Which of the following would be the least appropriate in the management of acute suppurative mediastinitis?

D. Long-term systemic antibacterials.

DISCUSSION: Acute suppurative mediastinitis is a classic wound problem and forms a paradigm for principles of management. Wide débridement is perhaps the most important step in correcting this type of invasive wound sepsis. Drainage requires removal of tissue with vascular compromise. Tissue that is infected and can serve as an ongoing nidus for infection, particularly cartilage, must be removed. Irrigation is effective only when the irrigation fluid reaches into and flushes out débris and bacteria. The irrigation is insufficient if only dilutional and not also mechanically effective. Since infected tissue tends to become isolated from the systemic circulation the direct application of antibacterials reaches avascular areas. Some, such as silver sulfadiazine, penetrate avascular tissue better than, for instance, ointments or povidone iodine, and such an agent should be chosen. Wide débridement and the washing of debris with pressure irrigation make the wound then available to topical applications, which are often best packed into these deep, irregular cavities. Long-term systemic antibacterials serve no purpose and lead to potential resistant bacterial overgrowth. Although systemic antibacterials provide a measure of protection up to the margin where vascularized and nonvascularized tissues meet, topical agents are better in the actual infected site. Once closed, these wounds rapidly become sterilized. Even the infection at the bone level is far different from traditional osteomyelitis, and long-term systemic therapy is unnecessary. Muscle flaps are a great advance in closure technique, since they provide bulky protection, obliterate dead space, and help vascularize the wound.