Treatment of gram-positive deep sternal wound infections in cardiac surgery -experiences with daptomycin-

Abstract

The reported incidence of deep sternal wound infection (DSWI) after cardiac surgery is 0.4-5% with Staphylococcus aureus being the most common pathogen isolated from infected wound sternotomies and bacteraemic blood cultures. This infection is associated with a higher morbidity and mortality than other known aetiologies. Little is reported about the optimal antibiotic management. The aim of the study is to quantify the application of daptomycin treatment of DSWI due to gram-positive organisms post cardiac surgery.We performed an observational analysis in 23 cases of post sternotomy DSWI with gram-positive organisms February 2009 and September 2010. When the wound appeared viable and the microbiological cultures were negative, the technique of chest closure was individualised to the patient.The incidence of DSWI was 1.46%. The mean dose of daptomycin application was 4.4 ± 0.9 mg/kg/d and the average duration of the daptomycin application was 14.47 ± 7.33 days. In 89% of the patients VAC therapy was used. The duration from daptomycin application to sternal closure was 18 ± 13.9 days. The parameters of infection including, fibrinogen (p = 0.03), white blood cell count (p = 0.001) and C-reactive protein (p = 0.0001) were significantly reduced after daptomycin application. We had no mortality and wound healing was successfully achieved in all patients.Treatment of DSWI due to gram-positive organisms with a daptomycin-containing antibiotic regimen is safe, effective and promotes immediate improvement of local wound conditions.Based on these observations, daptomycin may offer a new treatment option for expediting surgical management of DSWI after cardiac surgery.

First Evidence of Sternal Wound Biofilm following Cardiac Surgery

“…These interventions are highly limited in productivity as the incidence of mortality in these case remains high [20], [21]. In particular, non-responsiveness of post-sternotomy deep wound infections to broad spectrum antibiotics remains a major clinical challenge [19], [22].…”

Midterm results after treatment of gram-positive deep sternal wound infections with daptomycin for cardiac surgery patients

“…Interestingly, data on the optimal antibiotic management or duration of therapy for DSWI is scarce. Daptomycin has shown to be effective combined with multiple surgeries for treatment of DSWI in cardiac surgery [1,3,4]. However, up till now, no study has shown midterm results in terms of re-infection or re-operation for patients who were successfully treated with daptomycin for gram-positive DSWI.…”

“…We have published our results of prospective study about treatment of gram-positive DSWI with daptomycin for cardiac surgery patients performed between February 2009 and September 2010 [1]. Twenty-three consecutive patients with post-sternotomy mediastinitis from gram-positive organisms (out of 1574 primary sternotomies) were identified and treated with intravenous daptomycin with acceptable mortality and morbidity.…”

“…These patients were treated in the past with daptomycin combined with multiple surgeries for deep sternal wound infection (DSWI) due to gram-positive organisms. The initial surveillance was achieved in 100% and wound healing was successfully established in all patients at the time of discharge for the initial clinical course [1]. After discharge, all patients were followed up in terms of mortality, re-infection, and re-operation.…”

Review of Common Pathogens in Deep Sternal Wounds, Blood Stream and Bone Infections in Patients Following Sternotomy: A 10 Year Follow up

“…Other studies advocate for a less aggressive line of treatment, a prophylactic regimen of Cefazoline alone or in conjunction with Gentamicin/Amikacin, starting sixty minutes prior to the surgical incision to be continued for no longer than 48 h. These studies suggest that vancomycin be reserved mainly for patients with a history of type I allergic reaction (anaphylaxis, urticaria, angioedema, or bronchospasm) to B-lactam agents or when MRSA is of special concern [13,14]. Additional publications demonstrate that the empirical regimen should include agents active against a range of Gram-negative organisms (aminoglycosides, carbapenems or cephalosporins with antipseudomonal activity), an agent active against methicillin-resistant Gram-positive organisms (vancomycin), and metronidazole [2,[13][14][15][16][17][18]. These studies also conclude that the duration of antibiotic treatment should be based upon wound culture results and by clinical picture dynamics.…”