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…BUTOnly if used in the correct context and as part of a comprehensive infection service.

Infections in vascular patients

Plan

Part 1 – Treatment guideline updatePart 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 manyConflictingUnhelpfulDifficult to followIgnoredHard to findOut of date…….

IDSA: Antibiotic choice for DFI

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 “specialty-specific” 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 infection4. Mycotic aneurysms5. Diabetic foot infection6. Cellulitis/ulcer infection

8179 Jan 2011692 July 2008

“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 bypass2. Removal with replacement with autologous vessel3. Partial removal and replacement4. Endovascular arterial reconstruction5. No surgery

Vascular graft infection

Duration of therapy vs surgical strategy

1. Removal/extra anatomical 6/52 IV2. Removal/ in situ autologous 6/52 IV/po3. Partial removal 6/52 IV + suppression?4. EVAR 6/52 IV + suppression5. 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+)

•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

Prophylaxis

Infections in vascular patients

Summary

Guidelines do have a role in the management of infections in vascular surgical patients…BUTOnly 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.