A sternum infection represents a rare but potentially serious cause of central chest pain that demands prompt recognition and treatment. While most people experiencing discomfort in the chest area have benign conditions, infection of the breastbone and surrounding structures can lead to significant complications if left unaddressed. The chest wall can become infected by bacteria or viruses, and in rare cases, fungal infections can also occur. Cardiac surgery, specifically median sternotomy, is the leading cause of sternal infections.
These infections can involve the sternum bone itself, the cartilage connecting the ribs to the breastbone, or the soft tissue of the anterior chest wall. This cartilage acts as a flexible connective tissue and functions as a shock absorber in the joints between the ribs and sternum. The condition may present as primary sternal osteomyelitis, where bacteria reach the bone through the bloodstream, or secondary infection following surgery, trauma, or spread from adjacent structures.The majority of sternal infections occur after medical procedures or trauma.
Most cases are caused by bacteria, with Staphylococcus aureus being the predominant organism responsible for approximately 40-60% of confirmed cases. In certain populations, including intravenous drug users and prison populations, methicillin-resistant strains (MRSA) are increasingly common. Primary osteomyelitis, particularly in the pediatric population, can present with non-specific symptoms and poses diagnostic challenges due to its rarity and similarity to other conditions.
One of the challenges with sternum infection is that symptoms often mimic cardiac or lung disease. Patients frequently experience sharp chest pain that may be mistaken for a heart attack or other cardiac conditions. This similarity can delay diagnosis and treatment, sometimes by several weeks.
Early diagnosis combined with appropriate antibiotic treatment and timely thoracic surgical input is essential to prevent severe complications such as mediastinitis, where infection spreads to the central compartment of the chest containing the heart and major blood vessels.
Mr Marco Scarci, consultant thoracic surgeon in London, regularly manages complex chest wall and sternal infections. His approach combines advanced surgical techniques with tailored treatment plans designed to optimise outcomes while minimising recovery time. A multidisciplinary evaluation is always used to determine the most appropriate treatment option for each individual patient.
Primary sternal osteomyelitis is uncommon, but it should always be considered a serious condition requiring urgent attention. Unlike many causes of chest discomfort that resolve on their own, bone and soft tissue infections of the sternum can progress rapidly without appropriate treatment.
It’s helpful to contrast sternum infection with other, more common causes of central chest pain:
Condition | Nature | Typical Course | Treatment Needed |
|---|---|---|---|
Costochondritis | Non-infectious inflammation | Self-limiting over weeks | Rest, NSAIDs |
Tietze Syndrome | Inflammatory, affects costochondral joint | May persist longer but benign | Conservative |
Sternal Osteomyelitis | Bacterial infection of bone | Progressive without treatment | Antibiotics, often surgery |
Deep Sternal Wound Infection | Post-surgical infection | Can escalate rapidly | Urgent specialist care |
Condition
Nature
Typical Course
Treatment Needed
Costochondritis
Non-infectious inflammation
Self-limiting over weeks
Rest, NSAIDs
Tietze Syndrome
Inflammatory, affects costochondral joint
May persist longer but benign
Conservative
Sternal Osteomyelitis
Bacterial infection of bone
Progressive without treatment
Antibiotics, often surgery
Deep Sternal Wound Infection
Post-surgical infection
Can escalate rapidly
Urgent specialist care
When left untreated, sternum infection can spread beyond the bone to involve the mediastinum, the protected space containing the heart, major vessels, and airways. This progression to mediastinitis carries mortality rates reported as high as 25-50% in severe cases. The infection can also seed the bloodstream, leading to sepsis and multi-organ failure.
Postoperative sternal wound infections following cardiac surgery, particularly after coronary artery bypass grafting, represent a particularly high-risk scenario. These deep sternal wound infection cases occur in approximately 1-3% of patients, rising to 5-10% in those with additional risk factors such as diabetes or obesity.
The reassuring reality is that with prompt antibiotics and, when necessary, surgical debridement, most patients recover well. Serious complications are avoidable when the condition is recognised and treated early. Cure rates exceed 85% in cases that haven’t progressed to involve the mediastinum.
Any new or unexplained central chest pain warrants assessment rather than assumption that it’s muscular or benign. Pain that worsens over a few weeks, particularly when accompanied by other signs of infection, should prompt medical evaluation.
Sternum infections develop when microorganisms reach the bone or surrounding soft tissue through one of three main routes: the bloodstream (haematogenous spread), direct inoculation from trauma or surgery, or contiguous spread from nearby infected structures.
The organisms most frequently responsible include:
Staphylococcus aureus (including MRSA) — the most common cause, identified in 40-60% of cases
Coagulase-negative staphylococci — particularly in postoperative infections
Pseudomonas aeruginosa — especially prevalent in intravenous drug users
Gram-negative organisms — more common in hospital-acquired infections
Anaerobic bacteria — occasionally involved in polymicrobial infections
Mycobacterium tuberculosis — causes chronic, insidious presentations
Primary sternal osteomyelitis caused by haematogenous seeding occurs when bacteria travel through the bloodstream from a distant focus of infection. This pattern is more frequently seen in children and younger adults who have no obvious chest trauma or surgical history. The original source may be a skin infection, urinary tract infection, or even dental abscess. Primary sternal osteomyelitis is a rare condition that is frequently caused by Staphylococcus aureus. The primary cause of a sternal infection is bacterial invasion from skin flora during or after surgical procedures.
Secondary sternum infection develops following:
Median sternotomy for cardiac surgery
Blunt or penetrating chest trauma
Chest compressions during CPR
Contaminated central venous catheters
Extension from adjacent lung or pleural infections
Certain conditions substantially increase the likelihood of developing a sternum infection:
Risk Factor | Mechanism | Increased Risk |
|---|---|---|
Diabetes mellitus | Impaired immune function, poor wound healing | 2-4 fold |
Obesity | Obesity (BMI >30) increases the risk of sternal infections due to vascularity issues and wound tension. | 2-3 fold |
Intravenous drug use | Direct inoculation, right-sided endocarditis | Up to 10 fold |
Immune suppression | HIV, chemotherapy, long-term steroids | Variable |
Chronic kidney disease | Impaired immunity, frequent vascular access | Elevated |
Prolonged ICU stay | Hospital-acquired organisms, invasive lines | Elevated |
Poor nutritional status | Delayed healing, reduced immune response | Moderate |
Smoking | Smoking and COPD impair immune function and healing, increasing the risk of infections. | Moderate |
Risk Factor
Mechanism
Increased Risk
Diabetes mellitus
Impaired immune function, poor wound healing
2-4 fold
Obesity
Obesity (BMI >30) increases the risk of sternal infections due to vascularity issues and wound tension.
2-3 fold
Intravenous drug use
Direct inoculation, right-sided endocarditis
Up to 10 fold
Immune suppression
HIV, chemotherapy, long-term steroids
Variable
Chronic kidney disease
Impaired immunity, frequent vascular access
Elevated
Prolonged ICU stay
Hospital-acquired organisms, invasive lines
Elevated
Poor nutritional status
Delayed healing, reduced immune response
Moderate
Smoking
Smoking and COPD impair immune function and healing, increasing the risk of infections.
Moderate
It’s important to recognise that sternum infection can occur even in an immunocompetent adult without obvious risk factors. The absence of predisposing conditions should not lead clinicians or patients to dismiss the possibility when symptoms are suggestive.
Sternum infections can be categorized based on their origin and clinical presentation, which is crucial for determining the most effective treatment approach. The two main types are primary and secondary sternal osteomyelitis.
Primary sternal osteomyelitis is a rare but serious infection that develops when bacteria, most commonly Staphylococcus aureus, reach the sternum through the bloodstream. This type of infection can affect both children and adults, and is more likely to occur in individuals with certain risk factors such as diabetes mellitus, immunodeficiency, or intravenous drug use. Because primary sternal osteomyelitis often starts without any obvious injury or surgical history, it can be challenging to diagnose early, making prompt recognition and antibiotic treatment essential to prevent complications.
Secondary sternal osteomyelitis typically arises from direct contamination of the sternum, most often following trauma or surgical procedures like coronary artery bypass grafting. In these cases, bacteria may enter the bone during or after surgery, leading to infection. Deep sternal wound infections are a specific form of secondary osteomyelitis that can develop after cardiac surgery. These infections are particularly concerning because they may progress rapidly and often require both surgical intervention—such as debridement of infected tissue—and prolonged antibiotic therapy to achieve full recovery.
Understanding the type of sternal osteomyelitis is vital, as it influences the choice of treatment and the urgency of surgical management. Early identification of risk factors and close monitoring after procedures involving the sternum can help reduce the likelihood of severe infection and improve patient outcomes.
The symptoms of sternum infection frequently mimic heart or lung disease, with pain in the chest being the dominant complaint. This overlap with cardiac conditions means patients sometimes present to the emergency room concerned about a potential heart attack. Symptoms of sternal infections include localized pain, tenderness over the breastbone, and discharge from the surgical wound. The most common symptom related to a chest wall infection is chest pain, which may become more severe with activity.
Key features to recognise include:
Localised pain over the breastbone, typically worsened by breathing deeply, coughing, or upper body movement
Tenderness when pressing on the sternum or surrounding ribs
Visible swelling or warmth over the affected area
Skin changes — redness, irritation, or changes in the overlying skin
Systemic symptoms — fever, chills, night sweats, or sweating
Reduced mobility — difficulty moving the arms or shoulders due to pain
General malaise — feeling unwell, fatigue, or reduced appetite
In some patients, particularly those with postoperative infections, symptoms may include:
Fluctuant swelling or a palpable abscess over the sternum
Discharge from a surgical wound or sinus tract
Wound breakdown with exposed cartilage or bone
Clicking or instability of the breastbone
In early or milder cases, pain may be the only symptom. The discomfort might start suddenly or develop gradually over days to weeks. Some patients notice their symptoms become worse with physical stress or pressure on the chest. Blood tests may show elevated inflammatory markers even when external signs are minimal.
You should attend A&E or call emergency services if:
Chest pain is severe or rapidly worsening
You experience shortness of breath or difficulty breathing
Pain radiates to the neck, jaw, or arms
You feel dizzy, faint, or have palpitations
You feel acutely unwell with high fever
There is spreading redness or signs of sepsis
Contact your GP or arrange a private consultation if:
Chest pain persists for more than a few days without explanation
There is visible swelling or redness over the sternum
You experience intermittent fevers without clear cause
You have recently undergone cardiac or chest surgery
Symptoms follow chest trauma or CPR
Early assessment can prevent progression and lead to more straightforward treatment.
Accurate diagnosis of sternum infection relies on combining clinical assessment, laboratory investigations, and imaging studies. This process often involves collaboration between a thoracic surgeon, infectious diseases specialist, and radiologist. Diagnosis of sternal infections is primarily clinical, based on physical symptoms, and supported by lab and imaging studies. A combination of clinical symptoms, laboratory testing, and advanced imaging is used to diagnose sternal infections.
The initial assessment includes:
Detailed history — onset and duration of pain, any preceding trauma, recent surgery, intravenous drug use, and symptoms suggesting distant infection
Physical examination — checking for local tenderness, swelling, warmth, fluctuance, wound breakdown, and signs of systemic infection
Assessment of stability — in post-sternotomy patients, checking for sternal movement or clicking
Essential laboratory investigations include:
Test | Purpose | Typical Findings in Infection |
|---|---|---|
Full blood count | Assess white cell count | Often elevated (though may be normal early) |
C-reactive protein (CRP) | Inflammation marker | Usually >50 mg/L, often >100 mg/L |
Erythrocyte sedimentation rate | Inflammation marker | Elevated |
Blood cultures | Identify causative organism | Positive in 30-50% of cases |
Renal and liver function | Plan antibiotic dosing | Baseline assessment |
Test
Purpose
Typical Findings in Infection
Full blood count
Assess white cell count
Often elevated (though may be normal early)
C-reactive protein (CRP)
Inflammation marker
Usually >50 mg/L, often >100 mg/L
Erythrocyte sedimentation rate
Inflammation marker
Elevated
Blood cultures
Identify causative organism
Positive in 30-50% of cases
Renal and liver function
Plan antibiotic dosing
Baseline assessment
Blood cultures should be obtained before starting antibiotics whenever possible, as they may identify the responsible organism and guide treatment.
Chest X-ray may appear normal in early infection but can show soft tissue swelling, bony erosion, or widening of the mediastinum in advanced cases. It’s useful for excluding other causes of chest symptoms.
CT scan of the chest with contrast is the workhorse investigation, offering detailed visualisation of:
Sternal bone erosion and cortical destruction
Retrosternal fluid collections
Chest wall abscesses
Involvement of mediastinal structures
A CT scan is the gold standard for assessing the depth of infection in sternal infections.
MRI provides superior sensitivity for detecting early marrow changes and soft tissue inflammation. It achieves approximately 90% sensitivity compared to 70% for CT in identifying early osteomyelitis. MRI is particularly valuable when initial imaging is inconclusive. MRI is superior to chest x-ray for diagnosing sternal osteomyelitis.
In many patients, targeted aspiration or biopsy of the affected bone or abscess collection is necessary. This procedure:
May be performed under CT or ultrasound guidance
Provides material for culture and antibiotic sensitivity testing
Helps differentiate infection from other pathology
Guides selection of appropriate antibiotic therapy
In children, clinicians often prioritise non-invasive approaches initially, with blood cultures and imaging, reserving bone biopsy for cases where the diagnosis remains uncertain. Bone biopsy provides a definitive diagnosis of sternal osteomyelitis and is recommended whenever feasible.
Diagnosing costochondritis or Tietze syndrome, by contrast, is largely clinical and doesn’t require extensive investigation. The key distinction is the absence of fever, systemic symptoms, and normal inflammatory markers in these non-infectious conditions. Costochondritis is the inflammation of the cartilage that connects the ribs to the sternum. The main symptom of costochondritis is chest pain that appears centrally. Costochondritis usually improves on its own after a few weeks but can sometimes take longer. Treatment for costochondritis often includes self-help steps and painkillers to manage symptoms.
Effective treatment of sternum infection combines prolonged antibiotic therapy with careful surgical intervention when necessary. The approach is tailored to disease severity, causative organism, and individual patient factors. Patients often start with high-dose intravenous (IV) antibiotics for sternal infections.
Initial empiric treatment typically involves broad-spectrum intravenous antibiotics covering:
Gram-positive organisms including MRSA (often vancomycin or daptomycin)
Gram-negative bacteria (often a cephalosporin or piperacillin-tazobactam)
Adjustment once culture results and sensitivities are available
Duration of treatment generally includes:
2-6 weeks of intravenous antibiotics
Followed by several weeks of high-dose oral therapy
Total duration often 6-12 weeks depending on response
Infectious diseases specialists play a crucial role in optimising antibiotic selection and monitoring for toxicity, including nephrotoxicity which affects approximately 20% of patients on prolonged aminoglycoside courses.
Surgical intervention becomes necessary when:
An abscess greater than 2 cm is present
There is clear bone necrosis visible on imaging
The sternum is unstable
Antibiotic treatment alone fails to control infection
Infection recurs after previous treatment
Mediastinal involvement is suspected
The surgical approach may include:
Incision and drainage of superficial or deep abscesses
Surgical debridement of dead bone, cartilage, and infected soft tissue
Mediastinal washout if infection has spread centrally
Chest wall reconstruction when significant sternal segments require removal
Wound closure — primary, delayed, or using vacuum-assisted closure (VAC) systems
VAC therapy has demonstrated superior wound healing rates (approximately 85%) compared to traditional dressings (60%) and is now widely used in complex sternal wounds.
Mr Marco Scarci employs contemporary techniques including:
Minimally invasive and muscle-sparing approaches where anatomy permits
VAC dressings to promote granulation and reduce bacterial load
Biological or synthetic mesh for chest wall stability
Rigid plate fixation (offering union rates of 95% versus 75% with wire closure)
Muscle flap coverage when needed for successful closure
Optimal outcomes require collaboration between:
Thoracic surgery
Infectious diseases
Anaesthetics and pain management
Physiotherapy
Plastic surgery (for complex soft tissue coverage)
Nutrition support
Pain medication typically includes NSAIDs to reduce inflammation, with opioids reserved for severe pain and regional nerve blocks for selected patients. Venous thromboembolism prophylaxis is standard during inpatient treatment.
The majority of patients with sternum infection, including those with relatively extensive disease, can return to their usual activities following appropriate treatment. Recovery timelines vary considerably based on disease severity and treatment requirements.
Length of admission depends on the complexity of infection:
Scenario | Typical Hospital Stay |
|---|---|
Limited infection, antibiotics only | A few days to 1-2 weeks |
Surgical debridement required | 1-3 weeks |
Complex postoperative infection | Several weeks |
Mediastinal involvement | Often 4-8 weeks or longer |
Scenario
Typical Hospital Stay
Limited infection, antibiotics only
A few days to 1-2 weeks
Surgical debridement required
1-3 weeks
Complex postoperative infection
Several weeks
Mediastinal involvement
Often 4-8 weeks or longer
After discharge, patients typically undergo:
Repeat blood tests — CRP and white cell count to confirm normalisation
Interval imaging — CT or MRI to document resolution
Outpatient reviews — regular appointments with the thoracic surgeon and infectious diseases team
Wound assessment — monitoring for any signs of recurrence
Many patients complete their antibiotic course at home, sometimes with outpatient parenteral therapy arranged through specialist teams.
Returning to normal function involves:
Gradual resumption of daily activities
Avoiding heavy lifting and strenuous upper body exercise until cleared
Physiotherapy to optimise breathing mechanics and posture
Shoulder and upper body mobilisation exercises
Building activity levels progressively over weeks to several months
For patients who have undergone larger debridements or reconstructive surgery, physiotherapy plays a particularly important role in restoring function. Physical therapy exercises may be prescribed as treatment for chest wall infections.
When infection is fully eradicated and chest wall stability restored, recurrence rates are low. However, certain factors warrant longer surveillance:
Diabetes mellitus
Ongoing immunosuppression
MRSA infection (recurrence rates 15-25%)
Extensive bone involvement
Delayed or incomplete treatment can lead to:
Chronic sinus tracts with persistent drainage
Chronic pain in the affected area
Recurrent abscesses requiring repeat surgery
Progression to life-threatening mediastinitis
Sepsis with systemic organ dysfunction
Deep sternal wound infections (DSWI) have a significantly higher mortality rate of 10-47%.
Patients should contact their surgical team or seek urgent review if they experience:
Persistent or worsening pain despite pain medication
New fevers or night sweats
Changes in the surgical wound (redness, swelling, discharge)
General deterioration in wellbeing
Any symptoms that concern them
Sternal instability, indicated by a clicking or shifting sensation of the bone, is a symptom of infection.
Purulent drainage from the incision is a primary indicator of sternal infection.
Treatment failure can cause complications such as mediastinitis, abscess collection, chronic infection, fistulae, and sinus tracts formation.
Most patients make an excellent recovery, but vigilance during the initial months after treatment ensures any problems are caught early.
Preventing sternum infections involves a combination of personal health practices and medical vigilance. For individuals at risk of primary sternal osteomyelitis, maintaining good hygiene and minimizing exposure to infectious diseases are important first steps. Managing chronic health conditions, especially diabetes mellitus, is also crucial, as high blood sugar levels can impair the body’s ability to fight infection and heal wounds.
Avoiding behaviors that increase the risk of infection, such as intravenous drug use, can further reduce the likelihood of developing sternal osteomyelitis. For patients undergoing surgery involving the sternum, such as cardiac procedures, careful attention to wound care and strict adherence to post-operative instructions are essential. This includes keeping the surgical site clean, monitoring for any signs of infection like increased pain, swelling, or redness, and promptly reporting these symptoms to a healthcare provider.
Healthcare professionals play a key role in prevention by closely monitoring patients for early signs of infection and initiating treatment at the first indication of a problem. By combining proactive self-care with professional oversight, the risk of developing a sternum infection can be significantly reduced.
Mr Marco Scarci is a London-based consultant thoracic surgeon with extensive experience managing complex sternal and chest wall infections across both NHS and private settings.
Patients benefit from:
Rapid assessment of unexplained chest pain and chest wall swelling
Advanced imaging access — CT, MRI, and interventional radiology
Multidisciplinary planning — coordinated care with infectious diseases specialists, radiologists, and other relevant teams
Comprehensive treatment — from initial diagnosis through to surgery and long-term follow-up
Mr Scarci specialises in:
Innovative chest wall reconstruction techniques
Approaches designed to minimise pain, hospital stay, and visible scarring working in collaboration with plastic surgeons and orthopedic surgeons specialised in bone infection.
These modern techniques often allow for quicker recovery and reduced complications compared to traditional open approaches.
Both face-to-face and virtual consultations are available for:
International patients requiring expert opinion
Second opinions on previously diagnosed sternum infections
Pre-surgical planning for complex cases
Specialist thoracic surgical review is particularly valuable for:
Patients who have undergone previous heart or chest surgery
Those with recurrent chest wall infections
Individuals with complex comorbidities including diabetes or immunosuppression
Cases where initial treatment has not achieved resolution
Anyone seeking expert guidance on management options
To arrange a private consultation with Mr Scarci:
Referrals can be made through your GP or directly as a self-referral
Bring any relevant medical records, operation notes, and imaging (ideally on CD)
Virtual consultations can be arranged for initial assessment if attending in person is difficult
Appointments are typically available within a short timeframe for urgent cases
Early specialist input can make a significant difference to outcomes in sternum infection. If you’re experiencing persistent chest pain, have concerns following cardiac surgery, or have been diagnosed with a sternal or chest wall infection, seeking expert thoracic surgical advice is a prudent step toward recovery.
In summary, sternum infections—including primary sternal osteomyelitis and deep sternal wound infections—are serious medical conditions that require timely diagnosis and comprehensive treatment. Recognizing the different types of sternal osteomyelitis, understanding risk factors, and being aware of symptoms such as chest pain, tenderness, and swelling are essential for early intervention and prevention of complications.
By practicing good hygiene, managing underlying health issues like diabetes mellitus, and following proper wound care after surgery, individuals can lower their risk of developing these infections. Ongoing research and advances in medical technology continue to improve the diagnosis and treatment of sternum infections, leading to better outcomes for patients.
If you experience persistent chest pain, swelling, or other concerning symptoms, it is important to seek medical attention promptly. Early diagnosis and treatment are key to a successful recovery and minimizing the risk of serious complications associated with sternal osteomyelitis.
020 7459 4367
