Mediastinitis in the intensive care unit patient: a narrative review

Abstract

Background: Mediastinitis is a rare but severe infection, defined as an inflammation of the connective tissues and structures within the mediastinum. Due to its proximity to vital structures, mediastinitis represents a highly morbid pathological process associated with a high risk of mortality. In most cases mediastinitis requires treatment in the intensive care unit. Objectives: To highlight to the reader the clinical features of mediastinitis, to attempt to define each clinical scenario, to describe the responsible pathogens and finally to depict both the medical and surgical treatments. Sources: We performed a literature search of the PubMed and Cochrane libraries, limited for articles published between January 2003 and December 2018, reporting on acute mediastinitis. Content: The term covers different entities of different aetiologies including deep sternal wound infection related to sternotomy; oesophageal perforation or anastomosis leakage; and finally descending necrotizing mediastinitis, often secondary to oropharyngeal abscess. The responsible pathogens and therefore subsequent management depends on the underlying aetiology. Empirical antimicrobial therapy should cover the suspected microorganisms while surgery and supportive measures should aim to reduce the inoculum of pathogens by providing adequate drainage and debridement. Implications: Literature concerning mediastinitis in the intensive care unit is relatively scarce. We have collated the evidence and reviewed the different causes and treatment options of acute mediastinitis with a particular focus on microbiological epidemiology. Future research in larger cohorts is needed to better understand the treatment of this difficult disease.

Necrotizing Mediastinitis Following Rabbit Bone Ingestion: A Case Report

“…Mediastinitis is a life-threatening infection of the mediastinal tissue. Depending on the cause, the disease can be infected or non-infected and acute or chronic (1). Mediastinitis often occurs after cardiac surgery or an esophageal rupture (2).…”

Improving care for the ICU patient with suspected infection: a multidisciplinary perspective

“…However, more uncommon infections may also be encountered in ICU patients, either as a reason for admission or as a complication during the ICU stay. In this issue of Clinical Microbiology and Infection, we focus on three uncommon yet severe infections: necrotizing skin and tissue infection [8], pancreatic infection [9] and mediastinitis [10]. By definition uncommon infections have a low prevalence, which often means that experience in treating these infections is diluted.…”

“…Pancreatitis and mediastinitis share a number of features [9,10]. First, they are often difficult to diagnose.…”

“…Another feature shared by the patients with such infections is the lack of consensus about the best duration of antimicrobial treatment. Five to 7 days, 7e14 days and 14e21 days are suggested for pancreatic infections [9], necrotizing skin and tissue infections [8], and mediastinitis [10], respectively. However, these durations are only based on expert opinion e no adequate randomized clinical trials were conducted to test different durations in the ICU patients.…”

“…In addition, the duration of antibiotic treatment is conditioned by the quality of source control, which remains often uncertain in these patients. Hence, experts advocate a duration adapted for each patient based on clinical response and repeated CT scans [9,10], but this again needs to be demonstrated in highquality studies.…”