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J Thorac Cardiovasc Surg 2000;119:190-191
© 2000 Mosby, Inc.

LETTERS TO THE EDITOR

Is the use of topical vancomycin to prevent mediastinitis after cardiac surgery justified?

Department of Cardiac Surgery, The National University Hospital of Singapore^a, 5 Lower Kent Rd
Singapore 1119074
Department of Cardiac Surgery, The Prince Sultan Cardiac Center^b, PO Box 7879
Riyadh 11159, Kingdom of Saudi Arabia

To the Editor:

Patients undergoing cardiopulmonary bypass (CPB) are at substantial risk of acquiring infections because of the increased number of potential ports of entry of pathogens in the presence of CPB-induced impairment of immune responses. ¹ Despite regular use of prophylactic intravenous antibiotics, postoperative mediastinitis occurs in 0.4% to 5% of patients undergoing cardiac operations. ¹ This complication is associated with a 14% to 47% risk of in-hospital mortality. ¹

Gram-positive bacteria are the most common isolates from patients with mediastinitis; Staphylococcus aureus and Staphylococcus epidermidis are identified in 70% to 80% of cases. ¹ In a prospective randomized controlled study, Vander Salm and associates ² found that topical vancomycin applied during wound closure after median sternotomy was associated with a significant reduction in the rate of sternal wound infection. Although this study has not been repeated, its findings were accepted by a number of cardiac surgeons who have adopted the routine use of topical vancomycin powder to prevent mediastinitis after CPB (unpublished data).

The risk of vancomycin resistance has been a concern of those who have adopted this approach. However, 2 factors have supported the use of vancomycin for this purpose. First, the drug is instilled in a confined space, which prevents free movements of organisms in and out of the area at risk. Second, topical application of vancomycin was believed to result in insignificant serum levels. We have studied the pharmacokinetics of vancomycin powder instilled between the edges of the sternum during closure of the median sternotomy in 4 patients undergoing CPB. Contrary to the common belief that topical vancomycin powder is poorly absorbed, levels up to 4.4 mg/L were found in the patients’ serum within 3 to 4 hours after topical application of 1 g of vancomycin powder (Fig 1).

View larger version (19K): [in this window] [in a new window]   Fig. 1. Vancomycin levels before and after instillation of 1 g of vancomycin powder between the sternal edges during wound closure. Vancomycin serum levels were measured before the operation and 1, 3, 6, 24, and 48 hours after instillation of vancomycin. The solid line represents the mean value of vancomycin levels in milligrams per liter obtained from 4 patients. The mean values are 0.1, 2.1, 2.2, 1.4, 1.2, and 0.8 mg/L, respectively.

We wish to debate this issue among the cardiothoracic surgeons and the experts in the field of antibiotic resistance. Such a debate will undoubtedly help to determine the risks versus the benefits of using topical vancomycin to prevent mediastinitis after median sternotomy.

References

1. El Oakley RM, Wright JE. Post-operative mediastinitis: classification and management. Ann Thorac Surg 1996;61:1030-6.[Abstract/Free Full Text]
   
2. Vander Salm TJ, Okike ON, Pasque MK, et al. Reduction of sternal infection by application of topical vancomycin. J Thorac Cardiovasc Surg 1989;98:618-22.[Abstract]
   
3. Hiramatsu K, Kanaki H, Ino T, Yabuta K, Oguri T, Tenover FC. Methicillin-resistant Staphylococcus aureus clinical strain with reduced vancomycin susceptibility. J Antimicrob Chemother 1997;40:135-6.[Free Full Text]
   
4. Smith TL, Pearson ML, Wilcox KR, et al. Emergence of vancomycin resistance in methicillin-resistant Staphylococcus aureus. N Engl J Med 1999;340:493-501.[Abstract/Free Full Text]
   
5. Sieradzki K, Roberts RB, Haber SW, Tomaasz A. The development of vancomycin resistance in a patient with methicillin-resistant Staphylococcus aureus infection. N Engl J Med 1999;340:517-23.[Free Full Text]
   

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				J. Desmond, A. Lovering, C. Harle, T. Djorevic, and R. Millner Topical vancomycin applied on closure of the sternotomy wound does not prevent high levels of systemic vancomycin Eur. J. Cardiothorac. Surg., May 1, 2003; 23(5): 765 - 770. [Abstract] [Full Text] [PDF]

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