1e:T423,Certain experimental and clinical observations indicate that the local use of antibiotics may be more effective in some situations than their systemic administration. Poth, for example, showed that when neomycin was added to a 10% suspension of human feces no bacteria could be cultured.¹Furthermore, if mice were inoculated intraperitoneally with 1 cc. of 10% human feces none survived, while in contrast, all survived if neomycin were given intraperitoneally within 1 hour of the fecal injection. Poth also demonstrated that the instillation of neomycin solution is effective in sterilizing the human intestinal tract within 30 minutes. Sterilization of peritoneal fluid has also been noted following intraperitoneal instillation of antibiotics in patients with acute bacterial peritonitis secondary to perforation of the gastrointestinal tract.² Because of these considerations antibiotics have been used intraperitoneally by us and our associates for several years in patients with peritoneal contamination and in patients undergoing1f:T4a3,Median sternotomy incision was routinely employed for 1,042 open-heart operations over a two-year period. Seventeen patients developed mediastinitis; seven died. Recognition of mediastinitis depended on sternal wound drainage or sternal dehiscence. Two patients withCandida albicansmediastinitis developed neither unstable sternum nor draining wound, and both died. Therapy in 15 patients consisted of mediastinum debridement followed by continuous irrigation of the closed wound with antibiotic solutions. Five of the 15 patients died. Mediastinum irrigation, usually with neomycin sulfate-bacitracin, resulted inC albicansovergrowth in six patients.Candida albicanswas directly implicated in four patients' deaths and the development of chronic chondritis in three others. Early debridement of the mediastinum upon the initial appearance of a draining, purulent sternal infection followed by continuous irrigation of the mediastinum by broad-spectrum antibiotic solution and specific systemic antibiotic therapy is the recommended therapy for postoperative mediastinal infection. The survival of ten patients out of 15 so treated strongly recommends this approach.20:T4d9,Postoperative mediastinitis complicated 21 (3.4%) of 616 median sternotomy procedures at Beth Israel Hospital (Boston, Mass.) between 1975 and 1979. These cases were analyzed by means of a case control study to identify host and operative risk factors and to characterize the clinical features of mediastinitis. Eighteen patients with mediastinitis (86%) had serious underlying noncardiac diseases, as compared with 14 (33%) of 42 noninfected controls (P = .001). Reoperation was positively associated with infection (P = .03). All patients had abnormal sternal wounds and fever; sternal instability and mediastinal widening were unusual. Twelve patients (57%) were bacteremic. Twenty-four organisms were recovered from the 21 patients with mediastinitis; 13 of the isolates were gram-positive, and 11 were gram-negative. Infections due to gram-negative bacteria appeared earlier and were more likely to be bacteremic (70%). All gram-negative isolates and five of six isolates of Staphylococcus epidermidis were resistant to the antimicrobial agent used perioperatively. Patients were treated with extensive debridement and appropriate antibiotics. The mortality rate was 24% (five of 21). Long-term complications in survivors were not seen.

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