title: Bacterial mediastinitis after heart transplantation: clinical presentation, risk factors and treatment.
abstract: BACKGROUND
  The incidence of mediastinitis after heart transplantation has been reported to be between 2.5% and 7.5%. Most previous reports from the transplant literature have assessed patients who had not received induction therapy.
  
  
  METHODS
  From December 1996 to January 2002, a total of 230 heart transplants were performed using induction therapy with rabbit anti-thymocyte globulin at La Pitié Salpêtrière Hospital (Paris, France). Mediastinitis developed in 15 patients (6.5%). A case-control study was performed to characterize the clinical presentation, microbiology, risk factors and therapy of mediastinitis after heart transplantation.
  
  
  RESULTS
  Only 4 patients (26%) had a temperature of >38 degrees C and 6 patients (40%) had a white blood cell count of >10,000 cells/mm(3). Septicemia (46%) and positive temporary epicardial pacing wires culture (60%) were frequently observed. Staphylococcus aureus (5 of 15), Staphylococcus epidermidis (5 of 15) and gram-negative bacteria (5 of 15) were the causative organisms cultured intra-operatively. Mean duration of mechanical ventilation (2.4 vs 1.6 days; p < 0.03) and use of ventricular assistance (20% vs 0%; p < 0.04) were different between cases and controls. The mortality rate at hospital discharge was 6.7% (1 of 15).
  
  
  CONCLUSIONS
  In the context of immunosuppression after heart transplantation, a high degree of suspicion is necessary to make the diagnosis of mediastinitis. Positive blood and temporary epicardial pacing wires cultures can be helpful in suggesting the presence of mediastinitis. Using vancomycin and an aminoglycoside as prophylaxis has to be considered because of the high prevalence of methilcilin-resistant S epidermidis and gram-negative bacteria. Conservative therapy (sternal debridement without muscle flap closure, and closed-chest drainage) showed excellent results in this series.
authors.affiliation: Service de Chirurgie Cardio-Vasculaire et Thoracique, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
authors.forename: Mario
authors.initials: M
authors.lastname: Sénéchal
authors.forename: Pascal
authors.initials: P
authors.lastname: LePrince
authors.forename: Sophie
authors.initials: S
authors.lastname: Tezenas du Montcel
authors.forename: Nicolas
authors.initials: N
authors.lastname: Bonnet
authors.forename: Michelle
authors.initials: M
authors.lastname: Dubois
authors.forename: Mohamed
authors.initials: M
authors.lastname: El-Serafi
authors.forename: J J
authors.initials: JJ
authors.lastname: Ghossoub
authors.forename: Alain
authors.initials: A
authors.lastname: Pavie
authors.forename: Iradj
authors.initials: I
authors.lastname: Gandjbakhch
authors.forename: Richard
authors.initials: R
authors.lastname: Dorent
mesh_terms: D000328:Adult; D000818:Animals; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis; D000961:Antilymphocyte Serum / Q000627:therapeutic use; D001424:Bacterial Infections / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D016022:Case-Control Studies; D003646:Debridement; D004322:Drainage; D005260:Female; D016027:Heart Transplantation; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D008297:Male; D008480:Mediastinitis / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D011817:Rabbits; D012307:Risk Factors; D014640:Vancomycin / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D000961:Antilymphocyte Serum; D007166:Immunosuppressive Agents; D014640:Vancomycin