Interactive Cardiovascular and Thoracic Surgery 2:131-132(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Endogenously acquired deep sternal wound infection after congenital cardiac surgery
Thomas Walthera,* and
Martin Elliottb
a Klinik für Herzchirurgie, Herzzentrum, Universität Leipzig, Strumpellstrasse 39 Leipzig 04289, Germany
b Great Ormond Street Hospital for Children, NHS Trust, London, UK
* Corresponding author. Tel.: +49-341-865-1424; fax: +49-341-865-1452
walt{at}medizin.uni-leipzig.de
Received August 7, 2002;
received in revised form December 10, 2002;
accepted December 16, 2002
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Abstract
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A 10-month-old child from the Middle East received complete correction for tetralogy of Fallot. Despite an initially uneventful postoperative course, he developed severe deep sternal wound infection after 7 days. This complication was endogenously acquired caused by a resistant and rarely present in Europe, Streptococcus pneumonia. Following surgical debridement, betadine rinsing for 3 days and with a course of specific antibiotic therapy, the patient was discharged in good health.
Key Words: Congenital cardiac surgery; Deep sternal wound infection; Endogenous infection
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1. Introduction
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In cardiac surgery, deep sternal wound infection remains a serious complication associated with considerable in-hospital mortality [1]. Recent studies on adult and pediatric populations revealed an incidence of up to 5% [2,3]. However, in pediatric cardiac surgery, deep sternal wound infection has been mostly associated with neonatal repairs and rather complex procedures [3]. Whereas the most common cause is intra-operative contamination, we present a case of endogenously acquired deep sternal wound infection that has not been reported before.
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2. Case report
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A 10-month-old patient from the Middle East with a body weight of 7.5kg and the diagnosis of tetralogy of Fallot was admitted. At pre-operative checkups, there were no signs of infection, no fever, a normal white blood cell (WBC) count and a negative nasal methicillin-resistant Staphylococcus aureus (MRSA) swab. He received complete correction with venticuloseptal defect (VSD) patch-closure and trans-annular right ventricular outflow tract patch enlargement. Routine perioperative antibiotic therapy consisted of Flucloxacillin and Amicacin given for 24h. The postoperative course was uneventful and he was extubated the next morning and transferred to the regular ward 2 days after surgery. At that stage, the patient did not have any signs of infection; he was feeding well and was fully mobilized. Before discharge on the 6th postoperative day, WBC count was elevated to 27.000, and there was an elevated C-reactive protein (CRP) and the sternotomy scar looked slightly reddish with no instability of the bone at this stage. Chest X-ray did not reveal any pathological findings; there were neither signs of pneumonia nor of a pulmonary abscess or pneumothorax. The next morning, the temperature raised to 38.1°C and suddenly pus was evacuated from the proximal part of the incision. He was started on intravenous Tazocin and received re-exploration the same day. Severe upper mediastinal infection with instability of the sternum was present. In addition, a slight laceration of the right upper lobe of the lung was found intra-operatively as well. Extensive debridement was performed and several swabs were taken. The sternum was rewired and the wound closed using single stitches. Diluted betadine rinsing was initiated for 3 days followed by another 3 days of clear rinsing. Microbiology testing revealed infection with a rare Streptococcus pneumonia not usually seen in Europe. Specific antibiotic therapy using Tazocin and Erythromycin were given intravenously for 1 week and orally for 2 weeks thereafter. The wound healed well and the patient was discharged in good health. At 1 month follow-up, he was well and flew back home.
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3. Discussion
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In cardiac surgery, there is a continuous thread of postoperative deep sternal wound infection, associated with high morbidity and mortality. The incidence of deep sternal wound infection usually is lower in the pediatric population than for adult patients, due to better wound healing properties and the absence of additional risk factors like obesity, diabetes or atherosclerosis. As such, deep sternal wound infection in children has been shown to be related to young age at operation and to rather complex procedures being performed [3]. The overall risk for deep sternal wound infection can be considered to be rather low after congenital cardiac surgery.
In the context of deep sternal wound infection, different pathogens have been reported. These include coagulase negative staphylococci in 23–64%, staphylococcus aureus in 12–32%, gram negative bacteria in 6–30% and other organisms in 10–12% whereas there is no growth at microbiological testing in 5–6% [4,5]. At present, there is no report in the literature of streptococcus pneumonia causing deep sternal wound infection after congenital cardiac surgery.
Intra-operative field contamination usually is considered to be the main cause for infection. Other sources of infection as an endogenous pathway have been described as well [6]. In this patient, we assume a completely endogenous infectious pathway without any evidence for intra-operative contamination due to the following findings: at re-exploration, the infection was diagnosed to spread from the upper mediastinum, close to the slight laceration of the right upper lobe of the lung. There was no pathway from skin to deeper tissue as the wound was perfectly closed until the day before re-exploration. Microbiology revealed a resistant pneumococcus that is usually seen in the Middle East and has to be considered to originate from the patients' lung.
In deep sternal wound infection, early recognition and treatment is essential. Thus aggressive treatment directly after the first signs of infection was performed in our patient, which proved to be the right decision. Complete debridement and persistent betadine rinsing are the most important therapeutic strategies for a complete cure. In addition, specific antibiotic therapy has to be administered. Thus when all these steps are taken early enough a good outcome can be expected. An endogenously acquired infection always has to be considered if no other cause is diagnosed.
doi:10.1016/S1569-9293(02)00119-6
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References
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Abstract
1. Introduction