206 of 260 cases (79.2%). The mean duration of antibiotic administration was 21.4 days (±17.6). Prolonged treatment over 14 days did not alter outcome (p = 0.226), in contrast, the number of multidrug resistances (p < 0.001). There was no prove of resistance against linezolid which is effective against the most common found infectious agents Staphylococcus epidermidis (n = 93; 24.0 %) & Staphylococcus aureus (n = 47; 12.1 %). CONCLUSION: There is no evidence of benefit from antibiotic therapy over 14 days, whereas multidrug resistance increases with prolonged antibiotic use. In the absence of infectious agents or clinical signs of inflammation, surgical treatment without additional antibiotic treatment is effective.Linezolid is a suitable antibiotic in the treatment of gram-positive infections which are the most frequent in DSWI.

Mortality after sternal reconstruction with pectoralis major flap vs omental flap for postsurgical mediastinitis: A systematic review and meta-analysis.

BACKGROUND: Deep sternal wound infections are rare but severe complications after median sternotomy and can be managed with sternal reconstruction. The use of pectoralis major flap (PMF) has traditionally been the first-line approach for flap reconstruction but the advantage in patients' survival when compared to the omental flap (OF) transposition is still not clear. We performed a study-level meta-analysis evaluating the association of the type of flap on postoperative outcomes. METHODS: A systematic search of the literature was performed to identify all studies comparing the postoperative outcomes of PMF versus OF for sternal reconstruction. The primary outcome was postoperative mortality. Secondary outcomes were the occurrence of sepsis, pneumonia, operative time, and length of stay. Binary outcomes were pooled using an inverse variance method and reported as odds ratio (OR) with corresponding 95% confidence interval (CI). Continuous outcomes were pooled using an inverse variance method and reported as standardized mean difference (SMD) with corresponding 95% CI. RESULTS: Four studies with a total of 528 patients were included in the analysis. Overall, 443 patients had PMF reconstruction, and 85 patients had OF reconstruction. Baseline characteristics were similar in both groups. There were no statistically significant differences between PMF patients and OF patients in mortality (OR 0.6 [0.16; 2.17]; p = .09), sepsis (OR 1.1 [0.49; 2.47]; p = .43), pneumonia (OR 0.72 [0.18; 2.8]; p = .11), length of stay (SMD -0.59 [-2.03; 0.85]; p < .01), and operative time (SMD 0.08 [-1.21; 1.57]; p < .01). CONCLUSION: Our analysis found no association between the type of flap and postoperative mortality, the incidence of pneumonia, sepsis, operation time, and length of stay.

Is vacuum-assisted closure therapy feasible for children with deep sternal wound infection after cardiac surgery? The pooling results from current literature.

Vacuum-assisted closure (VAC) has been used for children with deep sternal wound infections (DSWI); however, the safety and efficiency have not been determined. A meta-analysis was performed for outcomes of VAC therapy in children with DSWI after cardiac surgery. Electronic databases, including PubMed, Scopus, and Cochrane Library CENTRAL were searched systematically from January 1990 to October 2020 for the literature which reported the outcomes of VAC therapy for children with DSWI after cardiac surgery. Meta-regression and subgroup analyses were performed to find risk factors for prolonged length of VAC therapy and hospital stay. Eleven studies were included in this study, involving 217 subjects. VAC therapy was performed due to mediastinitis after congenital heart diseases (CHD) repair. In children with DSWI after cardiac surgery, length of VAC therapy, and hospital stay were 11.1 days (95% CI, 9.6-12.5 days) and 29.8 days (95% CI, 22.8-36.9 days), respectively. Incidence of infectious and wound-related complications was 8.5% (95% CI, 4.1%-13.0%). Overall mortality in this setting was 5.8% (95% CI, 2.5%-9.1%). In conclusion, in children with DSWI after cardiac surgery, length of VAC therapy and hospital stay were 11.1 and 29.8 days, respectively. Overall mortality was 5.8%. Although not significant, delayed chest closure, complex CHD, and Gram-negative bacilli/fungal infections may potentially contribute to prolonged duration of VAC treatment.

Analysis on the effect of two methods in different degrees deep sternal wound infection after undergoing cardiac surgery / 中华胸心血管外科杂志

Objective:To analysis the effect of two methods of transposition of pectoralis major in different degrees deep sternal wound infection(DSWI) after undergoing cardiac surgery.Methods:128 patients with DSWI after cardiac surgery were treated, 72 were mild, and 56 were severe. 66 cases of pectoralis major muscle flap docking method(medial muscle flap docking group) and 62 cases of lateral pectoralis major muscle flap turnover method(lateral muscle flap turnover group) were implemented respectively. Drainage tube indwelling time, reoperation rate, incidence of lung infection, long-term thoracic stability and other aspects were observed to compared the treatment effect.Results:In the mild patients, the medial muscle flap docking group and the lateral muscle flap turnover group were compared( P<0.05). The postoperative hospital stay [(14.2±4.7)days vs.(17.1±3.9)days], drainage tube retention time[(6.2±1.7)h vs.(9.1±2.9)h], and reoperation rate(2.4% vs. 6.7%), the incidence of lung infection(14.3% vs. 23.3%), long-term thoracic stability[73.8%(31/42)vs.43.3%(13/30)]. In the severe patients, the medial muscle flap docking group and the lateral muscle flap turnover group were compared. The postoperative hospital stay[(24.2±7.2)days vs.(20.1±3.5)days], drainage tube retention time[(20.2±6.6)h vs.(13.2±3.1)h], reoperation rate(20.8% vs.12.5%), incidence of pulmonary infection(41.7% vs. 31.3%), long-term thoracic stability[25.0%(6/24)vs.68.8%(22/32)]. The differences of the indicators in each group were significant , P<0.05. In the mild group, each index of the pectoralis major medial muscle flap docking method was superior to the lateral muscle flap turnover method, but the treatment results of the two methods in the severe group were opposite. Conclusion:Patients with mild deep DSWI treated with medial pectoralis major muscle flap docking and suture have less hospital stay, less reoperation rate, less complications and better treatment effect than reverse lateral pectoralis major muscle flap turnover. But the two treatments in the severe DSWI have the opposite effect.

The impact of incisional negative pressure wound therapy on the wound healing process after midline sternotomy.

Previous studies have reported that the use of incisional negative pressure wound therapy (INPWT) might reduce the incidence of wound infections, although its mechanism remains unknown. We designed a prospective study to explore the effects of INPWT on different stages of the wound healing process. After meeting the inclusion criteria, 108 patients were enrolled. Based on exclusion criteria four patients were excluded and 104 patients were randomised into two groups. INPWT was applied after primary closure of the midline sternotomy in the study group (n = 52), while conventional wound dressing was applied in the control group (n = 52). We documented the incidence of deep sternal wound infections and analysed the pre- and postoperative inflammatory biomarkers and scar size in both groups. No wound infections were observed in the study group compared with six cases (11.1%) in the control group, (P = .026). No significant differences were observed in the inflammatory biomarkers between the groups. Scar size was significantly smaller in the study group. We concluded that INPWT has less effect on the inflammatory phase and appears to have more effect on the proliferation phase through pronounced scar formation.

Bilateral-pectoral major muscle advancement flap combined with vacuum-assisted closure therapy for the treatment of deep sternal wound infections after cardiac surgery.

OBJECTIVES: The median sternotomy is the most common surgical approach for cardiac surgery. Deep sternal wound infection is a fatal complication after median sternotomy. The aim of this study was to evaluate the therapeutic effect of Bilateral-pectoral major muscle advancement flap combined with Vacuum-assisted closure therapy on rehabilitation for the treatment of deep sternal wound infection after cardiac surgery. METHODS: Between January 2016 to January 2018, 21 patients (10 males, 11 females) with deep sternal wound infection after cardiac surgery underwent Bilateral-pectoral major muscle advancement flap combined with Vacuum-assisted closure therapy. These patients were followed-up 12 months postoperative. The patient characteristics, duration of vacuum-assisted closure therapy, the mean hospital stay, postoperative complications, long-term survival of patients were retrospectively analyzed. RESULTS: Most patients undergone 1-3 times vacuum-assisted closure treatment sessions before closure. All patients were cured to discharge, the mean hospital stay was 21.1 days. Most patients' healing wounds were first-stage healing, only one patient's wound was second-stage healing, none was third-stage healing. One patient developed pulmonary infection and respiratory failure during the 12-month follow-up. None of the patients died during follow-up. CONCLUSIONS: Bilateral-pectoral major muscle advancement flap combined with Vacuum-assisted closure therapy for the treatment of deep sternal wound infections after cardiac surgery can shorten the hospital stays and few complications. However, this is a retrospective case series presentation with no comparison group, the number of inferences is limited, so further large-scale controlled studies are needed.

Vacuum-assisted closure therapy combined with bi-pectoral muscle flap for the treatment of deep sternal wound infections.

Deep sternal wound infection (DSWI) is a fatal complication after median sternotomy. This study was to assess the effect of vacuum-assisted closure (VAC) combined with bi-pectoral muscle advancement flap therapy on rehabilitation for the treatment of DSWI. Fifty-two patients with DSWI underwent treatment of VAC and bi-pectoral muscle flap. These patients were followed-up 12 months postoperation. The patient characteristics, duration of VAC therapy, the mean hospital stay, and postoperative complications were retrospectively analysed. All patients underwent 1 to 3 VAC treatment sessions before closure. Fifty-one of 52 DSWI patients were cured to discharge; the mean hospital stay was 26.5 days. The drainage tube continued to drain a large amount of bloody fluid in three patients after the wound was closed. Respiratory failure occurred in one patient with severe mediastinal and pulmonary infections and died eventually in hospital. One patient died of acute cerebral haemorrhage during the12-month follow-up. VAC therapy combined with bi-pectoral muscle flap is a simple and effective treatment for DSWIs with short hospital stays and few complications. However, this is a retrospective case series presentation with no comparison group; further large-scale controlled studies are needed.

The risk of mediastinitis and deep sternal wound infections with single and bilateral, pedicled and skeletonized internal thoracic arteries.

Bilateral internal thoracic artery (BITA) grafting may prolong survival in coronary artery bypass graft (CABG) patients, but its use has been curtailed due to concerns of deep sternal wound infections (DSWI) resulting in mediastinitis. This article examines the association of single internal thoracic artery (SITA) and BITA grafting and the role of harvesting techniques with the development of DSWI in CABG patients. The development of DSWI following BITA grafting is multifactorial and is independent of the harvesting technique.

Efficacy of a novel strategy for poststernotomy deep sternal infection after thoracic aorta replacement using a prosthetic graft.

BACKGROUND: Poststernotomy deep sternal wound infections are persistent and occasionally fatal, especially in cases involving prosthetic grafts, because of their complicated structure and virtual impossibility of removal. We aimed to verify the influence of cooperation with plastic surgeons and our novel strategy for treating deep sternal wound infection after aortic replacement on cardiovascular surgery outcomes. PATIENTS AND METHODS: Nine hundred eighty-three consecutive patients were divided into two groups: an early group (2012-2013) and a late group (2014-2015). The late group had received cooperatively improved perioperative wound management: our novel strategy of deep sternal infection based on radical debridement and immediate reconstruction decided by reference to severities of the patient's general condition and widespread infection by early intervention of plastic surgeons. The groups were analysed retrospectively. Binary variables were analysed statistically with the Fisher exact test and continuous variables with the Mann-Whitney U test. Inter-group differences were assessed with the chi-square test. RESULTS: Twenty of 390 cases in the early group and 13 of 593 cases in the late group were associated with deep sternal infection. Morbidity rates of deep sternal wound infection and associated mortality rates 1 year after reconstruction surgery were significantly less (p <0.05 for both) in the late group. CONCLUSIONS: Intervention by plastic surgeons improved perioperative wound management outcomes. Our treatment strategy for deep sternal wound infection also reduced associated mortality rates. Facilities should consider the early inclusion of plastic surgeons in the treatment of patients undergoing aortic replacement to facilitate better outcomes.

Dalbavancin treatment in a deep sternal wound MRSA infection after coronary artery bypass surgery: a case report.

BACKGROUND: A deep sternal wound infection (DSWI) can become a severe complication after cardiac surgery, with in-hospital mortality rates reaching up to 35%. Staphylococci, particularly methicillin resistant Staphylococcus aureus (MRSA), play important roles in its etiology. CASE PRESENTATION: This case report presents a patient who underwent coronary artery bypass surgery, and suffered postoperatively from a DSWI caused by MRSA. The pathogen was susceptible to vancomycin and rifampicin in vitro; however, this therapy was clinically ineffective. Both clinical improvement and MRSA eradication were achieved after surgical debridement of the wound and the intravenous administration of dalbavancin. CONCLUSIONS: We decided to administer dalbavancin because of its convenient pharmacological profile. The patient's tolerance of the antimicrobial was good, the biochemical markers of inflammation returned to the normal ranges, and the microbiological results one week after the dalbavancin administration were negative. A good clinical outcome was achieved with both the surgery and antimicrobial administration. In this case, dalbavancin was more effective in the treatment of the sternal and surrounding tissue infections caused by MRSA, when compared to vancomycin.

New technique of pectoral muscle flap reconstruction for 23 patients with deep sternal wound infections / 中国胸心血管外科临床杂志

@#Objective    To study the effect of deep sternal wound infections（DSWIs）treated by the techniques of pectoral major muscular(PM) turnover and non-suture remain after the wound restitution. Method    We retrospectively analyzed the clinical data of 23 patients with DSWIs in our hospital between June 2016 and December 2016. There were 13 males and 10 females at age of 4-73(54.5±19.5) years. There were 8 patients with concomitant diabetes mellitus and 1 patient with chronic obstructive pulmonary disease(COPD) and brain infarction. Eigteen patients were of type Ⅱ, 5 patients of type Ⅲ according to Pairolero’ classification in the DSWIs. Five patients were with remaining abscess cavity in the mediastinum by thoracic compute tomography(CT). Under general anesthesia the DSWIs debrided thoroughly. The PM elevated from the anterior pectoralis major fascia off subcutaneous tissue to lateral to anterior axillary line, the PM cutted off, then made to the muscle flap, turnover PM flap filled and fixed to sternal wound by lighten tensile suture, the subcutaneous tissue and skin sutured by cutting full-thickness. Results    The sternal reconstruction after debridement of the sternal wound was used by bilateral PM flap in the 17 patients, unilateral PM in 6 patients. There were 21(91.3%) patients in stage Ⅰ healing, 2 patients deferment healing of local cut skin without reoperation. There were 22 patients with non-paradoxical breathing during the postoperation. One death resulted from multiple-organ failure of the concomitant disease. The average of hospital day was 10.6 days. The wound healing was good by chest CT at 1 month after the operation. Conclusion    The sternal forming by the technique of the PM flap turnover, without remain of fremde stoffe in wound for DSWIs is distinctive method, evident effect.

Sternal reconstruction after post-sternotomy mediastinitis.

BACKGROUND: Deep sternal wound complications are uncommon after cardiac surgery. They comprise sternal dehiscence, deep sternal wound infections and mediastinitis, which will be treated as varying expressions of a singular pathology for reasons explained in the text. METHODOLOGY AND REVIEW: This article reviews the definition, prevalence, risk factors, prevention, diagnosis, microbiology and management of deep sternal wound infections and mediastinitis after cardiac surgery. The role of negative pressure wound therapy and initial and delayed surgical management is discussed with special emphasis on plastic techniques with muscle and omental flaps. Recent advances in reconstructive surgery are presented. CONCLUSIONS: Deep sternal wound complications no longer spell debilitating morbidity and high mortality. Better understanding of risk factors that predispose to deep sternal wound complications and general improvement in theatre protocols for asepsis have dramatically reduced the incidence of deep sternal wound complications. Negative pressure wound therapy and appropriately timed and staged muscle or omental flap reconstruction have transformed the outcomes once these complications occur.

Hygienic interventions to decrease deep sternal wound infections following coronary artery bypass grafting.

BACKGROUND: The department of Cardiothoracic Surgery at Uppsala University Hospital has 25 beds in one to four patient rooms and an operating suite consisting of five operating rooms with ultraclean air. Around 700 open heart (250 isolated coronary artery bypass grafting, CABG) operations are performed annually. In 2009, the numbers of deep sternal wound infections (DSWIs) increased to unacceptable rates despite existing hygienic guidelines. AIM: To show how root cause analysis (RCA) followed by quality improvement interventions reduced the rate of DSWI after CABG surgery. METHODS: Only isolated CABG patients requiring surgical revision due to DSWI were included. Swabs and tissue biopsies were taken during surgical revision and analysed with standard methods. DSWIs were registered prospectively according to US Centers for Disease Control and Prevention definitions. RCA for infection was performed between September 2009 and April 2010. Interventions based on results of the RCA and on nationally recommended practices were concluded in April 2010, and thought to have taken full effect by July 1st, 2010. Air was actively sampled at ≤0.5m from the sternal incision. FINDINGS: DSWI incidence rates per CABG operations decreased from 5.1% pre intervention to 0.9% post intervention. Wound cultures pre intervention grew Staphylococcus aureus 27.1% and coagulase negative staphylococcus (CoNS) 47.1%, post intervention S. aureus 23.1% and CoNS 30.8%. Air counts did not exceed 5cfu/m(3). CONCLUSION: When the aetiology of an error is multifactorial, RCA engaging both the medical professions and the infection control team is a potential tool to map causes leading to adverse events such as healthcare-associated infections. A systematic quality improvement intervention based on the RCA may reduce the number of deep sternal wound infections after CABG surgery.