Treatment of Mediastinitis
The treatment of mediastinitis depends on its etiology, with aggressive surgical drainage and appropriate antimicrobial therapy forming the cornerstone of management for most types of mediastinitis. 1
Classification and Etiology-Based Treatment Approach
1. Acute Mediastinitis
A. Post-surgical Mediastinitis (after cardiac/thoracic surgery)
- Primary treatment:
- Surgical debridement of infected tissue
- Broad-spectrum antibiotics targeting Staphylococci (predominant pathogens) 1
- Initial empiric regimen: Beta-lactams alone or combined with metronidazole
- For MRSA risk: Add vancomycin, linezolid, or daptomycin
- Duration: Minimum 2-3 weeks of IV antibiotics followed by oral therapy
B. Descending Necrotizing Mediastinitis (from oropharyngeal/odontogenic infections)
- Primary treatment:
- Aggressive surgical drainage through transcervical approach 2
- Early CT scanning for diagnosis and surgical planning
- Broad-spectrum antibiotics covering polymicrobial infections with anaerobes
- Carbapenems have shown good efficacy against isolated organisms 2
- Consider tracheostomy if infection extends below the carina
C. Esophageal Perforation-related Mediastinitis
- Primary treatment:
- Immediate surgical repair of perforation
- Mediastinal drainage
- Broad-spectrum antibiotics covering polymicrobial infections with anaerobes 1
- Nutritional support (often parenteral initially)
2. Chronic/Granulomatous Mediastinitis
A. Fungal Mediastinitis (Histoplasmosis)
For Mediastinal Fibrosis (Fibrosing Mediastinitis):
For Granulomatous Mediastinitis:
- For severe obstructive complications: Amphotericin B (0.7-1.0 mg/kg/day) initially 3
- Switch to itraconazole (200 mg once or twice daily) after improvement 3
- For mild-moderate cases with symptoms >1 month: Itraconazole (200 mg once or twice daily for 6-12 weeks) 3
- For severe cases with airway obstruction: Prednisone (0.5-1.0 mg/kg daily, maximum 80 mg) in tapering doses over 1-2 weeks 3
- Surgical resection of obstructive masses if medical therapy fails 3
Antimicrobial Selection Based on Pathogen
Bacterial mediastinitis:
- Polymicrobial infections: Beta-lactams + metronidazole
- Staphylococcal infections: Vancomycin, linezolid, or daptomycin for MRSA risk
- Multidrug-resistant gram-negative bacteria: Consider polymyxins, glycylglycines, or new beta-lactam/beta-lactamase inhibitor combinations 1
Fungal mediastinitis:
- Histoplasmosis: Itraconazole 200 mg once or twice daily (for granulomatous type only)
- Other fungi (Candida, Aspergillus): Azoles, amphotericin B, or echinocandins 1
Important Clinical Considerations
- Early diagnosis using CT scanning is crucial for successful management 4, 2
- Surgical drainage and debridement are essential components of treatment for acute mediastinitis
- Mediastinitis remains a severe infection with high mortality requiring early and broad-spectrum antibiotic therapy 1
- For fibrosing mediastinitis, mechanical interventions like stenting may be more beneficial than antimicrobial therapy 3
- Duration of therapy is not well established in comparative studies 1
Pitfalls to Avoid
- Delaying surgical intervention in acute mediastinitis
- Relying solely on chest radiography, which may be misleading; cross-sectional imaging is generally required 4
- Treating fibrosing mediastinitis with antifungals, as they are typically ineffective 3
- Failing to recognize the distinction between granulomatous mediastinitis (which may respond to antifungals) and fibrosing mediastinitis (which typically does not)
- Underestimating the severity and potential mortality of mediastinitis, particularly descending necrotizing mediastinitis 5