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Background
Sternal wound infection is a devastating complication of cardiothoracic surgery that carries high postoperative morbidity and mortality rates. We explored whether our current program of extensive bacteriological examination including repeat blood cultures may contribute to the early diagnosis of sternal wound infection.
Methods
We retro...
Context in source publication
Context 1
... prevalence of sternal wound infection in patients whose cultures were negative culture and in those whose cultures were positive for other organism were 7.8% and 11.8%, respectively. However, 67% of patients whose cultures were positive for Staphylococcus aureus developed sternal infection (Figure 1, p < 0.0001). Of them, 8 patients required debridement of the infected tissues followed by reconstructive surgeries by omental and/or muscle flap, whereas others underwent only conservative managements such as negative pressure wound therapy. ...Similar publications
Pre-Fontan coil closure of aorto-pulmonary collaterals decreases single-ventricle volume load and improves outcome. Coiling of right and left internal mammary arteries may present a challenge to cardiothoracic surgery teams caring for these patients when future coronary artery bypass grafting is needed for SV patients. The goal of this study was to...
THORACOTOMY FOR CHEST TRAUMA-INDICATION, OPERATIVE FINDING AND OUTCOME
K. E. Okonta1, C. E. Amadi1, P. D. Okoh1 1university of Port Harcourt,Cardiothoracic Surgery Unit/Surgery/Health Sciences,Port Harcourt, RIVERS STATE, Nigeria
Introduction
To determine the rate, indication and case fatality of open thoracotomy in our country, we reviewed the c...
Citations
... Positive blood cultures in patients suspected of mediastinitis may be helpful in establishing aetiology. The presence of bacteraemia without other sources of infection within 90 days post-surgery may indicate mediastinitis, especially when S.aureus is isolated [72]. In such cases, the interpretation of positive cultures other than blood cultures is difficult and should be approached individually. ...
Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy
... DSWI is a life-threatening complication following cardiac surgery. Among the few risk factors for developing DSWI after median sternotomy are diabetes, a leading risk factor [6], and the use of bilateral internal mammary arteries for cardiac bypass [7]. Obesity, chronic obstructive pulmonary disease, osteoporosis, smoking, and prolonged intensive care unit stays are also well-known risk factors [2]. ...
... Medical treatment should be initiated immediately after diagnosis. Nakamura et al. [7] advocated the importance of taking repeat blood cultures in febrile patients for detecting Staphylococcus aureus, then administering broad-spectrum antibiotic therapy as needed. Conservative treatments include vacuum-assisted closure [1,[3][4][5], closed suction antibiotic catheter irrigation system [1], and hyperbaric oxygen therapy [9]. ...
Background
Closure of the deep sternal wound is a well-known challenge for chest and plastic surgeons. Various techniques have been described. However, there remains a need for a better one—a simple, safe procedure with minimal complications for patients, who usually present with underlying serious comorbidities. We present our technique for medium-size sternal wound closure in men.
Methods
Nineteen male patients, aged 52 to 85 years (average 71.7 years), with severe risk factors and underlining diseases underwent sternal wound closure with modified bipedicle pectoralis major myocutaneous flaps. The flaps have a rich blood supply from perforators of the pectoralis major muscles and branches of the thoracoacromial and superior epigastric arteries. This technique was performed as a single procedure for 12 patients (63%), as a second procedure for six patients (32%), and as a third one for one patient (5%). There was no need for humeral detachment of the muscle, and the skin deficit was solved by mobilizing skin medial to the axilla.
Results
No ischemic changes or dehiscence was shown in any of the flaps. Three patients (16%) had a second procedure, two because of bleeding in POD1 and POD14, and one due to infection. One patient (5%) had pulmonary emboli. Another patient (5%) had severe pulmonary effusion. Four patients (21%; average age 76y) died perioperatively (sepsis in 3 and cardiac arrest in 1).
Conclusions
The modified bipedicle pectoralis myocutaneous flaps technique is safe and simple. It should be considered in medium-size sternal wound closure in men.
Level of evidence: Level IV, therapeutic study.
... Staphylococcus aureus is the most problematic bacterium in wound infections (Tong et al., 2015) with a high incidence affecting the management practices. As reported by Nakamura et al. (2014), the blood stream infection by S. aureus is an important risk factor of wound infection. Staphylococcus aureus is able to express various virulence factors that facilitate cell adhesion and host response. ...
Resistant wound microorganisms are becoming an extremely serious challenge in the process of treating infected chronic wounds, leading to impaired healing. Thus, additional approaches should be taken into consideration to improve the healing process. The use of natural extracts can represent a valid alternative to treat/control the microbial infections in wounds. This study investigates the antimicrobial/antivirulence effects of Capparis spinose aqueous extract against the main chronic wound pathogens: Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans. The extract shows phenolic characterization with rutin (1.8 ± 0.14 μg/mg) as the major compound and antibacterial effect against bacteria (S. aureus PECHA 10 MIC 6.25%; P. aeruginosa PECHA 4 MIC 12.50%) without action against C. albicans (MIC and MFC ≥ 50%). Capparis spinose also shows a significant antivirulence effect in terms of antimotility/antibiofilm actions. In particular, the extract acts (i) on P. aeruginosa both increasing its swimming and swarming motility favoring the planktonic phenotype and reducing its adhesive capability, (ii) on S. aureus and P. aeruginosa biofilm formation reducing both the biomass and CFU/ml. Furthermore, the extract significantly displays the reduction of a dual-species S. aureus and P. aeruginosa Lubbock chronic wound biofilm, a complex model that mimics the realistic in vivo microbial spatial distribution in wounds. The results suggest that C. spinose aqueous extract could represent an innovative eco-friendly strategy to prevent/control the wound microbial infection.
... Fowler et al. [98] evaluated the clinical utility of blood cultures as a diagnostic tool to identify patients with mediastinitis. More recently, Nakamura et al. [107] retrospectively assessed the use of a microbiological evaluation protocol in 112 patients in the first 90 days following cardiac surgery. Microbiological evaluation of febrile patients consisted of collecting two blood samples for culture, a sample of urine, sputum and faeces on two consecutive days. ...
... Magnetic resonance imaging (MRI) is a diagnostic test rarely used in patients with suspected mediastinitis. Wires used in sternal suture may cause artefacts, hindering the assessment of the mediastinum [107,127,131]. ...
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
... Although BCx yield in severe sepsis is moderate (~25%) [8,55], BCx are mandated by the US Centers for Medicare and Medicaid Services (CMS) severe sepsis criteria of the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) [76]. If CMS rules were to change, a decision to obtain BCx could be made based on proven benefit (eg, in an otherwise healthy patient with severe sepsis due to purulent cellulitis, culture from pus is far more likely to give a microbiologic diagnosis than BCx). ...
Guidance regarding indications for initial or follow-up (FU) blood cultures (BCx) is limited. We conducted a scoping review of articles published between 1/2004-6/2019 that reported the yield of BCx and/or their impact in the clinical management of fever and common infectious syndromes in non-neutropenic adult inpatients. 2,893 articles were screened; 51 were included. Based on the reported incidence of bacteremia, syndromes were categorized into low, moderate and high pre-test probability of bacteremia. Routine BCx are recommended in syndromes with a high likelihood of bacteremia (e.g., endovascular infections) and those with moderate likelihood when cultures from the primary source of infection are unavailable or prompt initiation of antibiotics is needed prior to obtaining primary source cultures. In syndromes where BCx are low-yield, BCx can be considered for patients at risk of adverse events if a bacteremia is missed (e.g., patient with pacemaker and severe purulent cellulitis). If a patient has adequate source control and risk factors or concern for endovascular infection are not present, most Streptococci or Enterobacterales bacteremias do not require routine FUBCx.
... Similar results were reported by Nakamura et al. examining 112 patients and revealing a high incidence of MRSA. Filsoufi et al. also found S. aureus to be the predominant pathogen [21,22]. However, over time, the bacterial spectrum of DSWI changed, most likely because of the selective pressure of different antibiotics in use. ...
Background:
Mediastinitis after cardiac surgery can lead to devastating consequences such as deep sternal wound infections (DSWI). Staphylococcus epidermidis and other coagulase-negative staphylococci belong to the physiological skin flora and therefore generally are not considered pathogenic agents. Thus, local resistance patterns of these bacterial species often recovered from wound specimens generally are ignored while choosing antibiotics for peri-operative prophylaxis in cardiac surgery as well as in the selection of empiric antibiotic therapy of DSWI.
Methods:
During the period May 2012-May 2013, 52 patients suffering from DSWI were treated at our institution. For every patient, deep tissue samples were obtained during surgical debridement procedures and submitted to microbiologic analysis. The frequency of and the time to occurrence of a DSWI was recorded, and baseline data, previous operative interventions, complications, and the technique used for soft tissue reconstruction, as well as the microbiologic results and individual risk factors, were documented.
Results:
There were 32 male patients (62%) and 20 female. The patients' age at the time of revision was a mean of 67 ± 11.5 years (range 35-83 years). There was bacterial growth in 31 cases (60%), the predominant species being S. epidermidis (20 patients; 65%). Extended antibiotic therapy was indispensable to controlling the infection.
Conclusion:
The local resistance patterns of antibiotics should have a greater influence on the standardized prophylaxis or empirical therapy of DSWI and need to be discussed specifically for this high-risk population. Because of its multi-resistance spectrum, S. epidermidis must be classified as a potential pathogen. In the cases reported here, extended antibiotic therapy was necessary to support wound healing and thus good patient outcomes.
... The analgesic and anti-inflammatory pharmacological effects of saponins have been studied since the 1970s and 1980s. Verification documents, Notoginseng flower saponins concentration within a certain range (50-100 mg/kg) has obvious inhibitory effect on the model of rat foot swelling caused by carrageenan, 5-hydroxytryptamine and kaolinite, inflammatory model of mouse ear in mice caused by croton oil and changes in capillary permeability caused by bradykinin, 5-hydroxytryptamine and histamine [9]. Notoginseng flower total saponins of water gel can improve the rat acute skin wound model of wound healing rate and reduce wound infection, promote wound inflammatory exudate absorption and hyperplasia of epidermis, showed significant anti-inflammatory effect [10]. ...
... Источником стернальной инфекции могут быть эндотрахеальные выделения или выделения из носа и рта, необработанный антисептическими растворами при перевязке участок кожи пациента, а также медицинские работники. Выбор ванкомицина связан с тем, что метициллин-чувствительный золотистый стафилококк является наиболее распространенным патогенным микроорганизмом, который приводит к тяжелым инфекционным осложнениям [9,10]. Так как ванкомицин эффективен только в отношении грамположительной флоры, в схему профилактических мероприятий добавили гентамицин. ...
p> Aim. The article compares the effects of local and systemic use of antibiotics on the incidence of sternal wound infection in patients undergoing cardiac surgery.
Methods. 485 patients undergoing adult cardiac surgery for the incidence of sternal wound infection were retrospectively evaluated. The patients were divided into two groups who received systemic (cefazolin) and topical (vancomycin, gentamicin) administration of antibiotics for the prevention of sternal wound infection in the postoperative period. The incidence of sternal wound infection depending on the method of application of antibiotics was also assessed.
Results. According to the results of the statistical analysis, intraoperative topical application of antibiotics (vancomycin and gentamicin) significantly reduced the cases of sternal wound infection from 7.9 to 0.45% (odds ratio of 1871.9; 95% confidence interval 1.67-2.1×106; p = 0.036). Thus, to improve the efficiency of impact on the pathogenic flora in the wound and to reduce the risk of sternal infection, topical application of antibacterial drugs: vancomycin for the cancellous bone of the sternum, gentamicin for irrigation of tissue during suturing the wound is one of the methods.
Conclusion. As a result of the comparative analysis, prevention of sternal wound infection in cardiac patients with intraoperative topical antibiotics is more effective than systemic antibiotic prophylaxis. To reduce the risk of sternal wound infection, topical application of vancomycin as a putty for the cancellous bone of the sternum and gentamicin for irrigation of the soft tissue in the process of wound suturing is recommended.
Received 16 August 2016. Accepted 22 November 2016.
Conflict of interest: The authors declare no conflict of interest.
Financing: The study had no sponsor’s support.</p
... S. aureus is one of the principal bacterial pathogens in humans causing mild to severe life-threatening conditions such as skin, soft tissue, wound infections, and septicaemia, urinary tract infections, endocarditis ii and osteomyelitis as major sequelae (7,8,9). S. aureus is also an important pathogen in veterinary medicine. ...
The present study aimed to detect Staphylococcus aureus (S. aureus) among other coagulase positive staphylococci from animal origin by using conventional methods (biochemical tests and latex agglutination) and a molecular method, based on the nuc gene, as the gold standard and to assess the usefulness of these methods. For this purpose, total of 344 staphylococcal isolates were collected and analysed. A total of 156 isolates suspicious for S. aureus were detected by a conventional biochemical method – 88 from cows, 18 from goats, 7 from pigs, 17 from poultry, 7 from rabbits and 19 from dogs. The majority of S. aureus strains gave typical biochemical reactions with the exception of 30 (19.2%) and 25 (16%) that were VP negative and weak positive in fermenting mannitol, respectively. Twelve strains were found to be non-haemolytic (7.7%) and four strains did not ferment trehalose (2.6%). Other staphylococci were identified as S. pseudintermedius (n = 103), S. hyicus (n = 23) and the rest were coagulase-negative staphylococci. Latex agglutination test resulted in rapid positive reactions with S. aureus with exception of 5 strains (3.2%) from cow mastitis milk. Positive agglutination reactions were also established with S. pseudintermedius, and S. hyicus. PCR confirmed all strains that were preliminary identified as S. aureus by amplification of 270 bp fragment of nuc gene specific for this species. The atypical reactions in certain strains established in this study have shown that the precise detection of S. aureus from animal origin should be done by combination of conventional and molecular methods.
... A particularly devastating SSI is mediastinitis complicating median sternotomy for cardiac surgery. S. aureus is the most common cause of postoperative mediastinitis (333)(334)(335)(336)(337)(338). Fowler et al. demonstrated that the presence of SAB in the postoperative period was highly predictive of a diagnosis of mediastinitis, with a likelihood ratio (LR) of 25, compared to blood cultures positive for other pathogens or negative blood cultures (338). ...
... Fowler et al. demonstrated that the presence of SAB in the postoperative period was highly predictive of a diagnosis of mediastinitis, with a likelihood ratio (LR) of 25, compared to blood cultures positive for other pathogens or negative blood cultures (338). These findings were subsequently independently validated (334,336). Thus, the presence of SAB following sternotomy mandates aggressive investigation to exclude the possibility of postoperative mediastinitis. ...
Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.
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