A first- or second-generation cephalosporin is rec- ommended for prophylaxis in patients without methicillin-resistant Staphylococcus aureus coloniza- tion.897 905 (Level of Evidence: A) 3. Vancomycin alone or in combination with other antibiotics to achieve broader coverage is recom- mended for prophylaxis in patients with proven or suspected methicillin-resistant S. aureus coloniza- tion.900,906 908 (Level of Evidence: B) 4. A deep sternal wound infection should be treated with aggressive surgical debridement in the absence of complicating circumstances. Primary or second- ary closure with muscle or omental flap is recom- mended.909 911 Vacuum therapy in conjunction with early and aggressive debridement is an effective adjunctive therapy.912 921 (Level of Evidence: B) 5. Use of a continuous intravenous insulin protocol to achieve and maintain an early postoperative blood glucose concentration less than or equal to 180 mg/dL while avoiding hypoglycemia is indicated to reduce the risk of deep sternal wound infec- tion.583,586,590,591,922,923 (Level of Evidence: B) Class IIa 1. When blood transfusions are needed, leukocyte- filtered blood can be useful to reduce the rate of overall perioperative infection and in-hospital death.924 927 (Level of Evidence: B) 2. The use of intranasal mupirocin is reasonable in nasal carriers of S. aureus.928,929 (Level of Evidence: A) 3. The routine use of intranasal mupirocin is reason- able in patients who are not carriers of S. aureus, unless an allergy exists. (Level of Evidence: C) Class IIb 1. The use of bilateral IMAs in patients with diabetes mellitus is associated with an increased risk of deep sternal wound infection, but it may be reasonable when the overall benefit to the patient outweighs this increased risk. (Level of Evidence: C) See Online Data Supplements 35 and 36 for additional data on mediastinitis and perioperative infection. Nosocomial infections occur in 10% to 20% of cardiac surgery patients. 