A review of the AATS guidelines for the prevention and management of sternal wound infections

  • Harold L. LazarEmail author
Review Article



To summarize the AATS guidelines for the prevention and treatment of sternal wound infections.


The current AATS guidelines for the prevention of sternal wound infections during the preoperative, intraoperative, and postoperative periods, and the most effective methods and techniques to treat sternal wound infections were reviewed.


The guidelines identified multiple interventions that can be instituted during the preoperative, intraoperative, and postoperative periods to reduce sternal wound infections during cardiac surgery. These include the use of perioperative antibiotics, glycemic control to maintain serum glucose < 180 mg/dl, avoidance of bone wax and the use of vancomycin paste to the sternal edges, and figure of eight suture techniques to re-approximate the sternum. Wound Vac therapy should be instituted whenever possible to treat and enhance recovery from mediastinitis.


The prevention of sternal wound infections and mediastinitis can be achieved by adherence to the AATS guidelines. The institution of these interventions requires a multi-disciplinary team effort among surgeons, anesthesiologists, referring physicians, nurses, and OR and ICU personnel.


Mediastinitis Sternal wound infections Wound Vac therapy 


Compliance with ethical standards

Conflict of interest

The author declares that he has no conflict of interest.

Ethical approval, Statement of Human and Animal Rights, Informed consent--Being a Review article, these are not required.


  1. 1.
    Braxton JH, Marrin CA, McGrath PD, et al. Mediastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg. 2000;70:2004–7.CrossRefGoogle Scholar
  2. 2.
    Milano CA, Kesler K, Archibald N, Sexton N, Jones RH. Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival. Circulation. 1995;92:2245–51.CrossRefGoogle Scholar
  3. 3.
    Ferris TG, Torchiana DF. Public release of clinical outcomes data---Online CABG report cards. N Engl J Med. 2010;363:1593–5.CrossRefGoogle Scholar
  4. 4.
    Lazar HL, Salm VT, Engelman R, Orgill D, Gordon S. Prevention and management of sternal wound infections. J Thorac Cardiovasc Surg. 2016;152:962–72.CrossRefGoogle Scholar
  5. 5.
    D’Agostino RS, Jacobs JP, Bardhwar V, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2018 update on outcomes and quality. Ann Thorac Surg. 2018;105:15–23.CrossRefGoogle Scholar
  6. 6.
    Huang SS, Rifas-Shiman SL, Warren DK. etal. Improving methicillin-resistant staphylococcus aureus surveillance and reporting in intensive care units. J Infect Disease. 2007;195:330–8.CrossRefGoogle Scholar
  7. 7.
    Kamel C, McGahan L, Polisena J, Mierzwinski-Urban M, Embil JM. Preoperative skin antiseptic preparations for preventing surgical site infections: a systemic review. Infect Control Hosp Epidemiol. 2012;33:608–17.CrossRefGoogle Scholar
  8. 8.
    Engelman DT, Adams DH, Bryne JG. etal. Impact of body mass index and albumin on morbidity and mortality after cardiac surgery. J Thorac Cardiovasc Surg. 1999;118:866–73.CrossRefGoogle Scholar
  9. 9.
    Rich MW, Keller SJ, Schechtman KB, Marshall WG Jr, Kouchoukos NT. Increased complications and prolonged hospital stay in elderly cardiac surgical patients with low serum albumin. Am J Cardiol. 1989;63:714–8.CrossRefGoogle Scholar
  10. 10.
    Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134:36–42.CrossRefGoogle Scholar
  11. 11.
    Edwards LD. The epidemiology of 2,056 remote site infections and 1996 surgical wound infections occurring in 1,865 patients: a four year study of 40,923 operations at Rush-Presbyterian-St Luke’s Hospital, Chicago. Ann Surg. 1976;184:758–66.CrossRefGoogle Scholar
  12. 12.
    Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A. Glucose control lowers the risk of wound infection in diabetic patients after open heart operations. Ann Thorac Surg. 1997;63:365–1.Google Scholar
  13. 13.
    Lazar HL, Chipkin SR, Fitzgerald CA, Bao Y, Cabral H, Apstein CS. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation. 2004;109:1497–502.CrossRefGoogle Scholar
  14. 14.
    Nagachinta T, Stephens M, Reitz B, Polk BF. Risk factors for surgical- wound infection following cardiac surgery. J Infect Dis. 1987;156:967–73.CrossRefGoogle Scholar
  15. 15.
    Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR. The Society of Thoracic Surgeons Practice Guidelines Series: Antibiotic prophylaxis in cardiac surgery. Part I: Duration. Ann Thorac Surg. 2006;81:397–404.CrossRefGoogle Scholar
  16. 16.
    Engelman R, Shahian D, Shemin R. etal. The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic prophylaxis in cardiac surgery. Part II: Antibiotic choice. Ann Thorac Surg. 2007;83:1569–76.CrossRefGoogle Scholar
  17. 17.
    Zanetti G, Giardina R, Platt R. Intraoperative redosing of cefalozin and risk for surgical site infection in cardiac surgery. Emerg Infect Dis. 2001;7:828–31.CrossRefGoogle Scholar
  18. 18.
    Caffarelli AD, Holden JP, Baron EJ, et al. Plasma cefazolin levels during cardiovascular surgery: effects of cardiopulmonary bypass and profound hypothermic circulatory arrest. J Thorac Cardiovasc Surg. 2006;131:1338–43.CrossRefGoogle Scholar
  19. 19.
    Doenst T, Wijeysundera D, Karkouti K, et al. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2005;130:1144.CrossRefGoogle Scholar
  20. 20.
    Halasz NA. Wound infection and topical antibiotics: The surgeon’s dilemma. Arch Surg. 1977;112:1240–4.CrossRefGoogle Scholar
  21. 21.
    Vander Salm TJ, Okike ON, Pasque MK, et al. Reduction of sternal infection by application of topical vancomycin. J Thorac Cardiovasc Surg. 1989;98:618–22.Google Scholar
  22. 22.
    Lazar HL, Ketchedjian A, Haime M, Karlson K, Cabral H. Topical vancomycin in combination with perioperative antibiotics and tight glycemic control helps to eliminate sternal wound infections. J Thorac Cardiovasc Surg. 2014;148:1035–40.CrossRefGoogle Scholar
  23. 23.
    Arruda MVF, Braile DM, Joaquim MR, Suzuki FA, Alves RH. The use of vancomycin paste for sternal hemostasis and mediastinitis prophylaxis. Rev Bras Circ Cardiovasc. 2008;23:35–9.CrossRefGoogle Scholar
  24. 24.
    Lazar HL, Barlam T, Cabral H. The effect of topical vancomycin applied to sternotomy incisions on postoperative serum vancomycin levels. J Card Surg. 2011;26:461–5.CrossRefGoogle Scholar
  25. 25.
    Kowalewski M, Raffa GM, Szwed KA, Anisimowicz L. Meta-analysis to assess the effectiveness of topically used vancomycin in reducing sternal would infections after cardiac surgery. J Thorac Cardiovasc Surg. 2017;154:1320–3.CrossRefGoogle Scholar
  26. 26.
    Kowalewski M, Pawliszak W, Zaborowska K, et al. Gentamicin-collagen sponge reduces the risk of sternal wound infections after heart surgery: Meta analysis. J Thorac Cardiovasc Surg. 2015;149:1631–40.CrossRefGoogle Scholar
  27. 27.
    Prziborowski J, Hartrumpf M, Stock UA, Kuehnel RU. Albes JM. Is bonewax safe and does it help? Ann Thorac Surg. 2008;85:1002–6.CrossRefGoogle Scholar
  28. 28.
    Bhatti F, Dunning J. Does liberal use of bone wax increase the risk of mediastinitis? Interact Cardiovasc Thorac Surg. 2003;2:410–2.CrossRefGoogle Scholar
  29. 29.
    Almdahl SM, Halvorsen P, Veel T, Rynning SE. Avoidance of noninfectious sternal dehiscence: figure- of- eight wiring is superior to straight wire closure. Scand Cardiovasc J. 2013;47:247–50.CrossRefGoogle Scholar
  30. 30.
    Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open- heart surgery. J Thorac Cardiovasc Surg. 1977;73:267–8.Google Scholar
  31. 31.
    Lazar HL, McDonnell M, Chipkin SR, et al. The Society of Thoracic Surgeons Practice Guideline Series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg. 2009;87:663–9.CrossRefGoogle Scholar
  32. 32.
    Glick PL, Guglielmo BJ, Tranbaugh RF, Turkey K. Iodine toxicity in a patient treated by continuous povidone-iodine mediastinal irrigation. Ann Thorac Surg. 1985;39:478–80.CrossRefGoogle Scholar
  33. 33.
    Zec N, Donovan JW, Aufiero TX, Kincaid RL, Demers LM. Seizures in a patient treated with continuous povidone-iodine mediastinal irrigation. N Engl J Med. 1992;326:1784.Google Scholar
  34. 34.
    Baillot R, Cloutier D, Montalin L, et al. Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15- year review of 23,499 sternotomies. Eur J Cardiothorac Surg. 2010;37:880–7.CrossRefGoogle Scholar
  35. 35.
    Fuchs V, Zittermann A. Stuettgen B etal. Clinical outcome of patients with deep sternal wound infection managed by vacuum-assisted closure compared to conventional therapy with open packing: a retrospective analysis. Ann Thorac Surg. 2005;79:516–21.CrossRefGoogle Scholar
  36. 36.
    Petzina R, Hoffman J, Navasardyan A, et al. Negative pressure wound therapy for post-sternotomy mediastinitis reduces mortality rate and sternal re-infection rate compared to conventional treatment. Eur J Cardiothorac Surg. 2010;38:110–3.CrossRefGoogle Scholar
  37. 37.
    Abu-Omas Y, Naik MS, Catarino PA, Ratnatunga C. Right ventricular rupture during use of high-pressure suction drainage in the management of poststernotomy mediastinitis. Ann Thorac Surg. 2003;76:974–6.CrossRefGoogle Scholar
  38. 38.
    Perrault LP, Kirkwood KA, Chang HL, et al. A prospective multi-institutional cohort study of mediastinal infections after cardiac operations. Ann Thorac Surg. 2018;105:461–8.CrossRefGoogle Scholar

Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2018

Authors and Affiliations

  1. 1.From the Division of Cardiac SurgeryThe Boston University School of MedicineBostonUSA

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