What antibiotics are recommended for the treatment of mediastinitis?

Antibiotic Treatment for Mediastinitis

For mediastinitis treatment, broad-spectrum antibiotics targeting both gram-positive and gram-negative bacteria, including anaerobes, are recommended as initial therapy, with specific regimens determined by the suspected etiology and local resistance patterns. 1

Treatment Based on Etiology

Granulomatous Mediastinitis (Active Inflammatory Process)

• Amphotericin B (0.7-1.0 mg/kg/day) is recommended as initial therapy for severe obstructive complications of mediastinal histoplasmosis 2
• After clinical improvement, transition to itraconazole 200 mg once or twice daily to complete treatment 2
• For less severe cases, itraconazole 200 mg once or twice daily for 6-12 months may be used 2
• Prednisone 40-80 mg daily for 2 weeks should be considered in cases with major airway obstruction 2

Fibrosing Mediastinitis (Chronic Fibrotic Process)

• Antifungal treatment is generally not recommended as most authorities believe it does not improve outcomes 2
• A 12-week trial of itraconazole 200 mg once or twice daily may be considered if clinical findings cannot differentiate fibrosing mediastinitis from granulomatous mediastinitis 2
• Intravascular stents are recommended for selected patients with pulmonary vessel obstruction 2

Post-Surgical/Post-Traumatic Mediastinitis

• For MRSA-associated mediastinitis:

  • Vancomycin 30-60 mg/kg/day IV in 2-4 divided doses is the primary treatment 2
  • Teicoplanin, linezolid, or daptomycin are alternatives 2
  • Linezolid has shown efficacy in experimental MRSA mediastinitis at higher doses 3

• For polymicrobial infections (common after esophageal perforation):

  • Broad-spectrum beta-lactams alone or combined with metronidazole to cover both gram-positive, gram-negative, and anaerobic bacteria 1

Duration of Therapy

• For post-surgical mediastinitis: 4-6 weeks of appropriate antibiotic therapy 2
• For granulomatous mediastinitis: 6-12 weeks of antifungal therapy 2
• Longer courses may be necessary based on clinical response and imaging findings 2

Adjunctive Therapies

• Surgical drainage is essential in most cases of acute mediastinitis 4
• Hyperbaric oxygen therapy may provide additional benefit when combined with appropriate antibiotics 5
• For fungal mediastinitis, corticosteroids might be beneficial in cases with significant inflammation and obstruction 2

Special Considerations

• In patients with renal dysfunction, therapeutic drug monitoring should be considered when using agents like linezolid 6
• For multidrug-resistant organisms, newer agents such as polymyxins, glycylglycines, or new beta-lactam/beta-lactamase inhibitor combinations may be necessary 1
• Early and aggressive treatment is crucial due to the high mortality rate associated with mediastinitis 4

Common Pitfalls to Avoid

• Failing to distinguish between granulomatous (potentially responsive to antifungals) and fibrosing mediastinitis (generally not responsive) 2
• Delaying surgical drainage when indicated, which can lead to increased mortality 4
• Inadequate spectrum of antimicrobial coverage, particularly in polymicrobial infections 1
• Not considering local resistance patterns when selecting empiric therapy 1

Remember that mediastinitis remains a severe infectious disease with high mortality, requiring prompt diagnosis and aggressive treatment with appropriate antibiotics and, in many cases, surgical intervention 1, 4.