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Eur J Cardiothorac Surg 2002;21:825-830
© 2002 Elsevier Science NL

Postoperative mediastinitis in cardiac surgery — microbiology and pathogenesis

B. Gårdlunda*, C.Y. Bitkoverb, J. Vaageb

a Department of Infectious Diseases, Karolinska Hospital, Stockholm, Sweden
b Department of Thoracic Surgery, Karolinska Hospital, Stockholm, Sweden

Received 24 August 2001; received in revised form 27 January 2002; accepted 31 January 2002.

* Corresponding author. Tel.: +46-8-5177-0000; fax: +46-8-5177-1885
e-mail: bengt.gardlund{at}ks.se


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: During 1992–2000, postoperative mediastinitis developed after 126 (1.32%) of 9557 consecutive cardiac surgery procedures. The study was done to describe the variation in clinical characteristics and microbiological etiology in mediastinitis. Methods: The records of 126 cases of postoperative mediastinitis were reviewed. Results: The median time from operation to the development of mediastinitis was 7 days. Sternal dehiscence was seen in 86 patients (68%). Coagulase negative staphylococci (CNS) were isolated in 46% of the cases with a verified microbiological etiology, Staphylococcus aureus in 26% and gram-negative bacteria in 18%. CNS were more frequently isolated in patients with sternal dehiscence (44/80, 55%) than in patients with stable sternum (10/38, 26%) (P=0.003). However, S. aureus was more frequent in patients with stable sternum (18/38, 47%) than in patients with sternal dehiscence (13/80, 16%) (P<0.001). High body mass index was associated with coagulase negative staphylococci (P<0.001) and with sternal dehiscence (P=0.008). Chronic obstructive pulmonary disease was also associated with sternal dehiscence (P<0.001) and with coagulase negative staphylococci (P=0.04). Patients who had been reoperated before onset of mediastinitis tended to have an increased risk for a gram-negative etiology (32 vs. 15% in patients not reoperated, P=0.06). The overall 90-day all cause mortality in patients with mediastinitis was 19%. High age, need for reoperation before mediastinitis, and a long primary operation time was associated with increased mortality (P=0.02, P=0.007 and P=0.001, respectively). No specific bacterial etiology was associated with increased mortality nor was the presence of bacteriemia. Conclusions: Three different types of postoperative mediastinitis can be distinguished: (1) mediastinitis associated with obesity, chronic obstructive pulmonary disease, and sternal dehiscence, typically caused by coagulase negative staphylococci; (2) mediastinitis following peroperative contamination of the mediastinal space, often caused by S. aureus, and (3) mediastinitis mainly caused by spread from concomitant infections in other sites during the postoperative period, often caused by gram negative rods. The proposed classification of mediastinitis into three groups with different pathogenic mechanisms may be useful in understanding which prophylactic counter measures have the potentials to be effective in a given situation.

Key Words: Cardiac surgery • Mediastinitis • Postoperative complications • Surgical wound infection • Staphylococcus


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Postoperative mediastinitis after open heart surgery is an infrequent, but potentially a devastating complication with high morbidity, prolonged hospitalization, increased costs, as well as increased mortality. A number of patient-related and hospital-related predisposing factors like obesity, diabetes mellitus, chronic obstructive pulmonary disease, duration of surgery, blood loss on operation and many more have been identified [1–8]. The multitude of different risk factors described in different studies, sometimes with contradictory results, suggest both that postoperative mediastinitis is a multifactorial event and that the patient group may be inhomogenous. Clinical observations in our hospital have suggested that patients with mediastinitis vary substantially in their clinical presentations and there may in fact be different subtypes of mediastinitis. The present review of 126 cases of mediastinitis after open heart surgery over a 9 year period was done to describe the variations in clinical characteristics and microbiological etiology.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
During a 9-year period from 1992 to 2000, a total of 9557 cardiac surgery procedures with cardiopulmonary bypass were performed at our institution. All elective patients had a shower including body wash with an antiseptic solution the evening before surgery. This was repeated the next morning, followed by clipping of excessive hair with an electrical clipper with a disposable head before transfer to the operating room. On the operating table, the patients were washed from the neck to to the feet with an antiseptic solution three times. The thighs and legs were washed on both front and back. Isoxazolylpenicillin 2 g intravenously 30–60 min preoperatively, again after 4 h, and then every 6 h for a total of five doses was used as prophylaxis. Cefuroxime (1.5 g) with the same dose intervals was used in case of penicillin allergy. No topical antibiotics were routinely used before closing the sternum. Surgeons performing procedures in the groin or harvesting the saphenous vein routinely changed their gloves before commencing intra-thoracic work.

Patients who developed postoperative mediastinitis were identified in a prospective surveillance program. The final diagnosis of mediastinitis was based on positive bacterial cultures from the mediastinal space and/or obvious clinical signs of mediastinitis on reexploration, and/or positive cultures from pericardial effusions according to the Centers for Disease Control and Prevention (CDC) definitions of surgical site infections [9]. In addition, one patient who presented with mediastinitis 38 days after operation was included although the CDC definition limits the time from operation to first signs of infection to 30 days. The clinical data were retrospectively collected from the hospital records.

2.1. Statistical analysis
Data were analyzed using Statistica for Windows from StatSoft Inc. Statistical analyses of categorical data were done using Pearson Chi-square test. For continuous variables, significance testing was done using the Mann–Whitney U-test unless the variable was normally distributed when the t-test for independent samples was used. For correlation analyses, the Spearman Rank Order Correlation was used. Two-sided analyses were done throughout. P-values are given as exact values except for values <0.001 and >0.20.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
3.1. Patients characteristics
Postoperative mediastinitis was identified in 126 patients of over the 9-year period studied rendering the incidence of mediastinitis to be 1.32%. A decreasing trend was seen over time (R=-0.78, P=0.01) (Fig. 1 ). This may be influenced by the opening of completely new operating theatres in 1997. The median age was 68.0 years (range 36–85 years), and 99 were males and 27 females. Twenty-one per cent of the patients suffered from chronic obstructive pulmonary disease and 38% from diabetes mellitus. Diabetes includes all cases with a preoperative diagnosis of diabetes, independent of its severity. One case of mediastinitis, which occurred as a result of the unfortunate placing of a mediastinal drain through the stomach was not included in this study. Our principles for treatment of mediastinitis have recently been presented [10] and are not the subject of this work. Briefly, when mediastinitis is suspected, aggressive reexploration is employed with debridement and cleaning of the mediastinum. We generally try to close the sternum during the reexploration, either by using a specially made titanium prosthesis (the Ley prosthesis) [10], or if the sternum is intact and strong by plain rewiring. Out of 100 cases with mediastinitis recently reviewed in our clinic, only six cases were treated openly [10]. Postoperatively, a regime of 6–12 l per day of continuous irrigation with Ringer lactate containing antibiotics was used. A moderate suction (10–15 cm H2O) was applied to the drainage tubes. The duration of irrigation-drainage depended on the amount of debris drained and the clinical progress of the patient, but rarely exceeded 7 days.



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  		Fig. 1. Postoperative mediastinitis 1992–2000.

 
3.2. Reoperations before onset of mediastinitis
The primary operative procedures are listed in Table 1. Reoperation before the onset of mediastinitis was necessary in 23 of the patients. Nineteen patients were reoperated once, three twice and one three times before infection occurred. The most frequent reasons for reoperations were stabilizing of the sternum (in 46%) and postoperative bleeding (in 36%). A long primary operation time was associated with reoperation before mediastinitis (median operation time 280 vs. 210 min for patients not subsequently reoperated, P=0.002) as was an operation other than isolated coronary artery bypass grafting (10/81, 12% reoperated after coronary artery bypass grafting vs. 13/45, 29% after other procedures, P=0.01). Age, body mass index, chronic obstructive pulmonary disease, gender or diabetes were not associated with increased risk for reoperation. Reoperation before the presentation of mediastinitis did not increase the risk for subsequent dehiscence.


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  		Table 1. Operative procedures preceding mediastinitis in 126 consecutive casesa

 
3.3. Clinical signs
Of the 126 patients, 99 developed clinical signs of severe infection like high temperature (>39°C) and/or septic shock. Fifteen patients had minor signs of infection like low-grade fever or just increasing C-reactive protein. The remaining 12 had no clinical signs of infection but mediastinitis was revealed on reoperation for sternal dehiscence. The median time from operation or the last reoperation to the development of mediastinitis was 7 days (range 1–38 days) (Fig. 2 ).



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  		Fig. 2. Days from operation (or last reoperation) to the development of mediastinitis.

 
3.4. Bacteriological findings
All patients were reoperated for mediastinitis except one patient with Staphylococcus aureus mediastinitis who was treated with antibiotics and drainage through the pleura only. Sternal dehiscence was clinically evident either before or on reoperation in 86 patients (68%) and sternum was stable in 40 (32%). Multiple bacterial cultures were obtained during reoperation. In addition, the contribution from blood cultures, preoperative wound and abscess cultures, cultures from drainage fluids from pleura or pericardium led to a definite bacterial etiology in 118 of the 126 cases (Table 2). Coagulase negative staphylococci were isolated in 46% of the cases with a verified microbiological etiology and S. aureus in 26%. Of the coagulase negative staphylococci, 70% were methicillin resistant. No methicillin resistant S. aureus were isolated. Gram-negative bacteria were found in 18% of the cases.


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  		Table 2. Microbial etiology in 126 cases of postoperative mediastinitis

 
In patients with culture verified mediastinitis and sternal dehiscence on reoperation, coagulase negative staphylococci were isolated in the majority of the patients (44/80, 55%) which is more frequent than in the patients with stable sternum (10/38, 26%) (P=0.003). S. aureus was more frequently isolated in patients with stable sternum (18/38, 47%) than in patients with sternal dehiscence (13/80, 16%) (P<0.001). Gram-negative mediastinitis occurred in patients with stable and unstable sternum in similar frequencies: 6/38 (16%) vs. 15/80 (19%) (P>0.2).

Length of operation, time on cardiopulmonary bypass, age, diabetes, type of operation or the time span from operation until signs of infection was not associated with a special bacterial etiology. In contrast, high body mass index was associated with coagulase negative staphylococci (mean body mass index 30.1 in coagulase negative staphylococcal etiology vs. 26.7 for other bacteria, P<0.001) and with sternal dehiscence (mean body mass index 29.2 in patients with sternal dehiscence vs. 26.9 in patients with stable sternum, P=0.008). Chronic obstructive pulmonary disease was also associated with sternal dehiscence (29% of patients with sternal dehiscence had chronic obstructive pulmonary disease vs. 3% of patients with stable sternum, P<0.001) and with coagulase negative staphylococci (19/54, 30% of patients with coagulase negative staphylococcal etiology had chronic obstructive pulmonary disease vs. 9/64, 14% in patients with other bacterial etiology, P=0.04). Body mass index was lower with higher age (R=-0.34, P<0.001). Patients who had been reoperated before onset of mediastinitis tended to have an increased risk for a gram-negative etiology (32 vs. 15% in patients not reoperated, P=0.06). Coagulase negative staphylococcal mediastinitis was more often associated with little or no clinical signs of mediastinitis before reoperation (20/54, 37%) than mediastinitis caused by other bacteria (6/64, 9%, P<0.001). Despite less clinical symptoms, the time from operation until signs of infection appeared was not significantly longer in patients with mediastinitis caused by coagulase negative staphylococci than in mediastinitis of other etiology (Table 2). Bacteriemia with coagulase negative staphylococci was unusual (7%), despite aggressive invasive tissue infection. In contrast, about two-thirds of the patients with S. aureus and about half of those with gram-negative mediastinitis had bacteriemia.

3.5. Mortality
The 90-day all cause mortality in patients with mediastinitis was 19%. No specific bacterial etiology was associated with increased mortality (Table 2) nor was presence of bacteriemia. Mortality was associated with higher age (median age 72.8 years vs. 66.5 years in survivors, P=0.008), need for reoperation before mediastinitis (39% mortality in reoperated patient vs. 15% in non-reoperated, p=0.007), and a long-lasting primary operation (254 vs. 210 min in survivors, P=0.01).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Postoperative mediastinitis still causes substantial morbidity and mortality after heart surgery. In 11 recent publications comprising over 65,000 patients, the average incidence of postoperative mediastinitis was 1.05% [2–8,11–14] ranging from 0.46 to 2.39%. The incidence in our department from 1992 to 2000 is in the same range (1.32%). The crude mortality was reported in 10 of these studies [2–8,12–14] adding up to 20% but with considerable variations. The 90 day mortality attributable to mediastinitis has been estimated to be 13% in our department [10]. Some of the variations in morbidity and mortality are certainly due to variations in case definitions, surveillance and follow-up methods as well as selection of patients accepted for surgery. This makes comparisons of complication rates between centers difficult.

Reoperation, mainly as acute reoperations due to bleeding, has been recognized as a risk factor for mediastinitis in some studies [2,4,6,7,15], but not in others [8,16–18]. We observed that reoperations were preceded by unusually long and complicated primary operations. The observed increase in mortality in these patients is most likely associated with the surgical problems encountered. No specific bacterial etiology of mediastinitis carried a higher mortality risk, which may appear surprising considering the aggressive and septic nature of many S. aureus and gram negative infections as compared to infections caused by coagulase negatives. In our study, factors related to the surgical procedure and patient-related factors like age were more critical for survival than the bacterial etiology.

In the present investigation, coagulase negative staphylococcus was the most common pathogen, accounting for almost half of the cases of postoperative mediastinitis. Coagulase negative staphylococci have previously been regarded as fairly benign bacteria, rarely causing serious infections except for in connection with implanted prostheses and other foreign material. However, in cardiac surgery, this bacterium has emerged as a major pathogen carrying a substantial mortality, not different from the mortality of mediastinitis caused by other more virulent pathogens. The clinical presentation of mediastinitis caused by coagulase negative staphylococci was far less fulminant than other pathogens with little or no signs of systemic infection in many of the patients. These observations confirm the results from other studies [19,20].

Mediastinitis caused by coagulase negative staphylococci was more often associated with sternal instability than other bacterial etiology. Sternal instability itself is strongly associated with mediastinitis [2,7,8,19,21,22] and it is likely that mediastinitis often develop from a minor skin or subcutaneous infection in the sternal wound and that the infection may spread inwards to the mediastinal space if sternal dehiscence breaks the mechanical barrier between the presternal tissue and the mediastinum. A presternal wound infection with coagulase negative staphylococci would otherwise be expected to be benign and self-contained and not to pose a clinical problem.

S. aureus is another major pathogen in mediastinitis [2,5,7,20–22] which unlike coagulase negative staphylococci is not associated with sternal dehiscence or obesity. Obesity has otherwise consistently been identified as a major risk factor for mediastinitis, except for a few studies in which S. aureus was the predominant pathogen [1,17]. S. aureus mediastinitis has particularly been associated with carriage of S. aureus in the nose of the patient [17,23] or with the presence of a specific surgeon who is a carrier and disseminator of S. aureus in the operating theater [1]. The accumulated data suggest that S. aureus mediastinitis is due to peroperative contamination and that postoperative infection may occur regardless of sternal instability.

The third major group of bacteria identified in postoperative mediastinitis are aerobic gram negative rods. The typical pathogenic mechanisms could be entirely different from that of the staphylococci. Peroperative contamination of the sternal wound with gram-negatives appears unlikely considering the known bacterial flora in the chest region and that the isolation of gram-negative bacteria from air in the operating theater or from the wound after a long operation is rare [24]. The use of a vein graft harvested from a contaminated donor site in the groin or leg in coronary by-pass surgery could be a way of introducing gram-negative bacteria in the sternal wound. However, coronary artery bypass grafting did not carry an increased risk for gram-negative mediastinitis either in this or in previously published studies [19,22], or in bypass surgery with vein grafts compared to other bypass conduits [25]. Instead, gram-negative mediastinitis has been shown to be associated with concomitant infections, mainly pneumonia, with gram-negative bacteria in the immediate postoperative period and is typically associated with a more complicated postoperative course with prolonged mechanical ventilation, which increases the risk for nosocomial infections with gram-negatives [1,21,22,25]. Furthermore, outbreaks or accumulation of mediastinitis caused by specific gram-negatives like Pseudomonas or Serratia may suggest that nosocomial spread of gram-negative infections in the postoperative period is important for the development of gram-negative mediastinitis [7,12,15].

In conclusion, we propose that three basically different types of postoperative mediastinitis can be distinguished: (1) mediastinitis associated with obesity and sternal dehiscence, sometimes also with chronic obstructive pulmonary disease, and often caused by coagulase negative staphylococci; (2) mediastinitis following peroperative contamination of the mediastinal space often caused by S. aureus, and (3) mediastinitis caused by spread from concomitant infections in other sites than the mediastinum in the postoperative period, often caused by gram negative rods. This classification is of course not strict, but may be helpful in understanding the discrepancies and sometimes contradictory results from studies on risk factors in postoperative mediastinitis.

The classification of postoperative mediastinitis into the three major groups with partly different pathogenic mechanisms may also be useful in designing infection control programs. If gram-negative mediastinitis is a major problem in the institution, strict enforcing of hygienic barrier routines to reduce the spread of nosocomial infections in the postoperative ward seems most important. If S. aureus mediastinitis were a major problem, investigations aimed at identifying and eradicating sources of bacteria in individuals in the operating theater and to make sure the antibiotic prophylaxis is administered in a timely fashion would seem more appropriate. In addition, routines for hair removal, skin preparation and also the hygienic and ventilation standard of the operating rooms should be scrutinized. In mediastinitis caused by coagulase negative staphylococci, appropriate preventive measures are not as evident. Careful median sternotomy is vital to reduce the risk for subsequent sternal dehiscence [26]. Use of bilateral internal mammary arteries in coronary surgery may cause sternal ischemia and subsequent delayed sternal healing, especially in diabetics [4,8,16,25] who already suffer from impaired wound and bone healing. In such patients, the number of wires should be increased or alternative, stronger techniques of fixation should be considered. In addition, coughing and symptoms of chronic obstructive pulmonary disease in the postoperative period should be aggressively alleviated to relieve the sternal fixation from excessive strain.


   Acknowledgments
 
This study was supported by grants from the Karolinska Institute.


   Footnotes
 
Presented in part at the 49th Annual Meeting of The Scandinavian Association for Thoracic Surgery (SATS), Linköping, Sweden, August 24–26, 2000 and at the 40th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), Toronto, Canada, September 17–20, 2000.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Wouters R., Wellens F., Vanermen H., de Geest R., Degrieck I., de Meerleer F. Sternitis and mediastinitis after coronary artery bypass grafting. Analysis of risk factors. Tex Heart Inst J 1994;21:183-188.[Medline]
  2. Fariñas M.C., Peralta F.G., Bernal J.M., Rabasa J.M., Revuelta J.M., González-Macías J. Suppurative mediastinitis after open-heart surgery: a case-control study covering a seven-year period in Santander, Spain. Clin Infect Dis 1995;20:272-279.[Medline]
  3. Milano C.A., Kesler K., Archibald N., Sexton D.J., Jones R.H. Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival. Circulation 1995;92:2245-2251.[Abstract/Free Full Text]
  4. Zacharias A., Habib R.H. Factors predisposing to median sternotomy complications. Deep vs superficial infections. Chest 1996;110:1173-1178.[Abstract/Free Full Text]
  5. Valla J., Corbineau H., Langanay T., Sevray B., Felix C., Sellin M., le Couls H., Leguerrier A., Rioux C., Logeais Y. Les Médiastinites apres chirurgie cardiaque. Bilan sur. 10 ans (1985–1995). Ann Cardiol Angeiol 1996;45:369-376.
  6. El Oakley R., Paul E., Wong P.S., Yohana A., Magee P., Walesby R., Wright J. Mediastinitis in patient undergoing cardiopulmonary bypass: risk analysis and midterm results. J Cardiovasc Surg 1997;38:595-600.[Medline]
  7. Muñoz P., Menasalvas A., Bernaldo de Quirós J.C.L., Desco M., Vallejo J.L., Bouza E. Postsurgical mediastitnis: a case-control study. Clin Infect Dis 1997;25:1060-1064.[Medline]
  8. Antunes P.E., Bernardo J.E., Eugénio L., de Oliveira J.F., Antunes M.J. Mediastinitis after aorto-coronary bypass surgery. Eur J Cardiothorac Surg 1997;12:443-449.[Abstract]
  9. Mangram A.J., Horan T.C., Pearson M.L., Silver L.C., Jarvis W.R., The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20:247-278.
  10. Astudillo R., Vaage J., Myhre U., Karevold A., Grdlund B. Fewer reoperations and shorter stay in the cardiac surgical ward when stabilising the sternum with the Ley prosthesis in postoperative mediastinitis. Eur J Cardiothorac Surg 2001;20:133-139.[Abstract/Free Full Text]
  11. Liu J.Y., Birkmeyer N.J.O., Sanders J.H., Morton J.R., Henriques H.F., Lahey S.J., Dow R.W., Maloney C., DiScipio A.W., Clough R., Leavitt B.J., O'Connor G.T. Risk of morbidity and mortality in dialysis patients undergoing coronary artery bypass surgery. Circulation 2000;102:2973-2977.[Abstract/Free Full Text]
  12. Pasaoglu I., Arsan S., Yorgancioglu A.C., Bozer A.Y. A simple management of mediastinitis. Int Surg 1995;80:239-241.[Medline]
  13. El Gamel A., Yonan N.A., Hassan R., Jones M.T., Campbell C.S., Deiraniya A.K., Lawson R.A.M. Treatment of mediastinitis: early modified Robicsek closure and pectoralis major advancement flaps. Ann Thorac Surg 1998;65:41-47.[Abstract/Free Full Text]
  14. Satta J., Lahtinen J., Räisänen L., Salmela E., Juvonen T. Options for the mangement of poststernotomy mediastinitis. Scand Cardiovasc J 1998;32:29-32.[Medline]
  15. Ottino G., de Paulis R., Pansini S., Rocca G., Tallone M.V., Comoglio C., Costa P., Orzan F., Morea M. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987;44:173-179.[Abstract]
  16. Kouchoukos N.T., Wareing T.H., Murphy S.F., Pelate C., Marshall W.G., Jr Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg 1990;49:210-219.[Abstract]
  17. Kluytmans J.A.J.W., Mouton J.W., Ijzerman E.P.F., Vandenbroucke-Grauls C.M.J.E., Maat A.W.P.M., Wagenvoort J.H.T., Verbrugh H.A. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis 1995;171:216-219.[Medline]
  18. Bitkover C.Y., Grdlund B. Mediastinitis after cardiovascular operations: a case-control study of risk factors. Ann Thorac Surg 1998;65:36-40.[Abstract/Free Full Text]
  19. Sthle E., Tammelin A., Bergström R., Hambreus A., Nyström S.O., Hansson H.E. Sternal wound complications – incidence, microbiology and risk factors. Eur J Cardio-thorac Surg 1997;11:1146-1153.[Abstract]
  20. Mossad S.B., Serkey J.M., Longworth D.L., Cosgrove D.M., III, Gordon S.M. Coagulase-negative staphylococcal sternal wound infections after open heart operations. Ann Thorac Surg 1997;63:395-401.[Abstract/Free Full Text]
  21. Grossi E.A., Culliford A.T., Krieger K.H., Kloth D., Press R., Baumann F.G., Spencer F.C. A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures. Ann Thorac Surg 1985;40:214-221.[Abstract]
  22. Rodríguez-Hernández M.J., de Alarcón A., Cisneros J.M., Moreno-Maqueda I., Marrero-Calvo S., Leal R., Camacho P., Montes R., Pachón J. Suppurative mediastinitis after open-heart surgery: a comparison between cases caused by Gram-negative rods and Gram-positive cocci. Clin Microbiol Inf 1997;3:523-530.
  23. Jakob H.G., Borneff-Lipp M., Bach A., von Pückler S., Windeler J., Sonntag H.-G., Hagl S. The endogenous pathway is a major route for deep sternal wound infection. Eur J Cardio-thorac Surg 2000;17:154-160.[Abstract/Free Full Text]
  24. Bitkover C.Y., Marcusson E., Ransjö U. Spread of coagulase-negative staphylococci during cardiac operations in a modern operating room. Ann Thorac Surg 2000;69:1110-1115.[Abstract/Free Full Text]
  25. Loop F.D., Lytle B.W., Cosgrove D.M., Mahfood S., McHenry M.C., Goormastic M., Stewart R.W., Golding L.A.R., Taylor P.C. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-187.[Abstract]
  26. Shafir R., Weiss J., Herman O., Cohen N., Stern D., Igra Y. Faulty sternotomy and complications after median sternotomy. J Thorac Cardiovasc Surg 1988;96:310-313.[Abstract]



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