The mainstay of therapy in acute mediastinitis secondary to cardiothoracic surgery includes clindamycin and ceftriaxone. The preferred regimen for preoperative prophylaxis against acute mediastinitis includes either a second generation cephalosporin or vancomycin. Descending necrotizing mediastinitis is a very serious complication of oropharyngeal infections that should be treated promptly with early and aggressive surgical debridement and broad spectrum antibiotics that provide coverage against MRSA, beta-lactamase producing gram-negative organisms, and anaerobes.

• 1. Post-cardiothoracic surgery mediastinitis^[1]

• 1.1 Treatment

• Preferred regimen: Clindamycin 450 mg IV q6h AND Ceftriaxone 2 g IV q24h for > 2 weeks

• Note: A deep sternal wound infection should be treated with aggressive surgical debridement in the absence of complicating circumstances.

• 1.2 Prophylaxis

• 1.2.1 Methicillin susceptible staphylococcus aureus

• Preferred regimen: Cefazolin 2 g IV single dose OR Cefoxitin 2 g IV single dose OR Cefuroxime 1.5 g IV single dose

• 1.2.2 Methicillin resistant staphylococcus aureus

• Preferred regimen: Vancomycin 15 mg/kg IV single dose
• Note (1): Preoperative antibiotics should be administered to all patients to reduce the risk of mediastinitis in cardiac surgery.
• Note (2): The use of intranasal mupirocin is reasonable in nasal carriers of S. aureus.

• 2. Descending necrotizing mediastinitis

• Preferred regimen (1): Vancomycin 2 g/day IV q6-12h (trough levels 15-20 mg/L) AND Imipenem 500 mg IV q6h
• Preferred regimen (2): Vancomycin 2 g/day IV q6-12h (trough levels 15-20 mg/L) AND Meropenem 1 g IV q8h
• Preferred regimen (3): Vancomycin 2 g/day IV q6-12h (trough levels 15-20 mg/L) AND Piperacillin-Tazobactam 3.375 g IV q6h
• Note: The mainstay of therapy for descending necrotizing mediastinitis is surgical debridement.

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