Table 3. Strategies to reduce mediastinitis.

Preoperative strategies	Intraoperative strategies	Postoperative strategies
Optimization of glycemic control in diabetics (HbA1c <8.0%)56,57) Reduction of weight in obese (BMI <30 kg/m2)57) Cessation of cigarette smoking57) Optimization of pulmonary function in COPD patients (FEV1/FVC <0.70)32,57) Systematic preoperative decolonization measures (e.g. mupirocin nasal ointment)55)	Skin disinfection with remnant active agents, e.g. chlorhexidine58) Iodine-impregnated skin drapes67) Repetitive surgical glove exchange58) Avoidance of (excessive) bone wax67) Meticulous skeletonized IMA harvesting67) Cautious use of electrocautery67) Avoidance of long operative period (<7 hours)57) Avoidance of long cardiopulmonary bypass time (<180 minutes)57) Avoidance of the need for IABP support57) Use of antibiotic sponge or paste below/ on sternal marrow before closure66) Use >8 sternal wires for closure72)	Avoidance of low cardiac output status57) Avoid the usage of sympathomimetic agents and vasopressors57) Reduction of ventilator support time <48 hours57) Avoiding transfusion of packed red blood cell, single donor platelets57) Use of chest stabilizing vests (e.g. posthorax)77) Use of NPWT (e.g. PICO)79)

HbA1c: hemoglobin A1c; BMI: body mass index; COPD: chronic obstructive pulmonary disease; FEV₁: forced expiratory volume in the first second; FVC: forced vital capacity; IMA: internal mammary artery; NPWT: negative pressure wound therapy