Mediastinitis after cardiac surgery, from microbes to management: a systematic review

Introduction

The median sternotomy remains the most common method for exposure in cardiac surgery. Although this approach provides excellent surgical access, post-operative infections remain a recognized complication. Post-sternotomy infections may originate within the superficial soft tissues, extend along fascial or osseous planes, which may progress to sternal osteomyelitis and, in advanced cases, mediastinitis. Bacteria may also gain direct access to the mediastinum through areas of incomplete sternal approximation, wire-tract dehiscence, or localized tissue necrosis. Less commonly, infection develops through hematogenous seeding or contiguous spread from adjacent thoracic structures such as the pleura, pericardium, or lungs (1).

According to the Centers for Disease Control and Prevention (CDC), postoperative mediastinitis is a type of surgical site infection (SSI) that is a deep sternal wound infection (DSWI) of the mediastinal space with or without involvement of the sternal bone (2,3). For surveillance purposes, the CDC classifies cases meeting criteria for both mediastinitis and sternal osteomyelitis are reported as SSI-MED (mediastinitis) rather than SSI-bone (osteomyelitis). Diagnostic criteria for SSI-MED include either evidence of infection at reoperation, positive cultures from mediastinal fluid or tissue, or clinical features such as fever, chest pain, sternal instability, or purulent drainage (3). The El Oakley and Wright classification [1996] stratifies post-sternotomy mediastinitis by onset, etiology, and host risk factors, distinguishing early (≤2 weeks) and late (>2 weeks) infections, primary vs. secondary cases from prior wound complications, and recurrent or chronic presentations (4) (Table 1). Although post-operative mediastinitis is relatively uncommon (0.25–5%), it represents a severe complication associated with high morbidity and mortality, prolonged hospitalization, and increased healthcare cost (5). The infection may present with frank symptoms such as erythema, pain, and discharge from the incision site, typically within two to four weeks following cardiac surgery (6).

The most common pathogens responsible for mediastinitis are Staphylococcus aureus, coagulase-negative staphylococci (CoNS), and aerobic gram-negative bacteria (1,5,7). Resistance among these organisms has become significant, with an increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections in post-operative and medical-care settings (5).

The most significant preoperative patient risk factors for post-operative mediastinitis include insulin-dependent diabetes, obesity, previous myocardial infarction, hypertension, and active smoking (7-9). Intraoperative factors include bilateral internal thoracic artery (BITA) harvest, prolonged cardiopulmonary bypass or operative times, and transfusion volume (7-9). The Society of Thoracic Surgeons (STS) have issued prevention guidelines recommending weight-based cefazolin within 60 minutes of incision, with vancomycin substitution in patients colonized with MRSA or in institutions with high MRSA prevalence, along with redosing based on drug half-life and blood loss (10,11). Tight glycemic control with continuous intravenous (IV) insulin in diabetic patients demonstrated further reductions in mediastinitis risk by approximately 34% (12).

Intraoperatively, meticulous sternal hemostasis is essential, with sparing use of bone wax, which has been shown to impair osteogenesis and serve as a nidus for bacterial colonization (13). Many centers now advocate for limited or water-soluble alternatives to conventional bone wax to preserve sternal vascularity and healing (13). Harvesting skeletonized internal thoracic arteries (ITA), particularly in diabetic and obese patients, further reduces the risk of ischemic sternal complications by maintaining collateral blood flow to the sternum (14). Topical vancomycin paste, or powder along the sternal edges before closure can significantly lower the incidence of DSWI without increasing systemic toxicity or resistance (15). Predictive scores based on risk factors have excellent predictive power in the detection of mediastinitis within as early as 24-hours (Med-Score 24) (16).

The method of sternal closure and approximation is an additional determinant of postoperative integrity. Traditional monofilament or braided stainless-steel wires remain the standard for routine cases; however, in patients with osteoporotic bone, obesity, or redo sternotomy, rigid plate fixation systems provide superior biomechanical stability and are associated with lower rates of dehiscence and infection [American Association for Thoracic Surgery (AATS)/STS Class IIb, Level B recommendation] (17,18). In the immediate postoperative period, closed-incision negative-pressure wound therapy (ciNPWT) may provide benefits. In one study, it reduced surgical-site infections (4%) compared with standard dressings (16%) in high-risk obese patients when applied for 6 to 7 days postoperatively (19).

Despite advances in surgical technique, perioperative care and infection control, patient risk profiles and surveillance methodologies continue to drive variation in reported incidence rates (20,21). Accordingly, the objective of this systematic review is to synthesize the evidence on the incidence, microbiologic patterns, risk factors, preventive strategies, and management approaches for mediastinitis following cardiac surgery, and to summarize reported clinical outcomes, including mortality and recurrence. In this systematic review, we synthesize heterogeneous primary literature to enhance understanding of mediastinitis following cardiac surgery and derive actionable insights that reflect the breadth of evidence since its earliest characterization. We present this article in accordance with the PRISMA reporting checklist (22) (available at https://med.amegroups.com/article/view/10.21037/med-2025-1-75/rc).

Methods

Protocol and registration

The review was registered on Prospero (https://www.crd.york.ac.uk/PROSPERO/view/CRD420251177438) prior to conducting the data extraction phase. No significant deviations from the registered protocol occurred during the conduct of the review.

Search strategy

Ovid MEDLINE and EMBASE were searched from inception to October 2025 to identify all studies conducted on mediastinitis and mediastinal infections post cardiac surgery. The search was limited to studies published in English, with full-text articles from peer-reviewed journals. The following MESH terms and Boolean operators were used:

(“mediastinitis” OR “mediastinal infection” OR “deep sternal wound infection” OR “poststernotomy infection” OR “sternal wound infection” OR “wound abscess”) AND (“cardiac surgery” OR “open heart surgery” OR “coronary artery bypass” OR “valve replacement” OR “congenital heart surgery”) AND (“Staphylococcus aureus” OR “coagulase-negative staphylococci” OR “gram-negative bacteria” OR “fungal mediastinitis”) AND (“risk factors” OR “mortality” OR “outcomes” OR “prevention” OR “management” OR “debridement” OR “vacuum-assisted closure” OR “antibiotic therapy”).

Levels of evidence

The level of evidence was given based on standardized definitions as follows: Level 1a: meta-analysis of well-designed randomized control trials; Level 1b: well-designed randomized control trials; Level 2a: well-designed controlled study without randomization; Level 2b: well-designed quasi-experimental study; Level 3: well-designed non-experimental study (case studies); Level 4: expert opinion or consensus statement.

Eligibility criteria

Eligible studies met the following criteria: (I) adult patients (>18 years of age); (II) mediastinal infections occurring after cardiac surgery; and (III) primary literature reporting at least one of the following: incidence, mortality, microbiology, prevention, and treatment strategies. Reviews/meta-analyses, single case reports, conference abstracts, clinical guidelines statements, letters to the editors, and editorials that did not include original data were excluded from this review.

Study selection

All identified records were imported into Covidence for screening. After duplicate removal, two reviewers (A.S. and R.R.) independently screened titles and abstracts for eligibility. Full-text review was subsequently performed for potentially relevant studies. Discrepancies were resolved through discussion and consensus.

Primary outcomes

The primary outcomes of interest for this review include the incidence, mortality, microbiology, prevention, and treatment strategies for mediastinitis following cardiac surgery.

Data collection process

Each article was qualitatively assessed and screened using the Covidence. The following data was extracted independently: first author, year of publication, study design, study period, participant size, stated objective, incidence, mortality, microbes, management, prevention, and treatment.

Assessment of risk of bias (RoB)

Risk-of-bias assessment was performed according to study design independently by two reviewers (A.S. and R.R.), with disagreements resolved through discussion and consensus. Non-randomized studies were evaluated using the Newcastle-Ottawa Scale (NOS), which assesses methodological quality across three domains: selection of study groups, comparability of cohorts, and outcome assessment. Randomized controlled trials (RCTs) were assessed using the Cochrane RoB 2 tool, evaluating bias related to the randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selective reporting. Risk-of-bias findings were incorporated qualitatively into the narrative synthesis and were not used for quantitative weighting due to heterogeneity in study design and outcome reporting.

Data synthesis and subgroup analyses

Due to heterogeneity in study populations, definitions of mediastinitis, microbiological reporting, follow-up duration, and outcome measures, quantitative meta-analysis was not feasible. Therefore, findings were synthesized qualitatively. Incidence, mortality, microbiologic patterns, prevention strategies, and treatment approaches were summarized descriptively and stratified by study design and level of evidence where applicable. No formal subgroup analyses were performed due to heterogeneity in reporting and the absence of sufficiently comparable datasets. However, where reported, distinctions such as early vs. late mediastinitis and pathogen-specific outcomes were described narratively.

Results

A total of 1,311 records were identified through database and manual searches. After removing 287 duplicates identified through Covidence, 1,024 studies underwent title and abstract screening. A total of 964 studies were excluded for not meeting inclusion criteria, resulting in 60 primary research articles on patients who developed mediastinitis following cardiac surgery (Figure S1).

The included studies span over three decades [1989–2025] and represent a geographically diverse cohort across North America, Europe, Asia, and Australia. Most were retrospective cohort studies (Level III evidence, n=44), with a subset of RCTs (Level Ib, n=6), prospective observational cohorts (Level IIb, n=8) and clinical/non-randomized control trials (Level IIa, n=2). Sample sizes ranged from a three-patient observational study (23) to large registry-based datasets exceeding 300,000 participants (8) (Table S1). The incidence, mortality, and microbiology of mediastinitis after cardiac surgery are reported where available across these included studies (Table S2).

RoB

Across the included non-randomized studies, the overall RoB was most commonly moderate, largely attributable to potential confounding, inconsistent adjustment for baseline risk factors, and heterogeneity in outcome definitions and ascertainment. Selection bias was more prevalent in single-center cohorts and studies evaluating selected high-risk populations. The RCTs were generally assessed as low to moderate RoB. Although randomization procedures were typically described, some studies demonstrated limitations related to blinding and potential deviations from intended interventions. Overall, interpretation of findings is limited by heterogeneity in study design and the predominance of observational data.

Incidence

The incidence of post-sternotomy mediastinitis was reported in 46 of 60 studies, which ranged from 0.2% to 11.0% depending on population risk profile, surgical complexity, and surveillance definition, with one significant outlier (69.5%) due to a narrow selected cohort of patients (24). Large registry analyses reported incidences of 0.6% and 3.5% (8,20), while single-center series by Abboud et al. [2004] and Gummert et al. [2002] involving high-risk diabetic or redo patients reported incidence rates 0.5% and 1.44%, respectively (7,25).

Surgical complexity, such as BITA [odds ratio (OR) 3.9] (26) or prolonged cardiopulmonary bypass (>120 minutes, OR 1.8) (27), was consistently associated with higher incidence rates (25,28). Patient factors, including insulin-dependent diabetes (OR 2.3) (7), obesity [body mass index (BMI) >30 kg/m², OR 1.9] (25), and active smoking (OR 1.6) (29), increased risk. Variations in incidence were also influenced by institutional practices, such as inconsistent antibiotic prophylaxis timing (30) or broader surveillance definitions, including post-discharge follow-up (31).

Mortality

Mortality from post-operative mediastinitis was reported in 36 studies, which ranged from 1.5% to 60%. Early-onset mediastinitis (≤2 weeks, El Oakley type I/II) was associated with lower mortality (5% to 15%) (20,32). Late-onset or recurrent cases (El Oakley type III/IV) had higher mortality (20–40%), particularly with multidrug-resistant organisms or systemic sepsis (33-35). Fungal mediastinitis was notably severe, reporting a 30% mortality rate, driven by Candida species and delayed diagnosis (36). The negative effect of mediastinitis on patient survival extends far beyond the in-hospital and 30-day mortality time periods, with a marked increase in mortality during the first year post-coronary artery bypass grafting (CABG) and a threefold increase during a 4-year follow-up period (37). Patient comorbidities, such as chronic kidney disease (OR 2.5) or poorly controlled diabetes, amplified mortality risk (38). Early, radical debridement with culture-guided therapy is linked to improved outcomes in comparative cohorts and series (38-42).

Microbiology

Microbiologic data was reported in 43 studies and frequently evaluated by mediastinal tissue or fluid cultures (43). Blood cultures were typically obtained in cases of suspected systemic sepsis or recurrent infection, particularly when fever or hemodynamic instability accompanied mediastinal findings. Staphylococci predominate with variable MRSA/methicillin-susceptible Staphylococcus aureus (MSSA) proportions across cohorts; large prospective and national datasets report high rates of staphylococcal isolates with center- and era-specific MRSA burden (26,44,45). CoNS presented often in early-onset infections (26). Gram-negative bacilli, including Pseudomonas aeruginosa, Enterobacter species, and Klebsiella pneumoniae, were more common in late-onset or nosocomial cases (28). Fungal infections, primarily Candida albicans and Candida parapsilosis, comprised a minority of cases, and linked to broad-spectrum antibiotic overuse (46). Indolent organisms, such as Cutibacterium acnes and Corynebacterium species, were noted in chronic infections (47), often requiring prolonged cultures for detection (48).

Prevention

Preventive strategies were evaluated in 28 studies including 6 RCTs. Key findings include a 66% reduction in DSWI with continuous insulin in diabetics (12) and lower infection rates with IV vancomycin prophylaxis in high-MRSA settings (49,50). Local collagen-gentamicin implants reduced infections by 53% (51,52), though Schimmer et al. [2017] (n=996) found no added benefit when combined with sealants like InteguSeal^® (53). Optimal prophylaxis timing (<60 minutes pre-incision) reduced infections by 30% (54). ciNPWT for prophylaxis reduced infections in high-risk patients (55,56). Therapeutic ciNPWT, also called vacuum therapy (VAC), for established infection improved wound control and facilitated staged closure (40,41). Sternal stabilization also emerged as a determinant of infection risk: rigid plate fixation and multifilament wiring reduced dehiscence and subsequent infection compared to conventional wire closure, particularly in obese and re-operative patients (17,25). Observational cohorts suggest that topical vancomycin paste applied to sternal edges before closure, lowers DSWI in high-risk patients, without evidence of nephrotoxicity or resistance selection, supporting its role as a safe adjunct in high-risk populations, nevertheless evidence is limited and heterogeneous (57). Adjunctive dressing technologies, including silver-impregnated or hydrocolloid dressings, were variably reported but consistently reduced superficial contamination and seroma formation when combined with closed-incision negative-pressure wound therapy (NPWT). Skeletonized ITA harvest further reduced ischemic risk (57). However, triclosan-coated sutures and extended prophylaxis beyond 48 hours did not reduce infections in cardiac surgery cohorts (58,59), with concerns about resistance. Randomized control trials in DSWI prevention and management may be reviewed in Table 2.

Treatment

Treatment strategies, described in 48 studies (Table S1), emphasized surgical debridement and VAC therapy, which demonstrated improved survival and faster healing compared with conventional methods (38,41). ciNPWT reduced hospital stay by 10–15 days and facilitated staged management, typically involving initial radical debridement, temporary VAC therapy, and delayed closure or flap reconstruction (40,60). Muscle or omental flap reconstruction achieved 70–90% success in severe cases, with pectoralis and rectus flaps most frequently used and omental flaps reserved for deep or irradiated wounds (61,62). Incorporation of rigid sternal fixation during flap reconstruction improved chest wall stability and reduced recurrence (17,63). Tailored antibiotics administered for 4–6 weeks, most commonly vancomycin for MRSA, were standard (64), though pharmacokinetic data showed limited sternal penetration with linezolid (65). Broad-spectrum empiric regimens were typically narrowed once intraoperative cultures became available, and extended antibiotic courses beyond 6 weeks provided no additional benefit (66). Early intervention was a consistent predictor of improved outcomes (39), as delays in debridement were associated with mortality exceeding 52.8% (67). Fungal mediastinitis remained uncommon, but severe, with Candida species predominating and mortality approaching 30% despite combined surgical and antifungal therapy (36). Overall, the most effective management strategies integrated early, thorough debridement, vacuum-assisted therapy, targeted antimicrobial treatment, and definitive vascularized tissue coverage to optimize survival and minimize recurrence (68,69).

Discussion

Engelman et al. [1973] were the first to describe DSWIs following open-heart surgery (70). Their early observations included a mortality exceeding 40% possibly reflecting an era before routine prophylactic antibiotics, tight glycemic control, and prompt intervention. Over time, multicenter registries (8,71) reframed mediastinitis as a measurable outcome within cardiac surgical quality assurance, establishing the basis for benchmarking and prevention programs. The European Association for Cardio-Thoracic Surgery (EACTS) consensus by Abu-Omar et al. [2017] codified definitions, risk stratification, and evidence-based preventive measures, facilitating international harmonization (72). The progression from descriptive case series to structured surveillance reflects the maturation of mediastinitis from a surgical complication to a systems-level quality indicator.

Our systematic review reports that the incidence of mediastinitis following cardiac surgery is highly dependent on patient risk factors. Diabetes, obesity, chronic kidney disease, and chronic obstructive pulmonary disease confer a two- to three-fold increase in risk (7,25,44). Furthermore, intraoperative variables, including BITA harvest and prolonged cardiopulmonary bypass, compound risk through sternal ischemia and prolonged tissue exposure (27,28,73). The introduction of skeletonized ITA harvesting (57) represents a pivotal technical modification, preserving sternal perfusion and reducing ischemic susceptibility. Key risk factors for post-sternotomy mediastinitis may be visited in Table 3.

The microbiological spectrum of mediastinitis has shifted alongside hospital ecology. Historically dominated by Staphylococcus aureus, recent decades have seen an increasing prevalence of methicillin-resistant strains and polymicrobial infections involving Pseudomonas, Enterobacter, and Klebsiella species (33,34). These organisms reflect both nosocomial selection pressure and prolonged intensive care exposure. CoNS are now frequent in early postoperative infections, particularly after prolonged cardiopulmonary bypass or re-exploration (26), while indolent pathogens such as Cutibacterium acnes and Corynebacterium spp. are increasingly recognized in delayed presentations (47,48). The predominance of resistant, low-virulence organisms suggests that postoperative mediastinitis often reflects impaired host defenses and biofilm-mediated persistence, rather than purely an acute intraoperative contamination event (74). This shift complicates diagnosis, as standard cultures may miss infections, prompting use of molecular or extended-culture methods.

Preventive strategies have transitioned from empiric antibiotic extension to evidence-based, risk-targeted approaches. Meta-analyses and RCTs support weight-adjusted perioperative cefazolin within 60 minutes of incision, vancomycin substitution in MRSA-endemic environments, and redosing with significant blood loss (49,50,54,75). Adjunctive local measures, including collagen-gentamicin implants and platelet-rich plasma, have demonstrated additive benefit in several trials (51,52,76), though results are inconsistent when combined with topical sealants (53). ciNPWT has emerged as one of the most effective modern prophylactic interventions, reducing DSWI rates by up to 60% in high-risk cohorts (56). Importantly, these data suggest benefit not through direct bactericidal activity but from the modulation of tissue perfusion, lymphatic drainage, and wound tension (55,56). Despite these advances, overall mediastinitis rates have plateaued, suggesting that limitations stem from adherence and implementation rather than conceptual deficiencies. As Abu-Omar et al. [2017] highlight, prevention must be systematic, integrating metabolic, antimicrobial, and mechanical domains rather than relying on isolated interventions (72). Therapeutic paradigms have shifted from radical open drainage to controlled, staged reconstruction. VAC therapy, first popularized by Obdeijn et al. [1999] and validated by Sjögren et al. [2005], revolutionized the management of mediastinal infections by promoting granulation, reducing bacterial load, and facilitating delayed closure (23,41). Comparative analyses demonstrate superior survival and shorter hospitalization compared with conventional therapy (38,40). In extensive or recurrent disease, a vascularized flap coverage remains the standard of care, achieving success rates exceeding 80% (61,77). Early multidisciplinary involvement that coordinates cardiac surgery, plastic surgery, and infectious diseases is associated with better reconstruction success and fewer failures in large series of flap-based management and VAC-facilitated staged closure (39,40,61,63).

Controversies concerning prophylactic antibiotic duration and therapy for fungal infections persist. Evidence from Cutrell et al. [2016] and Harbarth et al. [2000] indicates no benefit to extending postoperative antibiotics beyond 48 hours (59,66), while fungal mediastinitis continues to carry mortality rates of 30–40% despite combined surgical and pharmacologic management (36).

The enduring burden of mediastinitis reflects the intersection of surgical progress and patient complexity. Increasing procedural longevity, reoperations, and older, comorbid populations sustain susceptibility despite technical advances (78-81). Moreover, the microbiological shift toward resistant and biofilm-forming species suggests that prevention alone may be insufficient without improved intraoperative detection and host optimization.

Emerging technologies offer new directions. Machine learning applied to perioperative datasets may permit individualized risk prediction integrating metabolic, operative, and microbiologic parameters (82). Early evidence suggests that intraoperative tissue oxygenation monitoring, bone perfusion assessment, and biomaterial coatings could further reduce infection risk (83). In parallel, molecular diagnostic tools, including 16S rRNA sequencing, may redefine the microbial spectrum of mediastinitis and facilitate earlier, pathogen-specific therapy (84,85).

The results of this review show that the determinants of mediastinitis are systemic and interdependent. Mechanical stability, perfusion, metabolic control, and antimicrobial stewardship act in concert to prevent infection; failure in any domain increases risk significantly. Historically, management evolved from surgical containment to integrated, multidisciplinary therapy; the next evolution must focus on prediction and personalization. In summary, mediastinitis remains a persistent but preventable complication that reflects an enduring measure of surgical discipline and systems integration. Continued progress will depend not on new antibiotics alone but on coordinated innovation across surgical design, perioperative medicine, and microbial science.

Limitations

This review has several limitations that should be acknowledged. The search was limited to studies published in English. Most of the included data were derived from retrospective single-center analyses with heterogeneous definitions of mediastinitis, variable follow-up durations, and inconsistent reporting of outcomes. Some studies pooled superficial and DSWIs, which may have led to misclassification and overestimation of incidence or mortality. Risk adjustment was not uniform, and ORs were inconsistently reported or derived from univariate analyses. RCTs were few, and many preventive and treatment strategies were supported only by observational evidence. Publication bias is also likely, as centers with lower infection rates or negative findings may have been underrepresented. Finally, differences in microbiologic surveillance methods, antibiotic protocols, and institutional practices limit the comparability of results across studies. These factors collectively reduce the strength of the pooled conclusions and highlight the need for standardized definitions, multicenter collaboration, and prospective trials to clarify optimal prevention and management strategies.

Conclusions

Post-sternotomy mediastinitis is uncommon but remains a serious and preventable complication of cardiac surgery. The strongest and most consistent signals favor a bundled approach that combines well timed weight-adjusted antibiotic prophylaxis, risk-targeted closed-incision negative pressure therapy, meticulous sternal technique, and early multidisciplinary intervention. Early radical debridement with temporary negative pressure therapy followed by definitive vascularized flap coverage improves survival and reduces recurrence. Rigid fixation benefits patients with poor bone quality or high mechanical risk and should be considered in selected cases. Antibiotic therapy should be culture guided, started promptly, and limited to the shortest effective duration. Incidence and outcomes vary widely due to patient risk, operative factors, and differences in definitions and surveillance. Most of the evidence comes from retrospective cohorts, and randomized trials remain limited. Future work should standardize case definitions and follow-up, test prophylaxis bundles in high-risk groups, clarify optimal antibiotic duration, and evaluate molecular diagnostics for biofilm-mediated infection. A disciplined systems approach that integrates surgical technique, metabolic control, and antimicrobial stewardship offers the best path to reduce morbidity and mortality.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://med.amegroups.com/article/view/10.21037/med-2025-1-75/rc

Peer Review File: Available at https://med.amegroups.com/article/view/10.21037/med-2025-1-75/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-2025-1-75/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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