Dual Topical Antibiotic Application Prior to Sternotomy Closure Reduces Sternal Wound Infection Rates: A Simple Solution to a Grave Morbidity
Keywords:topical antibiotic, sternal wound infection, vancomycin, gentamycin
Background: A significant cohort of patients who undergo cardiac surgery suffer from diabetes and atherosclerosis. These patients have impaired tissue perfusion, hence a reduction in antibiotic concentration in the subcutaneous tissues at the side of the mammary artery harvesting.
Topical application of gentamicin and vancomycin before wound closure broadens the antibiotic spectrum and reduces the incidence of deep sternal wound infection. In this article, we compare the use of single versus dual application of vancomycin and/or gentamicin in sternotomy wounds in a single tertiary center.
Methods: An observational cohort analysis with three sequential patient groups (N = 2550) was performed at Ain Shams University Hospital in Cairo. A control group (N = 850), vancomycin only group (N = 850), and vancomycin plus gentamicin group (N = 850) were included in the study, during the three-year period from January 2017 to December 2019. Patients who had minimal access surgery were excluded from this study. The presence of an infected postoperative sternotomy wound was assessed in all patients.
Results: The presence of an infected sternotomy wound (El Oakley class 2B) was present in 38 patients (4.5%) in the control group, in 19 patients (2.2%) in the vancomycin group, and in nine patients (1.1%) in the dual antibiotic group, respectively (P < .001). In contrast to the usual, we had a proliferous growth of gram-negative organisms 29 (3.4%) in the control group, 10 (1.2%) in the vancomycin group, and five (0.6%) in the dual antibiotic group, respectively (P < .001).
Conclusion: Deep sternal wound infection is a major cause of post-cardiac surgery morbidity and prolonged hospital stay. Adding the simple step of topical application of vancomycin and gentamicin to the sternotomy wound at the end of the procedure appeared to significantly reduce deep wound infection rates.
Abu-Omar Y, Kocher GJ, Bosco P, et al. 2017. European association for cardiothoracic surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg. 2017;51(1):10–29.
Andreas M, Muckenhuber M, Hutschala D, Kocher A, Thalhammer F, Vogt P, et al. 2017. Direct sternal administration of Vancomycin and Gentamicin during closure prevents wound infection. Interactive cardiovascular and thoracic surgery, 25(1), 6-11.
Andreas M, Zeitlinger M, Hoeferl M, Jaeger W, Zimpfer D, Hiesmayr JM, et al. 2013. Internal mammary artery harvesting influences antibiotic penetration into presternal tissue. Ann Thorac Surg. 95:1323–9; discussion 29–30.
Andreas M, Zeitlinger M, Wisser W, Jaeger W, Maier-Salamon A, Thalhammer F, et al. 2015. Cefazolin and linezolid penetration into sternal cancellous bone during coronary artery bypass grafting. Eur J Cardiothorac Surg. 48:758–64.
Antunes PE, Bernardo JE, Eugenio L, de Oliveira JF, Antunes MJ. 1997. Mediastinitis after aorto-coronary bypass surgery. Eur J Cardiothorac Surg. 12:443–9.
Arruda MVF, Braile DM, Joaquim MR, Suzuki FA, Alves RH. 2008. The use of vancomycin paste for sternal hemostasis and mediastinitis prophylaxis. Rev Bras Circ Cardiovasc. 23:35–9.
Atkins BZ, Onaitis MW, Hutcheson KA, Kaye K, Petersen RP, Wolfe WG. 2011. Does method of sternal repair influence long-term outcome of postoperative mediastinitis? Am J Surg. 202(5):565–567.
Borger MA, Rao V, Weisel RD, Ivanov J, Cohen G, Scully HE, et al. 1998. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg. 65:1050–6.
Cotogni P. 2015. Deep sternal wound infection after cardiac surgery: evidences and controversies. World J Crit Care Med. 4(4):265–273.
D’Agostino RS, Jacobs JP, Bardhwar V, et al. 2018. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2018 update on outcomes and quality. Ann Thorac Surg. 105:15–23.
De Feo M, Vicchio M, Santè P, Cerasuolo F, Nappi G. 2011. Evolution in the treatment of mediastinitis: single-center experience. Asian Cardiovasc Thorac Ann. 19(1):39–43.
De Santo LS, Rubino AS, Torella M, et al. 2020. Topical rifampicin for prevention of deep sternal wound infections in patients undergoing coronary artery bypass grafting. Sci Rep10, 7400.
El Oakley RM, Wright JE. 1996. Postoperative mediastinitis: classification and management. Ann Thorac Surg. 61:1030–6.
Fleck T, Gustafsson R, Harding K, Ingemansson R, Lirtzman MD, Meites HL, et al. 2006. The management of deep sternal wound infections using vacuum assisted closure (V.A.C.) therapy. Int Wound J. 3:273–80.
Friberg O, Svedjeholm R, Kallman J, Soderquist B. 2007. Incidence, microbiological findings, and clinical presentation of sternal wound infections after cardiac surgery with and without local gentamicin prophylaxis. Eur J Clin Microbiol Infect Dis. 26:91–7.
Halasz NA. 1977. Wound infection and topical antibiotics: the surgeon’s dilemma. Arch Surg. 112:1240–4.
Horan TC, Andrus M, Dudeck MA. 2008. CDC/NHSN surveillance definition of healthcare-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 36(5):309–332.
Jones G, Jurkiewicz MJ, Bostwick J, et al. 1997. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg. 225(6):766–776.
Jonkers D, Elenbaas T, Terporten P, Nieman F, Stobberingh E. 2003. Prevalence of 90-days postoperative wound infections after cardiac surgery. Eur J Cardiothorac Surg. 23:97–102.
Junker JP, Lee CC, Samaan S, Hackl F, Kiwanuka E, Minasian RA, et al. 2015. Topical delivery of ultrahigh concentrations of gentamicin is highly effective in reducing bacterial levels in infected porcine full-thickness wounds. Plast Reconstr Surg. 135:151–9.
Kowalewski M, Pawliszak W, Zaborowska K, Navarese EP, Szwed KA, Kowalkowska ME, et al. 2015. Gentamicin-collagen sponge reduces the risk of sternal wound infections after heart surgery: meta-analysis. J Thorac Cardiovasc Surg. 149:1631–40.e1–6.
Kowalewski M, Raffa GM, Szwed KA, Anisimowicz L. 2017. Meta-analysis to assess the effectiveness of topically used vancomycin in reducing sternal would infections after cardiac surgery. J Thorac Cardiovasc Surg. 154:1320–3.
Lazar HL. 2018. A review of the AATS guidelines for the prevention and management of sternal wound infections. Indian J Thorac Cardiovasc Surg. Dec;34(Suppl 3):349-354.
Lazar HL, Barlam T, Cabral H. 2011. The effect of topical vancomycin applied to sternotomy incisions on postoperative serum vancomycin levels. J Card Surg. 26:461–5.
Lazar HL, Ketchedjian A, Haime M, Karlson K, Cabral H. 2014. Topical vancomycin in combination with perioperative antibiotics and tight glycemic control helps to eliminate sternal wound infections. J Thorac Cardiovasc Surg. 148:1035–40.
Lazar HL, Salm VT, Engelman R, Orgill D, Gordon S. 2016. Prevention and management of sternal wound infections. J Thorac Cardiovasc Surg. 152:962–72.
Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. 1997. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 38(6):553–562.
Robicsek F. 2000. Postoperative sterno-mediastinitis. Am Surg. 66(2):184–192.
Schimmer C, Gross J, Ramm E, Morfeld BC, Hoffmann G, Panholzer B, et al. 2016. Prevention of surgical site sternal infections in cardiac surgery: a two-centre prospective randomized controlled study. Eur J Cardiothorac Surg. 51:67–72.
Sharma M, Berriel-Cass D, Baran J Jr. 2004. Sternal surgical-site infection following coronary artery bypass graft: prevalence, microbiology, and complications during a 42-month period. Infect Control Hosp Epidemiol. 25:468–71.
Singh K, Anderson E, Harper JG. 2011. Overview and management of sternal wound infection. Semin Plast Surg. 25(1):25–33.
Sjögren J, Gustafsson R, Nilsson J, Malmsjö M, Ingemansson R. 2005. Clinical outcome after poststernotomy mediastinitis: vacuum-assisted closure versus conventional treatment. Ann Thorac Surg. 79(6):2049–2055.
Tarzia V, Carrozzini M, Bortolussi G, Buratto E, Bejko J, Comisso M, Mescola V, Penzo V, Guarino M, De Franceschi M, Pagnin C, Castoro M, Guglielmi C, Testolin L, Bottio T, Gerosa G. 2014. Impact of vacuum-assisted closure therapy on outcomes of sternal wound dehiscence, Interactive Cardiovascular and Thoracic Surgery, Volume 19, Issue 1, Pages 70–75.
Vander Salm TJ, Okike ON, Pasque MK, Pezzella AT, Lew R, Traina V, et al. 1989. Reduction of sternal infection by application of topical vancomycin. J Thorac Cardiovasc Surg. 98:618–22.
Velebit V. 2010. Deep sternal wound infection—still a challenge. Eur J Cardiothorac Surg. 37:749.
Vogt P. 2016. EurAsia Heart. http://www.eurasiaheart.ch/de/eurasia-heart/science-research.php (25 September, date last accessed).
Yusuf E, Jordan X, Clauss M, Borens O, Mäder M, Trampuz A. 2013. High bacterial load in negative pressure wound therapy (NPWT) foams used in the treatment of chronic wounds. Wound Repair Regen. 2013;21(5):677–681.
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