Enterobacter-Related Deep Sternal Wound Infection After Cardiac Surgery with Delayed NPWT Success: A Rare Case Report

Enterobacter-Related Deep Sternal Wound Infection After Cardiac Surgery with Delayed NPWT Success: A Rare Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Enterobacter-Related Deep Sternal Wound Infection After Cardiac Surgery with Delayed NPWT Success: A Rare Case Report Omar Al Ayoubi, Mohammad Alaa Aldakak, Grace Tannous This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6779097/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Deep sternal wound infection (DSWI) is a rare but serious complication following cardiac surgery, particularly in high-risk patients with comorbidities such as diabetes, COPD, and a history of smoking. Socioeconomic barriers can further compromise outcomes, especially in resource-limited countries. Case Presentation: We report a 70-year-old male with diabetes, COPD, hypertension, and heavy smoking history who developed DSWI 20 days after coronary artery bypass grafting (CABG), following early discontinuation of antibiotics due to crisis-related non-adherence. He presented with fever, sternal instability, and wound dehiscence. Cultures identified Enterobacter spp, and treatment included targeted antibiotics and delayed initiation of negative-pressure wound therapy (NPWT). The patient achieved wound granulation and stabilization without the need for flap reconstruction. Conclusion: This case highlights the importance of early DSWI recognition, multidisciplinary management, and the efficacy of NPWT even when initiated late. It also underscores the impact of systemic challenges on adherence and recovery, and the need for tailored prevention strategies in resource-constrained environments. Deep Sternal Wound Infection (DSWI) Coronary Artery Bypass Grafting (CABG) Surgical Site Infection Negative-pressure wound therapy (NPWT) Enterobacter Case Report Figures Figure 1 Figure 2 Introduction Cardiac surgery provides life-saving treatment for severe cardiac conditions such as coronary artery disease, valvular dysfunction, and congenital defects [ 1 ]. While major complications like hemorrhage, cardiogenic shock, and perioperative infarction are associated with high mortality [ 2 ], surgical site infections remain a notable postoperative concern. Most are superficial and resolve with antibiotics; however, deeper infections such as deep sternal wound infection (DSWI ) may occur, involving sternal osteomyelitis and/or mediastinitis [ 3 ]. Though relatively rare, with an incidence of 1–5% [ 3 , 4 ], DSWI is a serious, potentially fatal complication that significantly increases morbidity, healthcare costs, and negatively affects quality of life [ 5 ]. Sternal wound infections are classified as superficial (limited to skin and subcutaneous tissue) or deep (involving muscle, fascia, sternum, or mediastinal spaces) [ 6 , 7 ]. As per Centres for Disease Control (CDC) guidelines, diagnosis is confirmed by mediastinal widening on imaging, fluid drainage, or positive blood/wound cultures [ 8 ]. Early intervention is crucial. However, Negative-pressure wound therapy (NPWT) has shown superiority over conventional care, reducing mortality, promoting granulation, and shortening hospital stays [ 4 , 9 ]. In this report, we present the case of a 70-year-old male with multiple comorbidities who developed a severe DSWI following CABG surgery. Case Presentation A 70-year-old Arabic male, with a history of heavy smoking (60 pack-years, quit 8 months prior), presented to the pulmonology department with chronic chest pain. He had type 2 diabetes mellitus for 3 years, hypertension for 15 years, and COPD for 5 years. His surgical history included cholecystectomy (1.5 years ago) and appendectomy (40 years ago). Due to worsening angina, he was referred to cardiac surgery and diagnosed with Non-ST-Elevation Myocardial Infarction (NSTEMI). Coronary angiography revealed two-vessel disease, and he underwent CABG with two grafts: A0–Saphenous Vein Graft (SVG)–Diagonal and Left Internal Mammary Artery (LIMA)–Left Anterior Descending (LAD). The postoperative course was uneventful. Echocardiography showed an EF of 55%, and he was discharged on day 5 with Intravenous IV Levofloxacin prophylaxis. However, due to personal and socioeconomic circumstances, he did not complete the antibiotic course. Twenty days post-discharge, he returned with systemic deterioration: shortness of breath, fatigue, low-grade fever (37.5°–38.5°C), mood changes, and localized sternal pain. Examination revealed sternal instability and deep wound dehiscence with necrotic tissue exposure [Figure 1, Fig. 2]. These findings met Centers for Disease Control (CDC) criteria for DSWI. Cultures from deep tissue isolated Enterobacter spp, which was sensitive to Amikacin, Levofloxacin, Ciprofloxacin, and Carbapenems. IV Amikacin and Levofloxacin were administered, with renal function monitored every 48 hours. Despite partial improvement, the wound remained open. However, Negative-pressure wound therapy (NPWT) was initiated, resulting in granulation and stabilization. Plastic surgery was consulted for delayed closure planning. Discussion The incidence of deep sternal wound infections (DSWI) following sternotomy has been reported to range between 1–5% [ 3 , 4 ]. The risk of death following DSWI remains significantly higher compared to uninfected controls for up to 10 years postoperatively [ 10 ]. Diabetes mellitus has been identified as a strong independent predictor of deep sternal wound infection (DSWI) following median sternotomy, with an odds ratio of 2.6. The risk increases further in diabetic patients undergoing CABG with bilateral internal thoracic artery (BITA) grafting, where the incidence of DSWI reaches 14.3%, compared to 1.3% in non-BITA diabetic patients. Male sex also independently contributes to increased risk. These findings highlight the importance of preoperative metabolic optimization and graft selection to reduce DSWI incidence in high-risk patients [ 11 ]. Although COPD is not an independent predictor of mortality, it was reported in 35% of patients with sternal dehiscence, indicating a relevant clinical association [ 12 ]. Our patient had multiple risk factors for DSWI, including poorly controlled diabetes and male sex—both independently linked to higher infection rates. While BITA was not used, the coexistence of COPD and diabetes likely contributed to infection development despite an initially uneventful recovery. Management options for DSWI range from repeated debridement and sternal rewiring to more extensive procedures such as total sternectomy with reconstruction using muscle or omental flaps [ 13 , 14 ]. Negative-pressure wound therapy (NPWT) improves local perfusion, controls exudate, facilitates wound cleansing, and promotes granulation, making it a valuable tool in DSWI management [ 15 ]. Although Negative-pressure wound therapy (NPWT) has become a cornerstone in the management of DSWI due to its efficacy in reducing bioburden, promoting granulation, and preparing the wound bed for secondary closure or flap coverage, most reports involved early application after debridement [ 16 , 17 ]. In our case, Negative-pressure wound therapy (NPWT) was introduced after extensive tissue necrosis and exposure of the entire sternotomy line, with a successful clinical outcome, demonstrating the feasibility of its use even in advanced cases and supporting its role as an effective bridge to further reconstructive options. While Staphylococcus aureus and CoNS are the most common pathogens in DSWI [ 18 ], our case was microbiologically distinct with the isolation of Enterobacter spp , a less common but documented nosocomial organism. This case underscores the importance of individualized, timely decision-making in DSWI management, especially in high-risk patients, and highlights that even delayed use of VAC therapy can lead to favorable outcomes when combined with targeted antibiotics and close clinical monitoring. Conclusion DSWI remains a serious post-cardiac surgery complication, especially in high-risk patients with comorbidities like diabetes, COPD, and a history of smoking. In our case, early surgical debridement, targeted antibiotic therapy against Enterobacter spp, and the timely use of Negative-pressure wound therapy (NPWT)—despite delayed initiation—led to successful wound stabilization without the need for flap reconstruction. This highlights the importance of individualized care, adherence monitoring, and multidisciplinary management. Preventive strategies such as strict glycemic control, postoperative surveillance, and patient education are essential to reduce risk and improve outcomes. Declarations Conflict of interest statement: The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article. Ethical Approval: Institutional Review Board (IRB) approval is not required for de-identified single case reports or case histories, in accordance with institutional policies. Patient consent Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution O.A. Contributed to writing the Introduction and Case Presentation sections.M.A. Contributed to writing the discussion and background sections.G.T. organized the figures and figure legends, and assisted in manuscript editing.All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work. References Gaudino M, Flather M, Capodanno D, Milojevic M, Bhatt DL, Biondi Zoccai G, et al. European Association of Cardio-Thoracic Surgery (EACTS) expert consensus statement on perioperative myocardial infarction after cardiac surgery. Eur J Cardiothorac Surg. 2024;65(2):ezad415. 10.1093/ejcts/ezad415 . Deng XQ, Yu H, Wang WJ, Wu QL, Wei H, Deng JS, et al. Effect of volatile versus propofol anaesthesia on major complications and mortality after cardiac surgery: a multicentre randomised trial. Br J Anaesth. 2024;133(2):296–304. 10.1016/j.bja.2024.05.008 . Steingrimsson S, Gottfredsson M, Kristinsson KG, Gudbjartsson T. Deep sternal wound infections following open heart surgery in Iceland: a population-based study. Scand Cardiovasc J. 2008;42(3):208–13. 10.1080/14017430801919557 . Baillot R, Cloutier D, Montalin L, Côté L, Lellouche F, Houde C, et al. Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15-year review of 23,499 sternotomies. Eur J Cardiothorac Surg. 2010;37(4):880–7. 10.1016/j.ejcts.2009.09.023 . Jidéus L, Liss A, Ståhle E. Patients with sternal wound infection after cardiac surgery do not improve their quality of life. Scand Cardiovasc J. 2009;43(3):194–200. 10.1080/14017430802573098 . Salehi Omran A, Karimi A, Ahmadi SH, Davoodi S, Marzban M, Movahedi N, et al. Superficial and deep sternal wound infection after more than 9000 coronary artery bypass graft (CABG): incidence, risk factors and mortality. BMC Infect Dis. 2007;7:112. 10.1186/1471-2334-7-112 . Bryan CS, Yarbrough WM. Preventing deep wound infection after coronary artery bypass grafting: a review. Tex Heart Inst J. 2013;40(2):125–39. Centers for Disease Control and Prevention (CDC). CDC/NHSN surveillance definitions for specific types of infections. January 2025. Available from: http://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf Petzina R, Hoffmann J, Navasardyan A, Malmsjö M, Stamm C, Unbehaun A, et al. Negative pressure wound therapy for post-sternotomy mediastinitis reduces mortality rate and sternal re-infection rate compared to conventional treatment. Eur J Cardiothorac Surg. 2010;38(1):110–3. 10.1016/j.ejcts.2010.01.028 . Risnes I, Abdelnoor M, Almdahl SM, Svennevig JL. Mediastinitis after coronary artery bypass grafting: risk factors and long-term survival. Ann Thorac Surg. 2010;89(5):1502–9. 10.1016/j.athoracsur.2010.02.038 . Borger MA, Rao V, Weisel RD, Ivanov J, Cohen G, Scully HE, et al. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg. 1998;65(4):1050–6. 10.1016/s0003-4975(98)00063-0 . Landes G, Harris PG, Sampalis JS, Brutus JP, Cordoba C, Ciaburro H, et al. Outcomes in the management of sternal dehiscence by plastic surgery: a ten-year review in one university center. Ann Plast Surg. 2007;59(6):659–66. 10.1097/SAP.0b013e31803b370b . Schols RM, Lauwers TM, Geskes GG, van der Hulst RR. Deep sternal wound infection after open heart surgery: current treatment insights. A retrospective study of 36 cases. Eur J Plast Surg. 2011;34(6):487–92. 10.1007/s00238-011-0573-2 . De Brabandere K, Jacobs-Tulleneers-Thevissen D, Czapla J, La Meir M, Delvaux G, Wellens F. Negative-pressure wound therapy and laparoscopic omentoplasty for deep sternal wound infections after median sternotomy. Tex Heart Inst J. 2012;39(3):367–71. Steingrimsson S, Gottfredsson M, Gudmundsdottir I, Sjögren J, Gudbjartsson T. Negative-pressure wound therapy for deep sternal wound infections reduces the rate of surgical interventions for early re-infections. Interact Cardiovasc Thorac Surg. 2012;15(3):406–10. 10.1093/icvts/ivs254 . Jiang Y, He S, Case Report. A review of two children with deep sternal wound infections after precordial surgery treated with a simple negative pressure closed drainage technique. Front Pediatr. 2024;12:1491944. 10.3389/fped.2024.1491944 . Guzek A, Suwalski G, Tomaszewski D, Rybicki Z. Dalbavancin treatment in a deep sternal wound MRSA infection after coronary artery bypass surgery: a case report. J Cardiothorac Surg. 2018;13(1):3. 10.1186/s13019-017-0690-5 . Morgante A, Romeo F. Deep sternal wound infections: a severe complication after cardiac surgery. G Chir. 2017;38(1):33–6. 10.11138/gchir/2017.38.1.033 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6779097","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":487896731,"identity":"0524323f-cec4-4d30-b3f4-c4d683279b04","order_by":0,"name":"Omar Al Ayoubi","email":"","orcid":"","institution":"Damascus University","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"Al","lastName":"Ayoubi","suffix":""},{"id":487896732,"identity":"454b6128-1d11-48f2-908c-f7d55c348895","order_by":1,"name":"Mohammad Alaa Aldakak","email":"data:image/png;base64,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","orcid":"","institution":"Damascus University","correspondingAuthor":true,"prefix":"","firstName":"Mohammad","middleName":"Alaa","lastName":"Aldakak","suffix":""},{"id":487896733,"identity":"1b1d58cb-65e2-488a-84f8-9bb4d693e19d","order_by":2,"name":"Grace Tannous","email":"","orcid":"","institution":"Damascus University","correspondingAuthor":false,"prefix":"","firstName":"Grace","middleName":"","lastName":"Tannous","suffix":""}],"badges":[],"createdAt":"2025-05-29 19:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6779097/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6779097/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87362999,"identity":"a98c9eb3-f907-4285-9e72-a587f507ca11","added_by":"auto","created_at":"2025-07-23 05:59:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57363,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eClinical photograph showing extensive sternal wound dehiscence with exposure of subcutaneous tissues and deep fascia. The wound bed demonstrates signs of necrosis and infection, with irregular granulation tissue along the margins and central depth indicating full-thickness disruption.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6779097/v1/5c029b7d697b48d907e82975.jpg"},{"id":87363531,"identity":"d7bc982d-7526-4f8f-b5c3-75c5f09918f9","added_by":"auto","created_at":"2025-07-23 06:07:11","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":701500,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eClinical photograph showing extensive sternal wound dehiscence with exposure of subcutaneous tissues and deep fascia. The wound bed demonstrates signs of necrosis and infection, with irregular granulation tissue along the margins and central depth indicating full-thickness disruption.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2..jpg","url":"https://assets-eu.researchsquare.com/files/rs-6779097/v1/197d1c77a0779bebe4da30f2.jpg"},{"id":92277040,"identity":"22ae3179-77b4-4e22-9a0a-41fbfa08a8a8","added_by":"auto","created_at":"2025-09-26 15:34:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1109345,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6779097/v1/bf25f78c-71c5-49cb-9075-960fd9b09eed.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enterobacter-Related Deep Sternal Wound Infection After Cardiac Surgery with Delayed NPWT Success: A Rare Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCardiac surgery provides life-saving treatment for severe cardiac conditions such as coronary artery disease, valvular dysfunction, and congenital defects [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While major complications like hemorrhage, cardiogenic shock, and perioperative infarction are associated with high mortality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], surgical site infections remain a notable postoperative concern. Most are superficial and resolve with antibiotics; however, deeper infections such as deep sternal wound infection (DSWI\u003cb\u003e)\u003c/b\u003e may occur, involving sternal osteomyelitis and/or mediastinitis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Though relatively rare, with an incidence of 1\u0026ndash;5% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], DSWI is a serious, potentially fatal complication that significantly increases morbidity, healthcare costs, and negatively affects quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Sternal wound infections are classified as superficial (limited to skin and subcutaneous tissue) or deep (involving muscle, fascia, sternum, or mediastinal spaces) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. As per Centres for Disease Control (CDC) guidelines, diagnosis is confirmed by mediastinal widening on imaging, fluid drainage, or positive blood/wound cultures [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Early intervention is crucial. However, Negative-pressure wound therapy (NPWT) has shown superiority over conventional care, reducing mortality, promoting granulation, and shortening hospital stays [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this report, we present the case of a 70-year-old male with multiple comorbidities who developed a severe DSWI following CABG surgery.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 70-year-old Arabic male, with a history of heavy smoking (60 pack-years, quit 8 months prior), presented to the pulmonology department with chronic chest pain. He had type 2 diabetes mellitus for 3 years, hypertension for 15 years, and COPD for 5 years. His surgical history included cholecystectomy (1.5 years ago) and appendectomy (40 years ago).\u003c/p\u003e\u003cp\u003eDue to worsening angina, he was referred to cardiac surgery and diagnosed with Non-ST-Elevation Myocardial Infarction (NSTEMI). Coronary angiography revealed two-vessel disease, and he underwent CABG with two grafts: A0\u0026ndash;Saphenous Vein Graft (SVG)\u0026ndash;Diagonal and Left Internal Mammary Artery (LIMA)\u0026ndash;Left Anterior Descending (LAD).\u003c/p\u003e\u003cp\u003eThe postoperative course was uneventful. Echocardiography showed an EF of 55%, and he was discharged on day 5 with Intravenous IV Levofloxacin prophylaxis. However, due to personal and socioeconomic circumstances, he did not complete the antibiotic course.\u003c/p\u003e\u003cp\u003eTwenty days post-discharge, he returned with systemic deterioration: shortness of breath, fatigue, low-grade fever (37.5\u0026deg;\u0026ndash;38.5\u0026deg;C), mood changes, and localized sternal pain. Examination revealed sternal instability and deep wound dehiscence with necrotic tissue exposure \u003cb\u003e[Figure 1, Fig.\u0026nbsp;2].\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThese findings met Centers for Disease Control (CDC) criteria for DSWI. Cultures from deep tissue isolated Enterobacter spp, which was sensitive to Amikacin, Levofloxacin, Ciprofloxacin, and Carbapenems. IV Amikacin and Levofloxacin were administered, with renal function monitored every 48 hours.\u003c/p\u003e\u003cp\u003eDespite partial improvement, the wound remained open. However, Negative-pressure wound therapy (NPWT) was initiated, resulting in granulation and stabilization. Plastic surgery was consulted for delayed closure planning.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe incidence of deep sternal wound infections (DSWI) following sternotomy has been reported to range between 1\u0026ndash;5% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The risk of death following DSWI remains significantly higher compared to uninfected controls for up to 10 years postoperatively [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Diabetes mellitus has been identified as a strong independent predictor of deep sternal wound infection (DSWI) following median sternotomy, with an odds ratio of 2.6. The risk increases further in diabetic patients undergoing CABG with bilateral internal thoracic artery (BITA) grafting, where the incidence of DSWI reaches 14.3%, compared to 1.3% in non-BITA diabetic patients. Male sex also independently contributes to increased risk. These findings highlight the importance of preoperative metabolic optimization and graft selection to reduce DSWI incidence in high-risk patients [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Although COPD is not an independent predictor of mortality, it was reported in 35% of patients with sternal dehiscence, indicating a relevant clinical association [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our patient had multiple risk factors for DSWI, including poorly controlled diabetes and male sex\u0026mdash;both independently linked to higher infection rates. While BITA was not used, the coexistence of COPD and diabetes likely contributed to infection development despite an initially uneventful recovery. Management options for DSWI range from repeated debridement and sternal rewiring to more extensive procedures such as total sternectomy with reconstruction using muscle or omental flaps [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Negative-pressure wound therapy (NPWT) improves local perfusion, controls exudate, facilitates wound cleansing, and promotes granulation, making it a valuable tool in DSWI management [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although Negative-pressure wound therapy (NPWT) has become a cornerstone in the management of DSWI due to its efficacy in reducing bioburden, promoting granulation, and preparing the wound bed for secondary closure or flap coverage, most reports involved early application after debridement [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In our case, Negative-pressure wound therapy (NPWT) was introduced after extensive tissue necrosis and exposure of the entire sternotomy line, with a successful clinical outcome, demonstrating the feasibility of its use even in advanced cases and supporting its role as an effective bridge to further reconstructive options. While Staphylococcus aureus and CoNS are the most common pathogens in DSWI [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], our case was microbiologically distinct with the isolation of \u003cb\u003eEnterobacter spp\u003c/b\u003e, a less common but documented nosocomial organism.\u003c/p\u003e\u003cp\u003eThis case underscores the importance of individualized, timely decision-making in DSWI management, especially in high-risk patients, and highlights that even delayed use of VAC therapy can lead to favorable outcomes when combined with targeted antibiotics and close clinical monitoring.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDSWI remains a serious post-cardiac surgery complication, especially in high-risk patients with comorbidities like diabetes, COPD, and a history of smoking. In our case, early surgical debridement, targeted antibiotic therapy against Enterobacter spp, and the timely use of Negative-pressure wound therapy (NPWT)\u0026mdash;despite delayed initiation\u0026mdash;led to successful wound stabilization without the need for flap reconstruction. This highlights the importance of individualized care, adherence monitoring, and multidisciplinary management. Preventive strategies such as strict glycemic control, postoperative surveillance, and patient education are essential to reduce risk and improve outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of interest statement:\u003c/h2\u003e\u003cp\u003eThe authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eEthical Approval:\u003c/h2\u003e\u003cp\u003eInstitutional Review Board (IRB) approval is not required for de-identified single case reports or case histories, in accordance with institutional policies.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003ePatient consent\u003c/h2\u003e\u003cp\u003e Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eO.A. Contributed to writing the Introduction and Case Presentation sections.M.A. Contributed to writing the discussion and background sections.G.T. organized the figures and figure legends, and assisted in manuscript editing.All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGaudino M, Flather M, Capodanno D, Milojevic M, Bhatt DL, Biondi Zoccai G, et al. 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G Chir. 2017;38(1):33\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11138/gchir/2017.38.1.033\u003c/span\u003e\u003cspan address=\"10.11138/gchir/2017.38.1.033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Deep Sternal Wound Infection (DSWI), Coronary Artery Bypass Grafting (CABG), Surgical Site Infection, Negative-pressure wound therapy (NPWT), Enterobacter, Case Report","lastPublishedDoi":"10.21203/rs.3.rs-6779097/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6779097/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDeep sternal wound infection (DSWI) is a rare but serious complication following cardiac surgery, particularly in high-risk patients with comorbidities such as diabetes, COPD, and a history of smoking. Socioeconomic barriers can further compromise outcomes, especially in resource-limited countries.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase Presentation:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe report a 70-year-old male with diabetes, COPD, hypertension, and heavy smoking history who developed DSWI 20 days after coronary artery bypass grafting (CABG), following early discontinuation of antibiotics due to crisis-related non-adherence. He presented with fever, sternal instability, and wound dehiscence. Cultures identified \u003cem\u003eEnterobacter\u003c/em\u003e spp, and treatment included targeted antibiotics and delayed initiation of negative-pressure wound therapy (NPWT). The patient achieved wound granulation and stabilization without the need for flap reconstruction.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis case highlights the importance of early DSWI recognition, multidisciplinary management, and the efficacy of NPWT even when initiated late. It also underscores the impact of systemic challenges on adherence and recovery, and the need for tailored prevention strategies in resource-constrained environments.\u003c/p\u003e","manuscriptTitle":"Enterobacter-Related Deep Sternal Wound Infection After Cardiac Surgery with Delayed NPWT Success: A Rare Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 05:59:07","doi":"10.21203/rs.3.rs-6779097/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f954026-1b8d-4c15-ac3c-a4bc45ae549a","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-26T15:31:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-23 05:59:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6779097","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6779097","identity":"rs-6779097","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}