Approach to managing mediastinitis following oesophageal rupture
Oesophageal rupture may be suspected following recent oesophageal instrumentation, suspected in patients with profound emesis, or associated with oesophageal foreign bodies.
Empirical therapy with activity against oropharyngeal bacteria is required for patients with mediastinitis following an oesophageal rupturePastene, 2020. Broader-spectrum treatment with activity against gram-negative bacteria or Candida species1 is required in certain circumstances.
If the patient has sepsis or septic shock or is at increased risk of oesophageal colonisation with gram-negative bacteria, see the treatment regimens in Mediastinitis following oesophageal rupture in patients with sepsis or septic shock, or at high risk of gram-negative bacteria or Candida species. Patients who meet any of the following criteria are at increased risk of oesophageal colonisation with gram-negative bacteria:
- oesophageal rupture that occurred in hospital
- haematological or solid organ malignancies
- a prolonged stay in hospital or frequent hospitalisation, particularly in those who received antibiotics.
Most patients do not require empirical therapy for Candida species. If the patient is at risk of invasive candidal infection, see the treatment regimens in Mediastinitis following oesophageal rupture in patients with sepsis or septic shock, or at high risk of gram-negative bacteria or Candida species. The following patients may be at risk of invasive candidal infection:
- patients with oesophageal candidiasis
- patients with immune compromise such as:
- organ transplant recipients
- patients with neutropenia
- patients with advanced HIV infection
- patients with haematological malignancies
- patients with septic shock or multi-organ failure requiring intensive care supportKeighley, 2021Pastene, 2020.
If the patient has a low risk of invasive candidal infection and oesophageal colonisation with gram-negative bacteria, and does not have sepsis or septic shock, see the treatment regimens in Mediastinitis following oesophageal rupture in patients with low risk of gram-negative bacteria or Candida species.