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NF is a potentially lethal infectious process usually found in the abdomen, perineum, or extremities. In the head and neck it usually starts from a dental infection but can be initiated from any source. One of the more serious sequelae is extension of the infection down the deep fascial planes of the neck leading to mediastinitis; this is associated with a higher mortality rate. The presence of an associated immunocompromising disease, such as diabetes, has been said to predispose an individual to NF, and the mortality rate has been shown to be higher (although perhaps not significantly so). When first described, NF was thought to be caused only by beta-hemolytic Staphylococcus. Now it known to be a polymicrobial infection with anaerobes and facultative anaerobes found most frequently. Treatment involves broad-spectrum intravenous antibiotics as soon as possible, narrowing the coverage as the results of the gram stain and cultures become available. The importance of aggressive, prompt surgical management cannot be overemphasized in the treatment of NF. Once the diagnosis of NF is strongly suspected, debridement of the affected areas must be accomplished as soon as possible. Despite the advances in the recognition and treatment of NF, there is still significant morbidity and mortality associated with this disease. Continued vigilance must be practiced if the survival rate is to continue to increase.
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PMID:Necrotizing fasciitis originating from pinna perichondritis. 756 23

The most serious infection after coronary artery bypass grafting (CABG) is mediastinitis following deep sternal wound infection. Antibiotic prophylaxis for at least 48 hours has been recommended. In this trial 551 consecutive patients were randomized to receive ceftriaxone in a single dose or cefuroxime thrice daily until the end of the second postoperative day. The overall infection rate was 7.7% in the ceftriaxone and 8.3% in the cefuroxime group, and the incidence of deep sternal infection was 2.9% in both groups. Significant risk factors for such infection were chronic respiratory disease (p < 0.001) and diabetes (p < 0.01). The antibiotic prophylaxis had no harmful effects on the colonic flora in either group. Acquisition and delivery costs for the prophylactic agents were three times higher in the cefuroxime than in the ceftriaxone group. Both antibiotics are concluded to be equally safe and effective. Single-dose ceftriaxone prophylaxis is as effective as cefuroxime given for 48 hours postoperatively. Single-dose ceftriaxone is also simple to use.
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PMID:Ceftriaxone vs cefuroxime for infection prophylaxis in coronary bypass surgery. 779 59

Cervical necrotizing fasciitis is a devastating polymicrobial soft tissue infection characterized by gas formation and extensive necrosis of subcutaneous fat and fascia with extension to skin and muscle. Involvement of the head and neck is rare and is typically dental in origin. Despite broad-spectrum antibiotics, mortality rates for this disease remain high. We report a successfully treated case of necrotizing fasciitis arising from a peritonsillar abscess. Review of the literature reveals only 6 other cases, with 3 successful outcomes. Early diagnosis, broad-spectrum antibiotics, and aggressive surgical debridement are the cornerstones of therapy. The pathophysiology is typically a mixed aerobic and anaerobic infection. Supportive treatment options such as hyperbaric oxygen therapy and high-calorie supplemental nutrition may be of benefit. A comprehensive literature review of craniocervical necrotizing fasciitis is presented. Factors associated with poor outcomes include diabetes mellitus, mediastinitis, cardiovascular disease, and peritonsillar abscess.
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PMID:Peritonsillar abscess: an unlikely cause of necrotizing fasciitis. 785 15

As part of a quality control program, we analyzed possible risk factors in the development of sternitis and mediastinitis after coronary artery bypass grafting. From 1 January 1990 through 31 December 1991, 1,368 consecutive coronary artery bypass grafting procedures were performed at our institution, either alone or in combination with other procedures. Twenty-three patients (1.7%) developed sternitis and/or mediastinitis; 7 (30.4%) of these patients died in an early postoperative phase. Univariate analysis revealed the following statistically significant (p < or = 0.05) risk factors: perfusion time, length of stay in operating room of longer than 5 hours 30 minutes, presence at the operation of a certain surgical resident, revision for bleeding, and postoperative mechanical ventilation lasting longer than 72 hours. After multivariate analysis, statistically significant independent risk factors were: diabetes mellitus, recent cigarette-smoking, reoperation, presence of a certain surgical resident at the operation, revision for bleeding, and length of mechanical ventilation of longer than 72 hours. The use of both internal thoracic arteries was not, in this study, shown to be an independent risk factor. We conclude that although the technique of using both internal thoracic arteries for myocardial revascularization carries no extra risk by itself in the development of sternitis or mediastinitis, associated factors such as prolonged stay in the operating room and reoperation could be responsible for a higher frequency of sternitis-mediastinitis in patients who have undergone this procedure. Therefore, it is advisable to use this technique selectively in high-risk patients. Close surveillance and reporting of wound infections is mandatory to detect risk factor related to the surgical staff (such as Staphylococcus aureus dissemination).
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PMID:Sternitis and mediastinitis after coronary artery bypass grafting. Analysis of risk factors. 800 Feb 63

In a study of 1040 patients undergoing cardiac surgery at The Osaka Medical College Hospital from 1984 through 1991, we analyzed the correlation between a variety of preoperative and operative parameters and the risk of postoperative sternal wound infection, as well as the efficacy of various therapeutic method for this condition. Sternal infection or mediastinitis developed after cardiac surgery in 31 patients (3.0%). As the risk factors for wound infections, age, diabetes mellitus, reexploration, duration of cardiopulmonary bypass and use of bilateral internal thoracic artery grafting were listed. Application of pectoral muscle flaps significantly led to shorten a duration between diagnosis of infection and hospital discharge, and increased survival rate, than the other treating methods such as debridement or irrigation. We conclude that bilateral internal thoracic artery grafts should not be used in the cases with diabetes, and closure with pectoral muscle flaps is effective for sternal infection and mediastinitis.
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PMID:[Risk factors and therapeutic methods for sternal wound infection following cardiac surgery]. 836 May 26

Due to its anatomical structure and physiological properties, omental tissue has proven to be beneficial when transposed to the thorax to treat severe mediastinal infections. Between April 1987 and July 1994, 17,005 open heart operations were performed at our institution. One hundred and forty patients who developed mediastinitis or serious wound infections postoperatively were treated by transposition of the greater omentum into the retrosternal space. These patients were compared with a control group of 100 patients operated in the same period, who did not develop infectious complications postoperatively. Significant differences were found in several risk factors, such as obesity, type, and duration of primary operation, ejection fraction < 30% (< 0.01), as well as the incidence of low cardiac output syndrome treated by insertion of an intra-aortic balloon pump (p < 0.05). However, no significant differences were observed in factors such as diabetes mellitus, emergency operation, reoperation, degree of postoperative bleeding, and duration of aortic cross-clamp time. The mortality of mediastinitis largely depended on the type of primary operation. It was 19.2% in patients who underwent coronary surgery, and 52.2% in patients who underwent transplantation (overall mortality 35.7%). Only in 2% of the patients did we find complications related to the creation of the omental pedicle and its translocation. Today, serious disturbances in sternal wound healing, especially involving mediastinitis, are rare complications in cardiac surgery. Nevertheless, they continue to be associated with high mortality and prolonged hospitalization.
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PMID:Poststernotomy mediastinitis treated by transposition of the greater omentum. 857 22

From January, 1990 through May, 1997, 100 CABG operations were conducted using only double arterial grafts. RITA/left internal thoracic artery (LITA) (n = 38) and RGEA/LITA (n = 62) groups were compared. The incidence of left main trunk lesion was higher in the RITA/LITA group (29%: 13%), and old myocardial infarction was greater in RGEA/LITA group (77%: 55%). Mean age in the RGEA/LITA group showed high tendency (66.8 +/- 8.5: 63.9 +/- 9.2). Both groups were essentially the same with respect to sex, poor left ventricular function, pre-operative aortic baloon pumping (IABP), diabetes mellitus, hypertension, cerevral vascular disease, hyperlipidemia, smoking, pre-operative ejection fraction (EF). Focal skin infection (32%: 6%) and total operative field infection (focal skin infection + mediastinitis) (39%: 8%) were higher in the RITA/LITA group. Operation time (443 +/- 81: 405 +/- 114) and pleural effusion (29%: 15%) showed high tendency in the RGEA/LITA group. Extracorporeal circulation time, aorta cross-clamping time, reoperation due to bleeding, reoperation due to mediastinitis, post-operative IABP, and post-operative EF were the same for the two groups. The difference of survival rate and cardiac event-free rate between two groups were not recognized. The RGEA/LITA group showed lower complication and similar survival rates than the RITA/LITA group. Based on the present results. RGEA may be considered more usefull than RITA.
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PMID:[Clinical evaluation of right gastroepiploic artery (RGEA) graft--comparison of RGEA with right internal thoracic artery (RITA) graft in the coronary bypass grafting (CABG) operation using only arterial grafts]. 972 Mar 75

We report a case of 59-year-old man of descending necrotizing mediastinitis (DNM) secondary to peritonsillar abscess. A 59-year-old man with diabetes mellitus was admitted to a local hospital because of cervical swelling related to a peritonsillar abscess. Despite administration of antibiotics, swelling of the neck, dysphagia and dyspnea deteriorated. Therefore he was urgently undergone a tracheotomy and transferred to our hospital by an ambulance. The surgery consisted with neck and anterior mediastinal drainage through neck and cervical collar incision. Culture of drainage fluid showed clostridium difficile. On postoperative day 5, we started hyperbaric oxygen therapy (HBOT). After lavage and HBOT, the patient improved by degrees, and discharged on postoperative day 82. DNM is a rare but serious complication of otopharyngeal and deep neck infection that spreads down to the mediastinum through the cervical-facial planes. Its mortality rate remains high even with aggressive surgical drainage and appropriate antibiotics. Our patient was successfully treated with urgent surgical drainage, antibiotics and HBOT. HBOT might be of great value as an adjunctive management to control this fatal infection.
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PMID:[Hyperbaric oxygen as an adjunctive treatment for descending necrotizing mediastinitis: report of a case]. 1093 94

We report the case of a 56-year-old man who developed bacterial mediastinitis with methicillin-resistant Staphylococcus aureus after undergoing heart transplantation. He had a history of insulin-dependent diabetes mellitus and prior cardiac surgery. To find the source of nosocomial infection, we cultured nasal swab specimens from all hospital personnel involved in this operation. We used antibiotic sensitivity profiling and pulsed-field gel electrophoresis to subtype the involved microorganism. The S. aureus isolates from the patient and the perfusionist were identical to each other and were different from the strains previously found in our hospital. It is almost certain that the S. aureus mediastinitis in this patient was transmitted from the perfusionist. We recommend obtaining cultures from hospital staff members when there is an outbreak of staphylococcal infection.
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PMID:Perfusionist-transmitted bacterial mediastinitis in a heart transplant recipient. 1133 Jul 45

This study was planned to assess the relationship of perioperative glycemic control to the subsequent risk of infectious complications and to compare early clinical outcomes of coronary artery bypass surgery in diabetics with nondiabetics in a single center. A total of 1090 adults who underwent coronary artery surgery in a five year period were included in a retrospective cohort study based on available chart review. Of 1090 patients, 400 had type II diabetes mellitus. Intraoperative and postoperative blood glucose levels in diabetic group were manipulated by means of a continuous insulin infusion. Data of pre- and postoperative blood glucose levels were evaluated with respect to postoperative infection risk for diabetics. Risks of early mortality, cerebrovascular accident, and postoperative infection in diabetic patients were compared with the nondiabetic group. High preoperative mean glucose levels were the main risk factor for the development of postoperative infection (p = 0.012 and p = 0.028 for the mean glucose levels 1 and 2 days before operation, respectively). For diabetic group, of 400 patients 20 (5%) were diagnosed to have postoperative infection (superficial sternal wound in 3 (0.75%), donor site infection in 4 (1%), mediastinitis in 5 (1.25%), urinary tract infection in 6 (1.5%), and lung infection in 2 (0.5%) patients). The diabetic group had significantly higher prevalence of mediastinitis, donor site infection, urinary tract infection and total infection (p values were 0.048, 0.013, 0.009, and 0.044, respectively). Early mortality was higher among diabetics than in nondiabetics (1.73% vs 3%, p = 0.048) but the risk of cerebrovascular accident in diabetics was not greater than in nondiabetics in early period. In patients with diabetes who undergo coronary artery bypass surgery, preoperative hyperglycemia is an independent predictor of short-term infectious complications and total length of stay in hospital.
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PMID:Perioperative hyperglycemia is a strong correlate of postoperative infection in type II diabetic patients after coronary artery bypass grafting. 1250 71


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