Vascular Graft Infections

5.1. Epidemiology and Microbiology

The frequency of graft infections ranges from 1-5%. The majority of infections are thought to occur at the time of implantation. Staphylococci are the most common microorganism. Early infections are usually caused by S. aureus, whereas later infections are usually caused by coagulase-negative staphylococci. Rarely, Gram-negative bacilli may also cause infections of grafts.

5.2. Clinical Manifestations and Diagnostic Tests

Graft infections, especially those involving coagulase-negative staphylococci, may not become evident for months to years. The majority of graft infections present as localized wound infections. Blood cultures are usually positive in less than 50% of patients. Graft thrombosis may suggest a graft infection. Graft infection may also manifest itself as an aortoenteric fistula with gastrointestinal bleeding. Needle aspiration of

Table 5

Endocarditis Prophylaxis and Dental Procedures

Endocarditis prophylaxis recommended0 Dental extractions

Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance Dental implant placement and reimplantation of avulsed teeth Endodontic (root canal) instrumentation or surgery only beyond the apex Subgingival placement of antibiotic fibers or strips Initial placement of orthodontic bands but not brackets Intraligamentary local anesthetic injections

Prophylactic cleaning of teeth or implants where bleeding is anticipated Not recommended

Restorative dentistry6 (operative and prosthodontic) with or without retraction cordc

Local anesthetic injections (nonintraligamentary)

Intracanal endodontic treatment; post placement and buildup

Placement of rubber dams

Postoperative suture removal

Placement of removable prosthodontic or orthodontic appliances

Taking oral impressions

Fluoride treatments

Orthodontic appliance adjustment

Shedding of primary teeth

"Prophylaxis is recommended for patients with high- and moderate-risk cardiac conditions (see text for definitions).

6This includes restoration of decayed teeth (filling cavities) and replacement of missing teeth. cClinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding.

Table 6

Endocarditis Prophylaxis and Gastrointestinal Procedures

Indicated0

Sclerotherapy for esophageal varices Esophageal stricture dilation

Endoscopic retrograde cholangiography with biliary obstruction Biliary tract surgery

Surgical operations that involve intestinal mucosa

Not indicated

Transesophageal echocardiography

Endoscopy with or without gastrointestinal biopsy (prophylaxis is optional for high-risk patients such as prosthetic valves)

0For moderate- to high-risk cardiac conditions (see text for definitions).

para graft collections under ultrasonographic or CT guidance can provide additional information. CT scans or white blood cell scans may also be helpful in diagnosing graft infections.

Table 7

Prosthetic Valve Endocarditis Prophylaxis and Respiratory and Genitourinary Procedures

Respiratory Indicated0

Tonsillectomy and/or adenoidectomy Surgical operations that involve respiratory mucosa Bronchoscopy with a rigid bronchoscope Not indicated Endotracheal intubation

Bronchoscopy with a flexile bronchoscope, with or without biopsy6 Tympanostomy tube insertion

Genitourinary Indicated0

Prostatic surgery Cystoscopy Urethral dilation Not indicated

Vaginal hysterectomy6

Vaginal delivery6

Cesarean section

In uninfected tissue

Urethral catheterization

Uterine dilation and curettage

Sterilization procedures

Insertion or removal of intrauterine devices

"Recommended for moderate- to high-risk cardiac conditions.

6Prophylaxis is optional for high-risk conditions (see text for definitions).

5.3. Treatment

For management of graft infections, the infected prosthetic needs to be removed and then revascularization considered after an appropriate course of antibiotics (25,26). Generally, patients with graft infections are treated with a minimum of 6 wk of parenteral therapy; depending on the microorganisms, a longer course of antibiotics may be required. If the newly implanted graft appears to have been contaminated at the anastomotic site or the if the arterial stump was closed proximal to the infected site, the clinician may need to consider lengthy, perhaps lifelong, suppressive regimens of oral antibiotics. Generally, surgical management includes excision of the affected graft followed by revascularization (25). An extra-anatomic bypass (EAB) such as an axillary-femoral artery conduit is often employed. Occasionally, in situ replacement of the infected graft is attempted. Mortality in the course of reconstructive efforts can be 25% or greater.

5.4. Prevention

For prevention of infection of a vascular graft, regimens similar to infective endocarditis prophylaxis could be considered. However, data are inadequate at this time to make firm recommendations. Nevertheless, clinicians may consider using prophylaxis especially during the first 4 mo postoperatively when the graft would be more susceptible to bacteremic seeding (24).

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