Routine Mediastinal Drainage Fluid Culture for Early Diagnosis of Poststernotomy Mediastinitis

Abstract

Background Early diagnosis of poststernotomy mediastinitis (PSM) is challenging. Since 2016, we have routinely performed mediastinal drainage fluid culture (MDFC) in patients undergoing sternotomy. This study aimed to determine the utility of MDFC for early diagnosis of PSM.

Methods Between November 2016 and April 2020, we conducted MDFC in 1,012 patients on the third postoperative day and prospectively observed for PSM occurrence for 3 months. If bacteria were identified, additional MDFC or blood culture was performed to reduce the possibility of false positives. Based on MDFC results, the decision for early treatment for PSM was at the attending physician's discretion.

Results Bacteria were identified in MDFC of 29 patients, eight of whom subsequently developed PSM. Among 983 patients with negative MDFC, only 15 developed PSM. In multivariate analysis, previous sternotomy history and positive MDFC were predictors of PSM. Positive MDFC was regarded as true positive if (1) PSM occurred subsequently, and/or (2) the same bacteria were identified in additional MDFC/blood culture. Non-occurrence of PSM in the absence of antibiotic treatment was regarded as false-positive MDFC. The sensitivity, specificity, and positive and negative predictive values of routine MDFC for diagnosis of mediastinal infection were 46.4, 99.0, 56.5, and 98.5%, respectively. When categorizing cases with positive MDFC based on the identified bacteria, the positive predictive value was highest (76.9%) when Staphylococci were identified.

Conclusion Routine MDFC after sternotomy can facilitate early diagnosis of PSM. Early treatment for PSM may be indicated in patients in whom Staphylococci are identified in the MDFC.

Keywords

mediastinum (incl. mediastinoscopy) - postoperative - sternum - surgery - complications - wound infection

Authors' Contribution

Prof. Jeong contributed to this work by establishing the overall research design with Dr. Jung. Specifically, Prof. Jung refined the research topic as well as the methods and timeline for MDFC implementation. Additionally, he was actively involved in the statistical analyses, interpretation of the results, and editing the manuscript.

Dr. Lee was the physician who performed MDFC on about half of the patients included in this study. He also determined if a early treatment for PSM would be necessary based on the routine MDFC results. In addition to data collection, his contribution as a co-first author includes the analyses of the collected data and writing the manuscript with Dr. Jung.

Dr. Oh contributed to this work as a co-author by carrying out data sorting, screening, and curation, as well as manuscript editing.

^* Jung and Lee contributed equally to this article as first authors.

Publikationsverlauf

Eingereicht: 22. September 2021

Angenommen: 27. Dezember 2021

Artikel online veröffentlicht:
25. Februar 2022

• References

• 1 van Wingerden JJ, Ubbink DT, van der Horst CM, de Mol BA. Poststernotomy mediastinitis: a classification to initiate and evaluate reconstructive management based on evidence from a structured review. J Cardiothorac Surg 2014; 9: 179
• 2 Kurlansky P. Arterial grafting and the risk of sternal infection: how we can learn from our experience. J Thorac Cardiovasc Surg 2014; 148 (05) 1896-1898
• 3 Management der Mediastinitis nach herzchirurgischen Eingriffen. (July 31, 2019). Online: awmf.org/leitlinien/detail/ll/011-022.html [accessed January 22, 2022]
• 4 Browdie DA, Bernstein RV, Agnew R, Damle A, Fischer M, Balz J. Diagnosis of poststernotomy infection: comparison of three means of assessment. Ann Thorac Surg 1991; 51 (02) 290-292
• 5 Maroto LC, Aguado JM, Carrascal Y. et al. Role of epicardial pacing wire cultures in the diagnosis of poststernotomy mediastinitis. Clin Infect Dis 1997; 24 (03) 419-421
• 6 Mekontso-Dessap A, Honoré S, Kirsch M, Houël R, Loisance D, Brun-Buisson C. Usefulness of routine epicardial pacing wire culture for early prediction of poststernotomy mediastinitis. J Clin Microbiol 2004; 42 (11) 5245-5248
• 7 Benlolo S, Matéo J, Raskine L. et al. Sternal puncture allows an early diagnosis of poststernotomy mediastinitis. J Thorac Cardiovasc Surg 2003; 125 (03) 611-617
• 8 San Juan R, Aguado JM, López MJ. et al. Accuracy of blood culture for early diagnosis of mediastinitis in febrile patients after cardiac surgery. Eur J Clin Microbiol Infect Dis 2005; 24 (03) 182-189
• 9 Misawa Y, Fuse K, Hasegawa T. Infectious mediastinitis after cardiac operations: computed tomographic findings. Ann Thorac Surg 1998; 65 (03) 622-624
• 10 Yamaguchi H, Yamauchi H, Yamada T, Ariyoshi T, Aikawa H, Kato Y. Diagnostic validity of computed tomography for mediastinitis after cardiac surgery. Ann Thorac Cardiovasc Surg 2001; 7 (02) 94-98
• 11 van Wingerden JJ, Maas M, Braam RL, de Mol BA. Diagnosing poststernotomy mediastinitis in the ED. Am J Emerg Med 2016; 34 (03) 618-622
• 12 El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996; 61 (03) 1030-1036
• 13 Gårdlund B, Bitkover CY, Vaage J. Postoperative mediastinitis in cardiac surgery—microbiology and pathogenesis. Eur J Cardiothorac Surg 2002; 21 (05) 825-830