We read with great interest the article by Steingrimsson et al. regarding the efficiency of vacuum-assisted closure (VAC) therapy for deep sternal wound infections (DSWI) in cardiac surgery [1]. The definition of DSWI as documented by the US Centers for Disease Control is an ‘infection involving fascia or deeper with at least one of the following: evidence of infection seen at re-operation or spontaneous dehiscence, positive culture of mediastinal fluid and/or positive blood culture and/or chest pain with sternal instability and temperature higher than 38°C [2].’
VAC therapy has now become a standard method of treatment for DSWI. In a prospective randomized trial by Moues and colleagues in 2004, a significant reduction in the wound surface area was noted in the VAC group compared to the conventional moist gauze therapy [3.8 ± 0.5 percent/day (mean ± SEM) vs 1.7 ± 0.6 percent/day respectively; p < 0.05]. However, the superiority of VAC therapy could not be explained by a significant reduction in the bacterial load [3].
In the retrospective cohort study by Gdalevitch and colleagues, the predictive factors identified for VAC treatment failure were the positive blood cultures (most sensitive predictor), wound depth of more than 4 cm (most specific predictor) and a high degree of sternal exposure and instability. Furthermore, the authors have suggested that these patients might be better managed by a surgical approach [4].
Luckraz and colleagues, in 2003, suggested that VAC therapy used alone or combined with other surgical modalities can offer acceptable results for the treatment of DSWI in cardiac surgery. In addition, the total cost for the hospitalization and treatment for patients in the VAC group was $16 400 per patient, compared with $20 000 per patient in the sternal rewiring and closed irrigation treatment group [5].
In conclusion, VAC therapy is an acceptable method for the treatment of DSWI. Patients with these devastating and potentially life-threatening complications can be assessed on an individual basis by an experienced team of cardiothoracic surgeons.
Conflict of interest: none declared.
References
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