Suspected Deep Sternal Wound Infection
Post-sternotomy patient with wound concerns
All Pathways
Cardiothoracic SurgeryManagement
Deep Sternal Wound Infection / Mediastinitis (AATS/STS)
Deep Sternal Wound Infection / Mediastinitis (AATS/STS): Suspected Deep Sternal Wound Infection → CDC Diagnostic Criteria → Classify Wound → Superficial...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action CDC Diagnostic Criteria
Confirm DSWI diagnosis
- One or more of:
- • Organism isolated from mediastinal tissue/fluid culture
- • Evidence of mediastinitis at surgery
- • Fever (>38°C) + sternal pain/instability + purulent drainage
- Risk factors: diabetes, obesity, COPD, renal failure, bilateral IMA
03Decision Classify Wound
Superficial vs Deep vs Organ-space
- Superficial: skin/subcutaneous only
- Deep: involving fascia/muscle
- Organ-space: mediastinitis (sternal bone/mediastinal space)
04Action Superficial SSI
Skin/subcutaneous only
- Open and drain
- Local wound care
- Antibiotics if cellulitis
- May heal by secondary intention
05Outcome Wound Healed
Long-term surveillance for recurrence
06Action Deep DSWI / Mediastinitis
Involves sternal bone or mediastinum
- Requires surgical intervention
- Obtain cultures (tissue, not swab)
- CT chest if extent unclear
- Blood cultures
- Start broad-spectrum antibiotics
07Action Empiric Antibiotics
Broad-spectrum coverage pending cultures
- Cover: S. aureus (including MRSA), gram-negatives
- Vancomycin + piperacillin-tazobactam or
- Vancomycin + cefepime or carbapenem
- Narrow based on culture results
- ID consultation recommended
08Action Surgical Debridement
Aggressive source control
- Return to OR for debridement
- Remove all necrotic tissue
- Remove infected sternal wires
- Debride to bleeding bone
- Copious irrigation
- Send tissue cultures
09Decision VAC Therapy Indicated?
Negative pressure wound therapy
- VAC recommended when delayed sternal closure anticipated
- MUST use protective barrier over heart/grafts
- Prevents tissue erosion and fatal hemorrhage
10Action VAC Therapy
Negative pressure wound therapy
- CRITICAL: Place barrier dressing over heart/great vessels
- Continuous or intermittent suction
- Change every 48-72 hours
- Promotes granulation tissue
- Reduces wound size
- Bridge to delayed closure or flap
11Action Muscle Flap Reconstruction
For extensive tissue loss
- Options (plastic surgery consult):
- • Pectoralis major flap (most common)
- • Rectus abdominis flap
- • Omentum flap
- Provides vascularized tissue coverage
- Fills dead space
- Improves healing in irradiated/ischemic tissue
12Action Antibiotic Duration
IV followed by oral
- IV antibiotics: minimum 2-4 weeks
- 6 weeks if osteomyelitis or hardware retained
- Transition to PO when clinically improved
- Total duration 6-8 weeks typical
- Follow inflammatory markers (CRP, WBC)
- Path rejoins step 05Shared downstream outcome
13Action Primary/Delayed Closure
If minimal tissue loss and controlled infection
- Sternal rewiring if bone viable
- Consider rigid fixation plates
- Closed suction drainage
- Close in layers
- Path rejoins step 12Shared downstream outcome
- Path rejoins step 13Shared downstream outcome
14Warning ⚠️ VAC Complication Risk
RV rupture/major bleeding (5-15%) possible with VAC. ALWAYS use barrier dressing over heart and grafts.
- Path rejoins step 08Shared downstream outcome
Guideline Source
AATS Guidelines for Prevention and Management of Sternal Wound Infections
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- VAC therapy requires specialized equipment and training
- Muscle flap reconstruction requires plastic surgery involvement
- Antibiotic choice depends on local resistance patterns
- Mortality 20-50% despite treatment
Applicable Regions
USEU
Version 1Next review: 2027-01-11
Next steps
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Related Resources
Frequently Asked Questions
What is the Deep Sternal Wound Infection / Mediastinitis (AATS/STS)?
The Deep Sternal Wound Infection / Mediastinitis (AATS/STS) is a management clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on AATS Guidelines for Prevention and Management of Sternal Wound Infections.
What guideline is the Deep Sternal Wound Infection / Mediastinitis (AATS/STS) based on?
This algorithm is based on AATS Guidelines for Prevention and Management of Sternal Wound Infections (DOI: 10.1016/j.jtcvs.2016.08.035).
What are the limitations of the Deep Sternal Wound Infection / Mediastinitis (AATS/STS)?
Known limitations include: VAC therapy requires specialized equipment and training; Muscle flap reconstruction requires plastic surgery involvement; Antibiotic choice depends on local resistance patterns; Mortality 20-50% despite treatment. Individual patient factors may require deviation from these recommendations.
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