Vascular graft infection: Difference between revisions

Revision as of 15:28, 7 March 2021

Background

Microbiology

Staphylococcus aureus (30-60%)
Coagulase-negative staphylococci (10-30%)
Gram-negative bacilli (10-30%), including Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae
Viridans group streptococci and enterococci (5%)
Others: Candida species, polymicrobial infections
Culture-negative (5-30%)

Etiologies

Intraoperative contamination (most common)
Contiguous spread from superficial infection or intraabdominal infection
Direct inoculation during subsequent procedure
Hematogenous spread, less common after the early postoperative period (first 2 months) due to endothelialization

Clinical Manfestations

Varies by site of graft and infection
Can be early-onset (first 2 months) or late-onset (after 2 months)
Late-onset infections tend to be indolent without sepsis

Samson Classification

Classification of peripheral arterial prosthetic graft infections 1
Minor infections
- Group I: infection no deeper than the dermis
- Group II: infection of subcutaneous tissue without visible involvement of graft
Group III: infections involving graft but not anastomosis
Group IV: infections involving exposed anastomosis without bacteremia or anastomotic bleeding
Group V: infections involving graft-to-artery anastomosis with bacteremia or anastomotic bleeding

Diagnosis

Diagnosis is made clinically
Ultrasound is usually the initial imaging procedure, followed by CTA or MRI if US is equivocal
CT- or US-guided aspiration can be helpful for a microbiologic diagnosis

Management

Local infection without graft involvement: antibiotics with or without incision and drainage (groups I & II)
- Duration 2 to 4 weeks
Infection involving graft but without bacteremia or anastomotic bleeding (groups III & IV)
- Incision and drainage
- Preservation of graft, or reconstruction with allograft, autograft, or prosthetic material
- 4 to 6 weeks of IV followed by 3 to 6 months of oral
Infection with bacteremia or anastomotic bleeding (group V)
- Extra-anatomic revascularization followed by graft excision
- 4 to 6 weeks IV followed by 6 months oral

References

^ Russell H. Samson, Frank J. Veith, Gary S. Janko, Sushil K. Gupta, Larry A. Scher. A modified classification and approach to the management of infections involving peripheral arterial prosthetic grafts. Journal of Vascular Surgery. 1988;8(2):147-153. doi:10.1016/0741-5214(88)90402-8.
^ Chiara Lauri, Roberto Iezzi, Michele Rossi, Giovanni Tinelli, Simona Sica, Alberto Signore, Alessandro Posa, Alessandro Tanzilli, Chiara Panzera, Maurizio Taurino, Paola Anna Erba, Yamume Tshomba. Imaging Modalities for the Diagnosis of Vascular Graft Infections: A Consensus Paper amongst Different Specialists. Journal of Clinical Medicine. 2020;9(5):1510. doi:10.3390/jcm9051510.
^ O.T.A. Lyons, M. Baguneid, T.D. Barwick, R.E. Bell, N. Foster, S. Homer-Vanniasinkam, S. Hopkins, A. Hussain, K. Katsanos, B. Modarai, J.A.T. Sandoe, S. Thomas, N.M. Price. Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC). European Journal of Vascular and Endovascular Surgery. 2016;52(6):758-763. doi:10.1016/j.ejvs.2016.09.007.

@@ Line 1: / Line 1: @@
+== Background ==
+=== Microbiology ===
+* [[Staphylococcus aureus]] (30-60%)
+* [[Coagulase-negative staphylococci]] (10-30%)
+* [[Gram-negative bacilli]] (10-30%), including [[Escherichia coli]], [[Pseudomonas aeruginosa]], [[Klebsiella pneumoniae]]
+* [[Viridans group streptococci]] and [[enterococci]] (5%)
+* Others: [[Candida species]], polymicrobial infections
+* Culture-negative (5-30%)
+=== Etiologies ===
+* Intraoperative contamination (most common)
+* Contiguous spread from superficial infection or intraabdominal infection
+* Direct inoculation during subsequent procedure
+* Hematogenous spread, less common after the early postoperative period (first 2 months) due to endothelialization
+== Clinical Manfestations ==
+* Varies by site of graft and infection
+* Can be early-onset (first 2 months) or late-onset (after 2 months)
+* Late-onset infections tend to be indolent without sepsis
+=== Samson Classification ===
+* Classification of peripheral arterial prosthetic graft infections [[CiteRef::samson1988a]]
+* Minor infections
+** '''Group I:''' infection no deeper than the dermis
+** '''Group II:''' infection of subcutaneous tissue without visible involvement of graft
+* '''Group III:''' infections involving graft but not anastomosis
+* '''Group IV:''' infections involving exposed anastomosis without bacteremia or anastomotic bleeding
+* '''Group V:''' infections involving graft-to-artery anastomosis with bacteremia or anastomotic bleeding
+== Diagnosis ==
+* Diagnosis is made clinically
+* Ultrasound is usually the initial imaging procedure, followed by CTA or MRI if US is equivocal
+* CT- or US-guided aspiration can be helpful for a microbiologic diagnosis
+== Management ==
+* Local infection without graft involvement: antibiotics with or without incision and drainage (groups I & II)
+** Duration 2 to 4 weeks
+* Infection involving graft but without bacteremia or anastomotic bleeding (groups III & IV)
+** Incision and drainage
+** Preservation of graft, or reconstruction with allograft, autograft, or prosthetic material
+** 4 to 6 weeks of IV followed by 3 to 6 months of oral
+* Infection with bacteremia or anastomotic bleeding (group V)
+** Extra-anatomic revascularization followed by graft excision
+** 4 to 6 weeks IV followed by 6 months oral
 ==Further Reading==
-* Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association. ''Circulation''. 2016;134:e412-e460. doi: [https://doi.org/10.1161/CIR.0000000000000457 10.1161/CIR.0000000000000457]
+*Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association. ''Circulation''. 2016;134:e412-e460. doi: [https://doi.org/10.1161/CIR.0000000000000457 10.1161/CIR.0000000000000457]
 [[Category:Endovascular infections]]