Nadir ancak ölümcül bir enfeksiyon üzerine karşılaştırmalı bir çalışma: Post-sternotomi mediastinit ve descending nekrotizan mediastinitte sonucu belirleyici faktörlerin analizi

Yıl 2024, , 8 - 15, 28.03.2024

Tülay Ünver Ulusoy , Hanife Nur Karakoç , Yunus Gürbüz , İrfan Şencan

https://doi.org/10.18663/tjcl.1414028

Öz

Amaç: Mediastinit; nadir görülen ciddi bir enfeksiyondur. Bu çalışmanın amacı, post-sternotomi mediastinit (PSM) veya descending nekrotizan mediastinit (DNM) tanısı alan hastaların demografik, klinik ve laboratuvar özelliklerini karşılaştırmak ve mortalite görülen hastaların özelliklerini belirlemektir.
Gereç ve Yöntemler: Bu çalışmaya 2015-2022 yılları arasında Sağlık Bilimleri Üniversitesi Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi'nde PSM ve DNM tanısı alan hastalar dahil edilmiştir. Hastalar hayatta kalanlar ve kalamayanlar olarak kategorize edilmiştir ve karşılaştırılmıştır.
Bulgular: Bu çalışmaya mediastinit tanısı konulan 25 hasta dahil edilmiştir. Ortalama yaş 54.9 ± 12.1 olup, hastaların %64'ü erkekti. Hastaların %92'sinden kan kültürü alınmıştır. Hastaların %88'inden pürülan akıntı kültürleri gönderilmiştir, %44'ünde üreme tespit edilmiştir. Hastaların %84'ünde komorbidite mevcuttur ve komorbidite varlığı, sepsis varlığı ve tanı sonrası yoğunbakım ünitesinde (YBÜ) yatış günü prevalansı PSM hastalarında anlamlı olarak daha yüksekti (p=0.017, p=0.004, p=0.026). Kalp yetmezliği, koroner arter hastalığı (KAH) ve hipertansiyon (HT) PSM hastalarında anlamlı olarak daha yüksekti (ps=0.000). PSM hastaları; hayatta kalamayan grupta da anlamlı olarak daha yaygındı (p=0.012). Hayatta kalamayan grupta yaş ortalaması daha yüksek, sigara içenlerin sayısı daha fazla ve tanı sonrası YBÜ'de kalma süresi daha uzundu (p=0,046, p=0,049, p=0,038). PSM, HT ve KAH olan hastalar hayatta kalamayan grupta anlamlı olarak daha yaygındı (p=0.012, p=0.008, p=0.033).
Sonuç: Mediastinit; nadir görülen ancak yüksek mortalite ve morbidite oranlarına sahip ciddi bir enfeksiyondur. Yaşlılar, sigara içenler, median sternotomi yapılanlar ve komorbiditeleri olanlar gibi mortalite riski daha yüksek olan hastalarda tedavi ve takip stratejileri geliştirilebilir.

Anahtar Kelimeler

Mediastinit, post-sternotomy mediastinitis, descending necrotizing mediastinitis, comorbidity, ölüm

A comparatıve study of the rare but deadly ınfectıon: post-sternotomy medıastınıtıs and descendıng necrotızıng medıastınıtıs wıth an analysıs of outcome-determınıng factors

Öz

Aim: Mediastinitis, a rare yet serious infection, affects the mediastinum. This study aims to compare the demographic, clinical, and laboratory characteristics of patients diagnosed with post-sternotomy mediastinitis (PSM) or descending necrotizing mediastinitis (DNM) to identify features of non-surviving patients.
Material and Methods: This study included patients diagnosed with PSM and DNM between 2015 and 2022 at the Health Sciences University Dışkapı Yıldırım Beyazıt Training and Research Hospital Patients were categorized and compared as survivors and non-survivors.
Results: This study included 25 patients diagnosed with mediastinitis. The average age was 54.9 ± 12.1, with 64% being male. Blood cultures were obtained from 92% of patients. Purulent discharge cultures were sent for 88% of patients, with 44% showing growth. Comorbidities were present in 84% and the prevalence of comorbidities, sepsis, and intensive care unit (ICU) hospitalization after diagnosis was significantly higher in PSM patients (p=0.017, p=0.004, p=0.026). Heart failure, coronary artery disease (CAD), and hypertension (HT) were significantly higher in PSM patients (ps=0.000). PSM patients were also significantly more common in the non-survivor group (p=0.012). The non-survivor group had higher average age, more smokers, and longer intensive care unit stays post-diagnosis (p=0.046, p=0.049, p=0.038). Patients with PSM, HT, and CAD were significantly more common in the non-survivor group (p=0.012, p=0.008, p=0.033).
Conclusion: Mediastinitis is a rare but serious condition with high mortality and morbidity rates. In patients with a higher risk of mortality, such as the elderly, smokers, patients with median sternotomy, and those with comorbidities, treatment and follow-up strategies can be improved.

Anahtar Kelimeler

Mediastinitis, post-sternotomy mediastinitis, descending necrotizing mediastinitis, comorbidities, mortality

Etik Beyan

This study has received ethical approval from the Ankara Etlik City Hospital Ethics Committee (approval no: AEŞH-EK1-2023-491, approval date: 06.09.2023).

Kaynakça

• Phoon PHY, Hwang NC. Deep Sternal Wound Infection: Diagnosis, Treatment and Prevention. J Cardiothorac Vasc Anesth. 2020;34:1602-13.
• Pastene B, Cassir N, Tankel J, et al. Mediastinitis in the intensive care unit patient: a narrative review. Clin Microbiol Infect. 2020;26:26-34.
• Song Y, Chu W, Sun J, et al. Review on risk factors, classification, and treatment of sternal wound infection. J Cardiothorac Surg. 2023;18:184.
• Hever P, Singh P, Eiben I, Eiben P, Nikkhah D. The management of deep sternal wound infection: Literature review and reconstructive algorithm. JPRAS Open.2021;28:77-89.
• Abu-Omar Y, Kocher GJ, Bosco P, et al. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg.2017;51:10-29.
• Reuter TC, Korell V, Pfeiffer J, et al. Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment, and long-term consequences—a retrospective follow-up study. Eur Arch Otorhinolaryngol.2023;280:1983-90.
• Ridder GJ, Maier W, Kinzer S, Teszler CB, Boedeker CC, Pfeiffer J. Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome. Ann Surg. 2010;251(3):528-34.
• Hu CY, Lien KH, Chen SL, Chan KC. Risk Factors of Descending Necrotizing Mediastinitis in Deep Neck Abscesses. Medicina. 2022;58:1758.
• Ariyaratnam P, Bland M, Loubani M. Risk factors and mortality associated with deep sternal wound infections following coronary bypass surgery with or without concomitant procedures in a UK population: a basis for a new risk model? Interact Cardiovasc Thorac Surg.2010;11:543-6.
• CDC/NHSN surveillance definitions for specific types of infections. [Cited 2023 Nov 23]. Available from: https://stacks.cdc.gov/view/cdc/127235
• Postoperative mediastinitis after cardiac surgery - [Cited 2023 Nov 13]. Available from: https://www.uptodate.com/contents/postoperative-mediastinitis-after-cardiac-surgery.
• Dal Lin C, Tona F, Osto E. The Heart is a Psychoneuroendocrine and Immunoregulatory Organ. Adv Exp Med Biol. 2018;1065:225-39.
• Taylor M, Patel H, Khwaja S, Rammohan K. Descending cervical mediastinitis: the multidisciplinary surgical approach. Eur Arch Otorhinolaryngol. 2019;276:2075-9.
• Song J, Fang X, Zhou K, Bao H, Li L. Sepsis‑induced cardiac dysfunction and pathogenetic mechanisms. Mol Med Rep.2023;28:227.
• Agewall S, Giannitsis E, Jernberg T, Katus H. Troponin elevation in coronary vs. non-coronary disease. Eur Heart J. 2011;32:404-11.
• Murphy GJ, Angelini GD. Side effects of cardiopulmonary bypass: what is the reality? J Card Surg 2004; 19: 481e8
• Abbasciano, R. G., Lai, F. Y., Roman, M. A., et al. Activation of the innate immune response and organ injury after cardiac surgery: a systematic review and meta-analysis of randomized trials and analysis of individual patient data from randomized and non-randomized studies. British Journal of Anaesthesia. 2021:365-375.
• Palma DM, Giuliano S, Cracchiolo AN, et al. Clinical features and outcome of patients with descending necrotizing mediastinitis: prospective analysis of 34 cases. Infection. 2016;44:77-84.
• İnan D, Saba R, Gölbaşi I, et al. Açık Kalp Cerrahisi Sonrası Gelişen Mediastinitlerde Risk Faktörlerinin Değerlendirilmesi. Flora.2002;7:57-61
• Weyand CM, Goronzy JJ. Aging of the Immune System. Mechanisms and Therapeutic Targets. Ann Am Thorac Soc.2016;13:S422-8.
• Abboud CS, Wey SB, Baltar VT. Risk factors for mediastinitis after cardiac surgery. Ann Thorac Surg. 2004;77:676-83.
• Anderson DJ, Kaye KS, Classen D, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol. 2008;29:51-61.
• Sá MPBO, Ferraz PE, Soares AF, et al. Development and Validation of a Stratification Tool for Predicting the Risk of Deep Sternal Wound Infection after Coronary Artery Bypass Grafting at a Brazilian Hospital. Braz J Cardiovasc Surg. 2017;32:1-7.
• Abdelnoor, M., Vengen, Ø. A., Johansen, O., Sandven, I., Abdelnoor, A. M. Latitude of the study place and age of the patient are associated with the incidence of mediastinitis and microbiology in open-heart surgery: a systematic review and meta-analysis. Clinical epidemiology, 2016;8,151–63.
• Ma JG, An JX. Deep sternal wound infection after cardiac surgery: a comparison of three different wound infection types and an analysis of antibiotic resistance. J Thorac Dis. 2018;10(1):377-87