Mediastinitis in Emergency Medicine Medication

Updated: May 29, 2019
  • Author: Feras H Khan, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Medication Summary

Because mediastinitis is usually a mixed growth infection, wide antimicrobial coverage is required. The cause of infection should be determined. Extension of S aureus osteomyelitis should be managed differently from an esophageal rupture; however, in the absence of a source and definitive microbiological data, broad-spectrum therapy is indicated. Antibiotic administration should not be delayed once the diagnosis is suspected. Combinations such as piperacillin-tazobactam plus vancomycin or vancomycin plus a fluoroquinolone and clindamycin should be used. An aminoglycoside may be added to broaden gram-negative coverage.

In general, S aureus, including MRSA, should be covered initially. In addition, coverage should include gram0negative bacteria, including P aeruginosa.



Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

Ceftriaxone (Rocephin)

Third-generation cephalosporin that has broad-spectrum gram-negative activity, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to one or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.

Clindamycin (Cleocin)

Lincosamide that is useful treatment of serious skin and soft tissue infections caused by most staphylococcal strains. Effective against aerobic and anaerobic streptococci, except enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.

Imipenem-cilastatin (Primaxin)

Used for treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated because of their potential for toxicity.

Metronidazole (Flagyl)

Active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells and the intermediate metabolized compounds that bind DNA are then formed and inhibit synthesis, causing cell death.

Gentamicin (Garamycin)

An aminoglycoside antibiotic effective against Pseudomonas aeruginosa,Escherichia coli,Proteus,Klebsiella, and Staphylococcus species.

Numerous dosing regimens are available, and they are adjusted based on creatinine clearance and changes in the volume of distribution. The dose of gentamicin may be given IV or IM.

Piperacillin and tazobactam sodium (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication. This medication has a broad antimicrobial spectrum that is effective again most oral, respiratory, and GI bacterial pathogens. Used in concert with gentamicin, strong anti-gram-negative activity occurs.

Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

Vancomycin (Vancocin)

Inhibits cell wall synthesis. Accomplished by binding to carboxyl units on peptide subunits containing free D-alanyl-D-alanine.

Effective against methicillin-resistant S aureus.