Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient.

INTRODUCTION: Delayed sternal closure after paediatric open heart procedure is often necessary. The risk of delayed sternal closure is infection: superficial wound or sternal and mediastinal infection. The incidence of sternal wound infection reported in the literature varies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to be high--from 14 to 47%. Established treatment includes surgical debridement, drainage and irrigation, antibiotics, frequent change of wound dressing and direct or secondary closure with omentum or pectoral muscle flap. PATIENTS AND METHODS: Between October 2003 and August 2005, three children, aged from 9 days to 2 years and who had developed severe mediastinitis after cardiac surgery were treated with the vacuum-assisted closure (VAC) system. RESULTS: The duration of VAC treatment ranged from 12 to 21 days. The response to VAC was rapid with local purulence and C-reactive protein (CRP) both decreasing within 72 h in all cases. After good granulation was obtained, two patients required a thin skin graft. DISCUSSION: All three children had peritoneal dialysis which did not permit omental use. The use of pectoralis major is a difficult technique in neonates and the haemodynamic conditions were poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitis in children: it plays a role in the reduction of infection and provides good healing.     

Mediastinitis after coronary artery bypass grafting: the effect of vacuum‐assisted closure versus traditional closed drainage on survival and re‐infection rate

Mediastinitis is treated with either vacuum‐assisted closure (VAC) or traditional closed drainage (TCD) with irrigation. The aim of the study was to determine the effect of the two treatments on mortality and re‐infection rate in a source population, using 21 314 consecutive patients undergoing isolated coronary artery bypass grafting (CABG) from January 1997 to October 2010. Median observation time was 2·9 years in the VAC group and 8·0 years in the TCD group. The epidemiological design was of an exposed (VAC, n = 64) versus non‐exposed (TCD, n = 66) cohort with two endpoints: (1) mortality and (2) failure of sternal wound healing or re‐infection. The crude effect of treatment technique versus endpoint was estimated by univariate analysis. Stratification analysis by the Mantel–Haenszel method was performed to quantify confounders and to pinpoint effect modifiers. Adjustment for confounders was performed using Cox regression analysis. Mediastinitis was diagnosed 6–105 (median 14) days after primary operation in the VAC group and 13 (5–29) days in the TCD group. There was no difference between groups in long‐term survival. Failure of sternal wound healing or re‐infection occurred less frequently in the VAC group (6%) than in the TCD group (21%; relative risk = 0·29, 95% CI = 0·06–0·88, P = 0·01). There are concerns for increase in right ventricle rupture in VAC compared with TCD. There was no difference in survival after VAC therapy and TCD therapy of post‐CABG mediastinitis. Failure of sternal wound healing or re‐infection was more common after TCD therapy.     

Managing deep sternal wound infections with vacuum-assisted closure

Deep sternal wound infection is an uncommon but serious complication of cardiac surgery. Currently, there is no consensus on the optimal management. Vacuum-assisted closure (VAC) has been increasingly used to facilitate wound healing. We aim to review the management of deep sternal wound infections using VAC dressing at our hospital. A retrospective review of consecutive cases of deep sternal wound infections was carried out. Median sternotomies were carried out in 2665 patients between July 2001 and June 2006. Thirty-one patients developed deep sternal wound infections (1.2%). In 26 of these patients, VAC dressing was used either as a stand-alone therapy or as an adjunct to late sternal reconstruction. Deep sternal wound infections were diagnosed on average 13 days from initial surgery. Of the patients treated with VAC dressing, 17 (65%) had stand-alone VAC therapy and 9 had VAC therapy followed by sternal reconstruction. The average duration of VAC dressing in the two groups were 21 and 13 days respectively. There were seven in-hospital deaths, six in the stand-alone VAC group and one death from a reconstructive patient who did not have VAC therapy. The length of hospital stay was similar in two VAC groups (37 vs 45 days). Median follow up was 17 months. No late relapse was found in the stand-alone group. In the intermediate therapy group, two patients had chronic wound sinuses and one patient had a wound collection. Vacuum-assisted closure dressing may be used both as a stand-alone and as an intermediate therapy for deep sternal wound infection. Reconstructive surgery may be avoided in a significant proportion of patients. No late relapse has been associated with VAC use.     

Treatment of recurrent postoperative mediastinitis with granulated sugar

BACKGROUND: The authors report their experience with granulated sugar as dressing technique in the treatment of postoperative mediastinitis refractory to a closed irrigation system. METHODS: Between January 1990 and January 1998, mediastinitis developed in 61 (0,93%) of 6521 patients who had undergone open heart surgery. Diagnosis of sternal infections was based on wound tenderness, drainage, cellulitis, fever associated with sternal instability. All of them were initially treated with surgical debridement and closed chest irrigation. Nine patients with postcardiotomy mediastinitis refractory to closed chest irrigation underwent open dressing with granulated sugar. All of them were febrile with leukocytosis and positive wound cultures. RESULTS: Bacteria isolated were staphylococcus aureus in 6 cases, staphylococcus epidermidis in 2 and pseudomonas in 1. Redebridement was performed in all cases and the wound was filled with granulated sugar four times a day. Fever ceased within 4.3+/-1.3 days from the beginning of treatment and WBC became normal after 6.6+/-1.6 days. Three patients had hyperbaric therapy as associated treatment. Complete wound healing was achieved in 58.8+/-32.9 days (three patients underwent successful pectoralis muscle flaps). CONCLUSIONS: Sugar treatment is a reasonable and effective option in patients with mediastinitis refractory to closed irrigation treatment. It may be used either as primary treatment or as a bridge to pectoralis muscle flaps.     

Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm

Poststernotomy mediastinitis, also commonly called deep sternal wound infection, is one of the most feared complications in patients undergoing cardiac surgery. The overall incidence of poststernotomy mediastinitis is relatively low, between 1% and 3%, however, this complication is associated with a significant mortality, usually reported to vary between 10% and 25%. At the present time, there is no general consensus regarding the appropriate surgical approach to mediastinitis following open-heart surgery and a wide range of wound-healing strategies have been established for the treatment of poststernotomy mediastinitis during the era of modern cardiac surgery. Conventional forms of treatment usually involve surgical revision with open dressings or closed irrigation, or reconstruction with vascularized soft tissue flaps such as omentum or pectoral muscle. Unfortunately, procedure-related morbidity is relatively frequent when using conventional treatments and the long-term clinical outcome has been unsatisfying. Vacuum-assisted closure is a novel treatment with an ingenious mechanism. This wound-healing technique is based on the application of local negative pressure to a wound. During the application of negative pressure to a sternal wound several advantageous features from conventional surgical treatment are combined. Recent publications have demonstrated encouraging clinical results, however, observations are still rather limited and the underlying mechanisms are largely unknown. This review provides an overview of the etiology and common risk factors for deep sternal wound infections and presents the historical development of conventional therapies. We also discuss the current experiences with VAC therapy in poststernotomy mediastinitis and summarize the current knowledge on the mechanisms by which VAC therapy promotes wound healing. Finally, we suggest a structured algorithm for using VAC therapy for treatment of poststernotomy mediastinitis in clinical practice.     

Vacuum‐assisted closure (VAC)‐Instill® with continuous irrigation for the treatment of Mycoplasma hominis mediastinitis

A 56‐year‐old patient who underwent ascending aorta replacement postoperatively developed mediastinitis with atypical Mycoplasma hominis. We present the first successful treatment of M. hominis mediastinitis after cardiac surgery with vacuum‐assisted closure (VAC)‐Instill^® therapy combined with dilute antiseptic irrigation for bacterial eradication.     

The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery

BACKGROUND: The VAC system (vacuum-assisted wound closure) is a noninvasive active therapy to promote healing in difficult wounds that fail to respond to established treatment modalities. The system is based on the application of negative pressure by controlled suction to the wound surface. The method was introduced into clinical practice in 1996. Since then, numerous studies proved the effectiveness of the VAC System on microcirculation and the promotion of granulation tissue proliferation. METHODS: Eleven patients (5 men, 6 women) with a median age of 64.4 years (range 50 to 78 years) with sternal wound infection after cardiac surgery (coronary artery bypass grafting = 5, aortic valve replacement = 5, ascending aortic replacement = 1) were fitted with the VAC system by the time of initial surgical debridement. RESULTS: Complete healing was achieved in all patients. The VAC system was removed after a mean of 9.3 days (range 4 to 15 days), when systemic signs of infection resolved and quantitative cultures were negative. In 6 patients (54.5%), the VAC system was used as a bridge to reconstructive surgery with a pectoralis muscle flap, and in the remaining 5 patients (45.5%), primary wound closure could be achieved. Intensive care unit stay ranged from 1 to 4 days (median 1 day). Duration of hospital stay varied from 13 to 45 days (median 30 days). In-hospital mortality was 0%, and 30-day survival was 100%. CONCLUSIONS: The VAC system can be considered as an effective and safe adjunct to conventional and established treatment modalities for the therapy of sternal wound infections after cardiac surgery.     

Efficacy of antimicrobial activity of slow release silver nanoparticles dressing in post-cardiac surgery mediastinitis

We report our preliminary experience in post-cardiac surgery mediastinitis using a recently introduced silver-releasing dressing claiming prompt antibacterial activity. Acticoat, a silver nanoparticles slow release dressing was used in four patients with documented post-cardiac surgery mediastinitis and persistently positive microbiological cultures despite vacuum-assisted closure (VAC) therapy. In all four patients negative cultures were obtained within a maximum of 72 h and patients were discharged within a maximum of 20 days.     

VAC therapy for the treatment of complex wounds after cardio‐thoracic surgery

The aim of this study is to report our experience about the treatment of complex sternal and thoracic wounds following cardiothoracic surgery, using vacuum‐assisted closure (VAC therapy. Twelve patients presenting with sternal (five cases) and thoracic (seven cases) wounds that were difficult to heal were treated through VAC therapy after the first surgical debridement. The duration of VAC application ranged from 12 to 36 days with an average hospital stay of 24·6 ± 11·4 days. During a mean follow‐up of 12 months, we observed complete wound healing in seven cases (58·3%), in an average period of 25·5 ± 14·3 days; one patient died during follow‐up, two patients were lost to follow‐up and two patients required definitive surgical closure of the wound cavity. In conclusion, VAC therapy promotes faster wound healing, with shorter hospital stay and subsequent lesser in‐hospital cost, reducing the mortality rate in the long run. It also promotes early rehabilitation and alleviates the need for a second procedure, thus improving patient satisfaction, with minimal discomfort or inconvenience.     

C‐reactive protein and leucocyte counts drop faster using the HeartShield® device in patients with DSWI

Right ventricular heart rupture is a devastating complication associated with negative pressure wound therapy (NPWT) in cardiac surgery. The use of a rigid barrier disc (HeartShield?) has been suggested to offer protection against this lethal complication by preventing the heart from being drawn up by the negative pressure and damaged by the sharp sternum bone edges. Seven patients treated with conventional NPWT and seven patients treated with NPWT with a protective barrier disc (HeartShield) were compared with regard to bacterial clearance and infection parameters including C‐reactive protein levels and leucocyte counts. C‐reactive protein levels and leucocyte counts dropped faster and bacterial clearance occurred earlier in the HeartShield® group compared with the conventional NPWT group. Negative biopsy cultures were shown after 3·1 ± 0·4 NPWT dressing changes in the HeartShield group, and after 5·4 ± 0·6 NPWT dressing changes in the conventional NPWT group (P < 0·001). All patients were followed up with clinical check‐up after 3 months. None of the patients in the HeartShield group had any signs of reinfection such as deep sternal wound infection (DSWI) or sternal fistulas, whereas in the conventional NPWT group, two patients had signs of sternal fistulas that demanded hospitalisation. HeartShield hinders the right ventricle to come into contact with the sharp sternal edges during NPWT and thereby protects from heart damage. This study shows that using HeartShield is beneficial in treating patients with DSWI. Improved wound healing by HeartShield may be a result of the efficient drainage of wound effluents from the thoracic cavity.     

Mediastinitis after pediatric cardiac surgery: a 15-year experience at a single institution

BACKGROUND: The spectrum of sternal wound infections after cardiac surgery ranges from superficial infections to a deep sternal infection known as mediastinitis. Mediastinitis is a rare but clinically relevant source of postoperative morbidity and mortality in adult and pediatric patients after cardiac surgery. METHODS: We retrospectively identified all patients diagnosed with mediastinitis after cardiac surgery from January 1987 to December 2002 (17 patients/7,616 surgeries = 0.2%). Demographic data, cardiac diagnosis, cardiac surgery, hospital length of stay, associated medical diagnosis, and surgical treatment for mediastinitis were collected. RESULTS: Fifteen pediatric patients (age < 18 years) were diagnosed with mediastinitis (mean age at diagnosis 37.5 months, range 21 days to 17 years. The median postoperative day of diagnosis was 14 days (6 to 50 days). The most common organism was Staphylococcus species (n = 9). Six patients had an associated bacteremia. The median hospital length of stay for all patients was 42.5 days (range 16 to 163 days). The hospital mortality was 1 of 15 (6%). Each patient was treated with intravenous antibiotics; sternal debridement; and rectus abdominus flap reconstruction (n = 7), pectoralis muscle flap reconstruction (n = 3), omentum reconstruction (n = 1), or primary sternal closure (n = 4). Three patients have undergone redo-sternotomy with orthotopic heart transplantation, bidirectional cavopulmonary anastomosis, and replacement of a right ventricle to pulmonary artery homograft. CONCLUSIONS: Timely diagnosis, aggressive sternal debridement, and liberal use of rotational muscle flaps can potentially minimize the morbidity and mortality in pediatric postoperative cardiac patients. Subsequent redo-sternotomy has not been problematic.     

An effective vacuum-assisted closure treatment for mediastinitis with aortic arch replacement

Little experience exists with the vacuum-assisted closure (VAC) therapy in the high-risk group of patients with perigraft abscess containing a large amount of prosthetic vascular grafts. We report our experience in the VAC therapy for patients with mediastinitis after aortic arch replacement. Between February 2003 and December 2006, five patients with a mean age of 72.2 years developed postoperative mediastinitis after aortic arch replacement, and were treated with the VAC system. In all the patients the mediastinal fluid and tissue examinations turned out to be negative for microbiological cultures, and successful closure of the midline incision was achieved with concomitant omental transfer after a mean duration of 22.6 days of VAC treatment. Four of the five patients survived to discharge and have been free from recurrent sign of mediastinal or graft infection at long-term follow-up. Our study indicates that the VAC treatment may reduce early mortality of life-threatening deep sternal wound infection complicated by a prior aortic arch replacement and become a preferred therapeutic option for the patients to whom another replacement is too risky.     

The ‘Two Bridges Technique’ for sternal wound closure. The use of vacuum‐assisted closure for the treatment of deep sternal wound defects: a centre‐specific technique

The objective is to describe the ‘Two Bridges Technique’ (TBT), which has proven to be successful and has been the standard technique at our centre for vacuum‐assisted closure (VAC) of post‐sternotomy mediastinitis. An extensive literature search was performed in four databases to identify all published articles concerning VAC for post‐sternotomy mediastinitis. Several VAC methods have been used; however, no article has described our specific technique. TBT consists of a two‐bridges construction using two types of foam with different pore sizes, which ensures an equally divided negative pressure over the wound bed and stabilisation of the chest. This guarantees a continuous treatment of the sternal defect and prevents foam displacement. It maintains an airtight seal that prevents skin maceration and provides enough protection to avoid right ventricular rupture. The main advantage of TBT is the prevention of shifting or tilting of the foam during chest movements such as breathing or couching. Along with targeted antibiotic treatment, this alternative VAC technique can be an asset in the sometimes cumbersome treatment of post‐sternotomy mediastinitis.     

Effectiveness of collagen/oxidised regenerated cellulose/silver‐containing composite wound dressing for the treatment of medium‐depth split‐thickness skin graft donor site wounds in multi‐morbid patients: a prospective,non‐comparative,single‐centre study

Split‐thickness skin grafting (STSG) is a widely used method in reconstructive surgery, but donor site wounds (DSWs) are often slow healing and painful. This prospective study evaluated the performance of a composite wound dressing containing collagen/oxidised regenerated cellulose in the treatment of medium‐depth (0·4 mm) DSWs in 25 multi‐morbid patients with chronic leg ulcers requiring STSG. The range of patients' ages was 44–84 years (mean 71·6 years) with DSW sizes ranging between 12 and 162 cm² (mean 78 cm²). Comorbidities included anticoagulation therapy (15 patients), anaemia (11 patients), diabetes (6 patients) and methicillin‐resistant Staphylococcus aureus (MRSA) ulcer colonisation (6 patients). The first dressing change was performed after 10 days. Complete reepithelialisation was observed between the 10th and 34th day (mean 17·2, median 14 days). Postoperative medium to strong bleeding occurred in only five patients (four with anticoagulation). Wound pain levels one day after harvesting were only moderate (range 0–1·5, mean 0·5, median 0·5 on a six‐item scale). No wound infection was observed during the first dressing. The composite dressing used allowed for the fast healing of medium‐depth DSWs with minimal or no postoperative pain and bleeding in older multi‐morbid patients under anticoagulation treatment.     

A statistical model that predicts the length from the left subclavian artery to the celiac axis; towards accurate intra aortic balloon sizing

The reported incidence of deep sternal wound infection (DSWI) after cardiac surgery is 0.4-5% with Staphylococcus aureus being the most common pathogen isolated from infected wound sternotomies and bacteraemic blood cultures. This infection is associated with a higher morbidity and mortality than other known aetiologies. Little is reported about the optimal antibiotic management. The aim of the study is to quantify the application of daptomycin treatment of DSWI due to gram-positive organisms post cardiac surgery. We performed an observational analysis in 23 cases of post sternotomy DSWI with gram-positive organisms February 2009 and September 2010. When the wound appeared viable and the microbiological cultures were negative, the technique of chest closure was individualised to the patient. The incidence of DSWI was 1.46%. The mean dose of daptomycin application was 4.4 ± 0.9 mg/kg/d and the average duration of the daptomycin application was 14.47 ± 7.33 days. In 89% of the patients VAC therapy was used. The duration from daptomycin application to sternal closure was 18 ± 13.9 days. The parameters of infection including, fibrinogen (p = 0.03), white blood cell count (p = 0.001) and C-reactive protein (p = 0.0001) were significantly reduced after daptomycin application. We had no mortality and wound healing was successfully achieved in all patients. Treatment of DSWI due to gram-positive organisms with a daptomycin-containing antibiotic regimen is safe, effective and promotes immediate improvement of local wound conditions. Based on these observations, daptomycin may offer a new treatment option for expediting surgical management of DSWI after cardiac surgery.     

Negative‐pressure wound dressings to secure split‐thickness skin grafts in the perineum

Several researches have shown that negative‐pressure wound dressings can secure split‐thickness skin grafts and improve graft survival. However, in anatomically difficult body regions such as the perineum it is questionable whether these dressings have similar beneficial effects. In this study, we evaluated the effects of negative‐pressure wound dressings on split‐thickness skin grafts in the perineum by comparing wound healing rate and complication rate with that of tie‐over dressings. A retrospective chart review was performed for the patients who underwent a split‐thickness skin graft to reconstruct perineal skin defects between January 2007 and December 2011. After grafting, the surgeon selected patients to receive either a negative‐pressure dressing or a tie‐over dressing. In both groups, the initial dressing was left unchanged for 5 days, then changed to conventional wet gauze dressing. Graft success was assessed 2 weeks after surgery by a single clinician. A total of 26 patients were included in this study. The mean age was 56·6 years and the mean wound size was 273·1 cm². Among them 14 received negative‐pressure dressings and 12 received tie‐over dressings. Negative‐pressure dressing group had higher graft taken rate (P = 0·036) and took shorter time to complete healing (P = 0·01) than tie‐over dressing group. The patients with negative‐pressure dressings had a higher rate of graft success and shorter time to complete healing, which has statistical significance. Negative‐pressure wound dressing can be a good option for effective management of skin grafts in the perineum.     

Assessment of vacuum‐assisted closure therapy on the wound healing process in cardiac surgery

Postoperative deep sternal wound infection (DSWI) is a serious complication in cardiac surgery (1–5% of patients) with high mortality and morbidity rates. Vacuum‐assisted closure (VAC) therapy has shown promising results in terms of wound healing process, postoperative hospital length of stay and lower in‐hospital costs. The aim of our retrospective study is to report the outcome of patients with DSWI treated with VAC therapy and to assess the effect of contributory risk factors. Data of 52 patients who have been treated with VAC therapy in a single institution (study period: September 2003–March 2012) were collected electronically through PAtient Tracking System PATS and statistically analysed using SPSS version 20. Of the 52 patients (35 M: 17 F), 88·5% (n = 46) were solely treated with VAC therapy and 11·5% (n = 6) had additional plastic surgical intervention. Follow‐up was complete (mean 33·8 months) with an overall mortality rate of 26·9% (n = 14) of whom 50% (n = 7) died in hospital. No death was related to VAC complications. Patient outcomes were affected by pre‐operative, intra‐operative and postoperative risk factors. Logistic EUROscore, postoperative hospital length of stay, advanced age, chronic obstructive pulmonary disease (COPD) and long‐term corticosteroid treatment appear to be significant contributing factors in the long‐term survival of patients treated with VAC therapy.     

Vacuum-assisted wound closure in the management of deep sternal wound infection

We herein present a case who underwent vacuum-assisted wound closure (VAC) therapy for post-sternotomy mediastinitis. A 71-year-old female with chronic renal failure on dialysis underwent a graft replacement of the ascending aortic aorta for the treatment of an acute aortic dissection. After she was discharged from the hospital, a purulent discharge was noted to occur from the median sternal wound. The wound was therefore reopened and all sternal wires were removed. Thereafter, polyurethane foam which was shaped to fit the defect was placed within the cavity. The area was covered with adhesive drape and suction drainage was carried out at -100 mmHg. The polyurethane foam was replaced every few days. The wound was finally closed using a muscle flap at 49 days after surgery. VAC therapy is therefore considered to be a useful treatment modality for deep sternal wound infections.     

Sternal osteomyelitis: use of vacuum-assisted closure device as an adjunct to definitive closure with sternectomy and muscle flap reconstruction

OBJECTIVES: Sternal osteomyelitis following cardiac surgery often requires debridement and flap coverage. The VAC (vacuum-assisted closure) device has been useful in complex wound coverage. A retrospective review of a single surgeon's experience with sternal reconstruction using the VAC device as an adjunct to debridement and muscle flap reconstruction was performed. METHODS: Thirteen consecutive patients over a 34-month period underwent debridement and reconstruction of sternal wounds. Eleven patients (85%) were males, and two (15%) were females. Mean age was 61 years (range: 43-73 years). Acute purulent sternal infections occurred in seven patients, while chronic sternal osteomyelitis was seen in six patients. Use of the VAC device during the perioperative period was evaluated. RESULTS: Of the 13 patients, the VAC device was used prior to flap closure in six patients, and after flap closure in two patients. Sternal debridement with bilateral pectoralis muscle flaps was used to reconstruct 12 patients, and one patient underwent debridement only with VAC placement. All 13 patients (100%) had complete closure of their complex wounds at an average of follow-up of 14 months. CONCLUSIONS: The VAC device is useful in the treatment of sternal osteomyelitis in three contexts: (1) as a temporary wound care technique preoperatively that minimizes dressing changes and prevents shear stresses of an open sternum, (2) as the sole method of wound closure in specific cases, and (3) as a technique to facilitate healing in postoperative flap reconstruction cases complicated by reinfection.     

Deep sternal wound infection: the role of early debridement surgery

Objective: This retrospective chart review study aimed to evaluate whether a more aggressive staged approach can reduce morbility and mortality following post-cardiotomy deep sternal wound infection. Methods: Between 1979 and 2000, 14 620 patients underwent open heart surgery: mediastinitis developed in 124 patients (0.85%). Patients were divided in two groups: in 62 patients (Group A) (1979–1994) an initial attempt of conservative antibiotic therapy was the rule followed by surgical approach in case of failure; in 62 patients (Group B) (1995–2000) the treatment was staged in three phases: (1) wound debridment, removal of wires and sutures, closed irrigation for 10 days; (2) in case of failure open dressing with sugar and hyperbaric therapy (11 patients, 17%); (3) delayed healing and negative wound cultures mandated plastic reconstruction (three patients, 4%). Categorical values were compared using the Chi-square test, continuous data were compared by unpaired t-test. Results: Incidence of mediastinitis was higher in Group B (62 out of 5535; 1.3%) than in Group A (62 out of 9085; 0.7%) (P=0.007). Mean interval between diagnosis and treatment was shorter in Group B (18±6 days) than in group A (38±7 days) (P=0.001). Hospital mortality was higher in Group A (19/62; 31%) than in Group B (1 out of 62; 1.6%) (P<0.001). Hospital stay was shorter in Group B (30.5±3 days) than in group A (44±9 days) (P=0.001). In Group B complete healing was observed in all the 61 survivors: 47 cases (76%) after Stage 1; 11 (18%) after Stage 2; three (4.8%) after Stage 3. Conclusions: Although partially biased by the fact that the two compared groups draw back to different decades, this study showed that an aggressive therapeutic protocol can significantly reduce morbility and mortality of deep sternal wound infection.