Transcript Infections in vascular surgery patients - UHSM

Treatment and Prophylaxis
Guidelines – Where are we up
to?
Dr Jonathan Sandoe, Consultant Microbiologist, Leeds
Management of infections in the vascular patient
Competing interests
• Paid by Pfizer to deliver a lecture on infections in
vascular surgical patients in 2011
• Research funding, sponsorship to attend
conferences or deliver lectures from Novartis,
Pfizer and Merck Sharp and Dohme, Biomet.
Infections in vascular patients
Aim
To persuade you that guidelines have a role in the
management of infections in vascular surgical
patients…
BUT
Only if used in the correct context and as part of a
comprehensive infection service.
Infections in vascular patients
Plan
Part 1 – Treatment guideline update
Part 2 – What do we want from guidelines?
Part 3 – Prophylaxis guideline update
Part 1
Treatment guideline update
Guidelines for diagnosis and
management of infected vascular
grafts…
Guidelines for radiological diagnosis
and management of infected
(mycotic) aneurysms….
Infections in vascular patients
Where are all the guidelines?
Part 2
What do we want from
guidelines?
Infections in vascular patients
The aim of treatment
To cure patients of infection with minimal
risk of harm in the most efficient way
possible.
Secondary aim…to suppress infection…
Infections in vascular patients
The aim of guidelines
To standardise and optimise the care of
vascular patients with infection?
Infections in vascular surgery
The aim of guidelines
• Is standardisation possible in complex
infection?
Infections in vascular patients
The aim of guidelines
Can anything be standardised?
• Diagnostic criteria
• Initial investigations
• Microbiological processing
• Empirical antimicrobial therapy
• Directed antimicrobials
• Surgery?
Infections in vascular patients
Guideline criticisms
Too many
Conflicting
Unhelpful
Difficult to follow
Ignored
Hard to find
Out of date
…….
IDSA: Antibiotic choice for DFI
Moderate
Oral or parenteral*
• cefoxitin
• ceftriaxone
• ampicillin-sulbactam
• linezolid +/- aztreonam
• daptomycin+/- aztreonam
• ertapenem
• cefuroxime +/-mtz
• ticarcillin-clavulanate
•co-trimoxazole, co-amoxiclav, levofloxacin
• piperacillin-tazobactam
• levofloxacin OR ciprofloxacin with clindamycin
Adapted from Lipsky (2004) IDSA guidelines: diabetic foot infection.Clin Infect Dis 39: 885–910
Infections in vascular patients
Guideline criticisms
NICE: AB - Diabetic foot infection (DFI)
• NICE are unable to make any
recommendations on individual agents
• Each hospital should have DFI guidelines.
Infections in vascular patients
Making the task manageable
• Infections can be viewed as “specialtyspecific” and “general”
• In the assessment of a vascular surgery
inpatient with infection, the differential
diagnosis may be broad...
Infections in vascular patients
“Specialty specific” infections
1. Surgical site infection (wound, stump,
early graft infection)
2. Vascular graft infection (early/late)
3. AV fistula infection
4. Mycotic aneurysms
5. Diabetic foot infection
6. Cellulitis/ulcer infection
692 July 2008
8179 Jan 2011
“Hits” on antimicrobial guidelines per month
Infections in vascular patients
Contrasting - situations
Mycotic aneurysm
Vascular graft infection
Microbiology
monomicrobial
polymicrobial
Microbiological diagnosis
(Blood culture)
reliable
unreliable
Comorbidity
IE, IVDU, none
DM, PVD, CKD
Prosthetic material
absent
present
Infections in vascular patients
Infected aneurysms
year
location
Cause
Intervention
1
2012
cerebral
Strep gordonii
None
2.
2011
splenic
Strep oralis
Radiological embolisation
3.
2011
brachial
Strep agalactiae
Resection/repair
Vascular graft infection
Guideline – “top level recommendations”
• Antimicrobial strategy determined by surgical strategy
• Surgical strategy determined by location of graft, patient
choice/suitability for surgery….
• Removal of infected graft and debridement of infected
tissue appears to be necessary for cure?
Vascular graft infection
Success of surgical strategy for infection
1. Removal and extra-anatomical bypass
2. Removal with replacement with autologous vessel
3. Partial removal and replacement
4. Endovascular arterial reconstruction
5. No surgery
Vascular graft infection
Duration of therapy vs surgical strategy
1.
2.
3.
4.
5.
Removal/extra anatomical 6/52 IV
Removal/ in situ autologous 6/52 IV/po
Partial removal 6/52 IV + suppression?
EVAR 6/52 IV + suppression
No surgery IV + suppression
Vascular graft infection
Guideline – Antimicrobial treatment
• Is it appropriate to draw parallels
between prosthetic valve endocarditis
and vascular graft infection?
• Prolonged (6/52) IV antimicrobials can
cure PVE
• Trial data needed
Vascular graft infection
Empirical therapy
1. Vancomycin + piperacillin/tazobactam
(appropriate spectrum, low CDI risk, low MRSA
colonisation risk)*
2. Vancomycin + ciprofloxacin +metronidazole
(penicillin allergic patient)*
(antifungals?)
*Empirical regimen should consider previous microbiology
Part 3
Guidelines for antimicrobial
prophylaxis in vascular
(surgery) patients
Infections in vascular patients
Prophylaxis
Peripheral arterial
reconstruction (EL
1+)
Infections in vascular patients
Prophylaxis
• Do not use antibiotic prophylaxis routinely
for clean non-prosthetic uncomplicated
surgery (!)
• DO for all implant surgery
Infections in vascular patients
Prophylaxis
• single dose prophylaxis IV on starting
anaesthesia (earlier for operations in which
a tourniquet is used).
Infections in vascular patients
Prophylaxis
• No recommendations on choice of agent
• “see local formulary”
Infections in vascular patients
Summary
Guidelines do have a role in the management of
infections in vascular surgical patients…
BUT
Only if used in the correct context and as part of a
comprehensive infection service.
More data are needed – high quality observational
studies if trials impractical.