From the Guidelines
The recommended treatment for mediastinitis involves prompt surgical debridement combined with broad-spectrum antibiotics, as this approach has been shown to improve outcomes in terms of morbidity, mortality, and quality of life. Patients should undergo immediate surgical intervention to remove infected and necrotic tissue, drain collections, and irrigate the mediastinal space.
- Antibiotic therapy typically includes vancomycin (15-20 mg/kg IV every 8-12 hours) plus piperacillin-tazobactam (4.5g IV every 6 hours) or a carbapenem like meropenem (1g IV every 8 hours), adjusted based on culture results and continued for 4-6 weeks.
- Supportive care is essential, including ICU admission, hemodynamic monitoring, respiratory support, and nutritional supplementation.
- For post-sternotomy mediastinitis, surgical options include closed irrigation, vacuum-assisted closure, or muscle/omental flap reconstruction.
- Treatment success depends on early diagnosis, aggressive surgical management, appropriate antimicrobial therapy, and addressing any underlying conditions like diabetes or immunosuppression.
- Delayed treatment significantly increases mortality risk, which can reach 10-40% even with optimal management, due to the proximity of vital structures and risk of sepsis, as noted in various studies 1.
- The use of broad-spectrum antibiotics is recommended, as the high risk of infection among patients with mediastinitis outweighs the risks of acquired antibiotic resistance 1.
- The choice of antibiotic regimen should be tailored according to the microbial isolation, and prolonged courses of empiric antibiotics should be guided by local antibiotic stewardship teams 1.
From the Research
Treatment of Mediastinitis
The treatment of mediastinitis typically involves a combination of antibiotics, surgery, and supportive care. The choice of antibiotics depends on the underlying cause of the infection and the suspected pathogens involved.
- Antibiotic Therapy: Broad-spectrum antibiotics, such as beta-lactams, are often used to treat mediastinitis, as they are effective against a wide range of bacteria, including Gram-positive and Gram-negative bacteria, as well as anaerobes 2.
- Surgical Intervention: Surgery may be necessary to drain abscesses, debride infected tissue, and repair any underlying defects, such as esophageal perforations 3.
- Supportive Care: Supportive care, such as fluid resuscitation, nutritional support, and pain management, is also important in the treatment of mediastinitis.
Specific Treatment Options
For patients with mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA), linezolid may be an effective treatment option 4, 5, 6.
- Linezolid: Linezolid is an antibiotic that is effective against MRSA and can be administered orally or intravenously. Therapeutic drug monitoring may be necessary to ensure adequate serum concentrations, especially in patients with renal dysfunction 6.
- Hyperbaric Oxygen Therapy: Hyperbaric oxygen therapy may also be used as an adjunctive treatment for mediastinitis, as it has been shown to potentiate the effects of antibiotics and reduce bacterial counts 5.
Considerations for Treatment
The treatment of mediastinitis should be individualized based on the underlying cause of the infection, the suspected pathogens involved, and the patient's overall health status.
- Multidrug-Resistant Bacteria: The increasing prevalence of multidrug-resistant bacteria, such as MRSA and vancomycin-resistant Enterococcus (VRE), requires careful consideration in the selection of antibiotics 2.
- Immunocompromised Patients: Immunocompromised patients, such as those with fungal infections, may require specialized treatment, including antifungal medications 2.