From the Guidelines
Mediastinitis management requires prompt, aggressive treatment with a combination of surgical debridement and broad-spectrum antibiotics. The primary steps are:
- Immediate surgical intervention: Perform extensive debridement of necrotic tissue, drainage of abscesses, and thorough irrigation of the mediastinum, as emphasized by the guidelines for treatment of candidiasis 1.
- Broad-spectrum antibiotic therapy: Start with a combination of vancomycin and piperacillin-tazobactam or meropenem, adjusting based on culture results, to address the high morbidity associated with untreated disease 1.
- Continuous irrigation: Implement a system for continuous mediastinal irrigation with saline or an antiseptic solution to provide more-definitive histopathological and microbiological documentation before initiation of prolonged therapy 1.
- Wound care: Use negative pressure wound therapy (wound VAC) to promote healing and prevent fluid accumulation.
- Nutritional support: Ensure adequate nutrition through enteral or parenteral feeding to support healing.
- Monitor closely: Watch for signs of sepsis, multiorgan failure, or deterioration, considering the indolent and delayed presentation of candidal mediastinitis 1.
- Consider hyperbaric oxygen therapy as an adjunct treatment in select cases.
The aggressive approach is crucial because mediastinitis can rapidly progress to life-threatening sepsis, and the combination of surgical debridement and broad-spectrum antibiotics addresses both the infectious source and systemic spread, as supported by the guidelines for treatment of candidiasis 1. Continuous irrigation helps remove debris and bacteria, while negative pressure therapy promotes tissue granulation and wound closure. Close monitoring is essential due to the risk of severe complications. Continue antibiotic therapy for at least 2-4 weeks, or longer based on clinical response and inflammatory markers, and consider surgical re-exploration if improvement is not seen.
From the Research
Management of Mediastinitis
The management of mediastinitis typically involves a combination of antibiotic therapy, surgical drainage, and supportive care.
- Antibiotic therapy should be broad-spectrum and cover the suspected microorganisms, with adjustments made based on bacterial cultures 2, 3, 4.
- Surgical drainage may be necessary to reduce the inoculum of pathogens and provide adequate drainage and debridement 3, 4, 5.
- Supportive care, including nutritional support and management of any underlying conditions, is also crucial 3, 4.
Antibiotic Therapy
- Broad-spectrum antibiotics, such as beta-lactams alone or combined with metronidazole, are often the therapy of choice for both Gram-positive and Gram-negative bacteria, including anaerobes 2.
- Additional antibiotic classes with a spectrum against methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) may be necessary for patients at risk 2.
- In cases of fungal infections, established and novel azoles, amphotericin B, and echinocandins may be effective 2.
Surgical Intervention
- Video-assisted thoracoscopic surgery (VATS) may be used as an alternative to thoracotomy for the management of acute purulent mediastinitis and pleural empyema 5.
- Surgical drainage and debridement may be necessary to reduce the inoculum of pathogens and provide adequate drainage 3, 4, 5.