Download Candidal mediastinitis successfully treated using vacuum

CASE REPORT
Interactive CardioVascular and Thoracic Surgery 14 (2012) 872–874
doi:10.1093/icvts/ivs084 Advance Access publication 14 March 2012
Candidal mediastinitis successfully treated using vacuum-assisted
closure following open-heart surgery
Hiroaki Osada*, Hiroyuki Nakajima, Manabu Morishima and Takamitsu Su
Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Kyoto, Japan
* Corresponding author. Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, 1 Katsuragoshomachi, Nishikyo-ku, Kyoto 615-8087, Japan.
Tel: +81-75-3812111; fax: +81-75-3927952; e-mail: [email protected] (H. Osada).
Received 28 November 2011; received in revised form 26 January 2012; accepted 14 February 2012
Abstract
Deep sternal wound infections (DSWIs) are an uncommon but serious complication after open-heart surgery. The reported incidence
of DSWIs due to Candida albicans is 0.4%, but these infections have an extremely high mortality of 56%. We herein report a rare
case of a 79-year old woman who suffered from Candidal DSWI after repeated open-heart surgeries. We treated her with negative
pressure wound therapy (NPWT). This is the rare case report that provides evidence that NPWT is a safe and suitable technique for the
management of Candidal DSWIs.
Keywords: Antibiotics • Mediastinal infection • Postoperative care • Candidal infection • Surgical site infection
INTRODUCTION
Deep sternal wound infection (DSWI) including osteomyelitis
and mediastinitis due to Candida albicans following open-heart
surgery is relatively rare. Once it occurs, however, extremely high
mortality and morbidity are unavoidable.
MATERIALS AND METHODS
A 79-year old woman was admitted to our hospital with a diagnosis of recent myocardial infarction of the inferior wall.
Coronary angiography showed total occlusion of the proximal
right coronary artery and severe stenosis of the proximal left
anterior descending and left circumflex arteries. Severe tricuspid
regurgitation was also evaluated by echocardiography.
We performed coronary artery bypass grafting and tricuspid
annuloplasty with a 30-mm MC3 annuloplasty ring (Edwards
Lifesciences, Irvine, CA, USA) under a standard cardiopulmonary
bypass. Because the inferior wall appeared to have undergone
haemorrhagic infarction, we avoided anastomosis to the right
coronary artery. The postoperative course was good, but a left
ventricular aneurysm with a diameter of 20 mm × 14 mm at the
basal inferior wall was revealed by transthoracic echocardiography 10 days after the initial operation.
Three months later, because echocardiography revealed a
gradually increasing size of ventricular aneurysm, she underwent
a second open-heart surgery involving left ventricular aneurysmectomy. The left ventricular aneurysm was closed with a bovine
pericardial patch from the left atrium. There was no mitral regurgitation. The posterior mitral leaflet was incised for visualization,
and mitral valvuloplasty and annuloplasty with a 26-mm Physio
annuloplasty ring (Edwards Lifesciences) were performed.
Two weeks after the closure of aneurysm, mitral regurgitation
suddenly worsened. Mitral valve replacement was performed urgently with a 25-mm Mosaic porcine bioprosthesis (Medtronic,
Inc., Minneapolis, MN, USA) under inotropic support.
On the 9th postoperative day after mitral valve replacement,
laboratory tests showed a sudden elevation of C-reactive protein
3.65 to 8.25 mg/dl without elevation of white blood cells or
high fever. A purulent exudate from the midline skin incision
was increased. Chest computed tomography (CT) revealed an
abscess forming behind her sternal bone.
Therefore, sternal exploration was performed. Her retrosternal
space was filled with purulent exudate. Candida albicans was
isolated from the sternal bone and mediastinum, and antifungal
therapy with micafungin (150 mg, intravenously, once daily) was
started. Blood cultures were negative for C. albicans.
We initiated negative pressure wound therapy (NPWT) as
delivered by the vacuum-assisted closure (VAC) Therapy
System (KCI USA, San Antonio, TX, USA) following surgical
debridement and irrigation (Fig. 1). Five layers of non-adhesive
silicone-coating sheets TREX-C (Fuji Systems Corp., Tokyo,
Japan) were placed on the epicardium and aorta, the second
and the third layers of polyurethane foam was placed between
the sternal edges and between the pectoral muscle edges. The
wound was sealed with a drape, and an evacuation tube was
connected to a continuous vacuum source (Fig. 2). Continuous
negative pressure was maintained at −50 mmHg. She was able
to walk around with the device for rehabilitation. The wound
filler was changed every 2–4 days under general anaesthesia
with debridement, partial sternectomy and irrigation before a
definitive secondary wound closure could be performed.
After 13 debridements and irrigations (six weeks from sternal
exploration), we confirmed a negative fungal culture in the
wound swab.
© The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
H. Osada et al. / Interactive CardioVascular and Thoracic Surgery
Figure 1: Frequent debridement of necrotic tissue and irrigation were
required.
Figure 2: The wound was sealed with a drape, and an evacuation tube was
connected to a continuous vacuum source.
Therefore, we performed the transposition of the greater
omentum and closed the chest wall using a major pectoral
muscle.
Because of a skin rash, micafungin was discontinued in 3
weeks. Intravenous fluconazole (200 mg once daily) was administered for 8 weeks and was then converted to oral therapy
(100 mg twice daily).
She developed acute heart failure and required inotropes to
control the condition twice during hospitalization.
873
multifactorial. In 2009, Modrau et al. [1] stated that the risk
factors of Candidal DSWI were Candidal colonization in tracheal
secretions or urine and reoperation before the diagnosis of
DSWI. Risnes et al. [3] reported that diabetes, obesity, chronic
obstructive pulmonary disease and age are important independent risk factors for mediastinitis. For this patient, age and
Candidal colonization in urine seemed to be significant risk
factors for DSWI. Moreover, frequent sternotomy procedures
should have been avoided.
In a randomized trial, Armstrong and Lavery [4] introduced the
effectiveness of NPWT with a VAC therapy system for a diabetic
foot in 2005. Several management techniques have been
discussed in patients with DSWI [5, 6]. Tocco et al. [7] and Petzina
et al. [8] reported the effectiveness of NPWT for poststernotomy
mediastinitis that reduces the mortality rate and sternal reinfection compared with conventional treatment.
Generally, the initiation of NPWT is a contraindication for
wounds in which the cardiac surface directly touches the device
because of the fear of haemorrhage. We initiated NPWT with a
non-adhesive silicone-coating sheet on the cardiac surface and
minimum low negative pressure of −50 mmHg. Major complications, such as active haemorrhage and impairment of cardiac
function, were not seen.
Malani et al. reported 11 cases of DSWI due to C. albicans.
They stated that azole therapy must be provided for at least
six months and longer if CT reveals bone destruction [9]. Based
on this recommendation, we have used micafungin for three
weeks and fluconazole for eight weeks intravenously and will
continue oral fluconazole therapy even after discharge.
A combination of NPWT with a VAC therapy system and conventional treatment, including surgical debridement, transposition of the greater omentum and intravenous antifungal
therapy, led to this patient’s favourable outcome. This is preferable for the management of DSWI due to C. albicans.
Although the device we used probably allowed for better
patient performance during hospitalization, further study is
needed to discuss if the secondary wound closure have been
actually shortened.
In summary, this case report provides evidence that our
technique for DSWI may represent a viable therapeutic approach
for patients with C. albicans infection.
Conflict of interest: none declared.
RESULTS
DISCUSSION
Although the most commonly isolated pathogens in primary
DSWI are Staphylococcus epidermidis, S. aureus and gramnegative bacteria, Candidal DSWI is clinically rare. Although the
incidence is estimated to be 0.4% in open-heart surgery patients
[1], Candidal DSWI has an extremely high mortality rate of 56%
[2] during perioperative care. The incidence of Candidal DSWI is
[1] Modrau IS, Ejlertsen T, Rasmussen BS. Emerging role of Candida in deep
sternal wound infection. Ann Thorac Surg 2009;88:1905–9.
[2] Clancy CJ, Nguyen MH, Morris AJ. Candidal mediastinitis: an emerging
clinical entity. Clin Infect Dis 1997;25:608–13.
[3] Risnes I, Abdelnoor M, Almdahl SM, Svennevig JL. Mediastinitis after
coronary artery bypass grafting risk factors and long-term survival. Ann
Thorac Surg 2010;89:1502–10.
[4] Armstrong DG, Lavery LA. Negative pressure wound therapy after partial
diabetic foot amputation: a multicentre, randomized controlled trial.
Lancet 2005;366:1704–10.
[5] Gustafsson RI, Sjogren J, Ingemansson R. Deep sternal wound infection: a
sternal –sparing technique with vacuum-assisted closure therapy. Ann
Thorac Surg 2003;76:2048–53.
[6] Sjogren J, Nilsson J, Gustafsson R, Malmsjo M, Ingemansson R. The impact
of vaccum-assisted closure on long-term survival after post-sternotomy
mediastinitis. Ann Thorac Surg 2005;80:1270–5.
CARDIAC GENERAL
REFERENCES
After rehabilitation and treatment for several comorbidities, she
recovered completely with no sequelae. She was discharged
after six weeks of VAC therapy and 11 weeks of antifungal
therapy.
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H. Osada et al. / Interactive CardioVascular and Thoracic Surgery
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et al. Improved results of the vacuum assisted closure and Nitinol clips
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A et al. Negative pressure wound therapy for post-sternotomy
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