Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections
2020; Elsevier BV; Volume: 59; Issue: 3 Linguagem: Inglês
10.1016/j.ejvs.2019.10.016
ISSN1532-2165
AutoresNabil Chakfé, Holger Diener, Anne Lejay, Ojan Assadian, Xavier Bérard, J. Caillon, Inge Fourneau, Andor W. J. M. Glaudemans, Igor Končar, Jes S. Lindholt, Germano Melissano, Ben R. Saleem, É. Senneville, Riemer H. J. A. Slart, Zoltán Szeberin, Maarit Venermo, Frank Vermassen, Thomas R. Wyss, ESVS Guidelines Committee, Gert J. de Borst, Frederico Bastos Gonçalves, Stavros Kakkos, Philippe Kolh, Riikka Tulamo, Melina Vega de Céniga, Document Reviewers, Regula S. von Allmen, Jos C. van den Berg, E. Sebastian Debus, Mark J.W. Koelemay, J.P. Linares Palomino, Gregory L. Moneta, Jean‐Baptiste Ricco, Anders Wanhainen,
Tópico(s)Aortic aneurysm repair treatments
ResumoAortobronchial fistula Aorto-oesophageal fistula Aorto-enteric fistula Aortopulmonary fistula Arterio-ureteral fistula Centers for Disease Control and Prevention Confidence interval Coagulase negative staphylococci C reactive protein Computed tomography Computed tomography angiography European Association of Nuclear Medicine Extra-anatomic reconstruction Endograft Endograft infection Expanded polytetrafluoroethylene European Society of Cardiology European Society for Vascular Surgery Endovascular aneurysm repair European Registry of Endovascular Aortic Complications 18F-fluoro-D-deoxyglucose positron emission tomography/computed tomography Guidelines Committee Gracilis muscle flap Great saphenous vein In situ reconstruction Lateral approach to crural arteries Left common carotid artery Left subclavian artery Lateral retrosartorius bypass Management of Aortic Graft Infection Multidrug resistant Magnetic resonance angiography Methicillin resistant Staphylococcus aureus Negative pressure wound therapy Odds ratio Obturator bypass Polymerase chain reaction Polyethylene terephthalate Perigeniculate artery Polytetrafluoroethylene Rectus abdominis flap Randomised controlled trial Rectus femoris flap Relative risk Supra-aortic trunk Superficial femoral artery Sartorius muscle flap Single photon emission computed tomography Surgical site infection Maximum standardised uptake value Thoracic endovascular aneurysm repair Ultrasound Vacuum assisted closure Vascular graft Vascular graft infection Vascular graft or endograft infection White blood cell scintigraphy Writing Committee After studying medicine at Hanover Medical School and philosophy and social psychology at the Leibniz University Hanover, Omke E. Teebken joined the Christian Albrechts University in Kiel at the end of the 1990s as a research fellow at the Clinic for Cardiovascular Surgery headed by Professor Dr Axel Haverich, whom Omke E. Teebken later followed back to Hanover. In Hanover, besides working as a clinician, Omke E.Teebken was particularly active scientifically, contributing to the establishment of the then newly founded Leibniz Laboratories for Biotechnology and Artificial Organs (LEBAO). His work focused on regenerative medicine and tissue engineering, and subsequently he wrote his habilitation thesis in in this field. After basic training in cardiac surgery, he specialised clinically in vascular surgery and played a pioneering role in the development of this field. Before being appointed director of the Clinic for Vascular Surgery – Endovascular Surgery at the Peine Clinic in 2016, Omke E. Teebken headed the Vascular Surgery – Endovascular Surgery Division of the Department of Cardiothoracic, Thoracic, Transplantation and Vascular Surgery at Hanover Medical School. Professor Teebken was a highly appreciated, committed, and competent colleague and teacher. On 8 April 2019, Professor Teebken passed away after a short and severe illness. He was member and author of the ESVS guideline writing committee, an esteemed colleague, and friend. We will always honor his memory. Prof. Dr. med. Omke Enno Teebken 21.8.1968 – 8.4.2019 Guidelines driven by scientific societies on vascular graft/endograft infection (VGEI) have not been published. The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with VGEI. The aim of this document is to assist physicians involved in the diagnosis and treatment of patients with VGEI in selecting the best management strategy in different scenarios. The potential users of this guideline include angiologists, vascular, cardiovascular and general surgeons, infectious disease physicians, and radiologists, and the target population comprises patients with VGEI in the supra-aortic trunks, thoracic and/or abdominal aorta, and peripheral arteries. Guidelines have the purpose of promoting a standard of care according to specialists in the field, in this case represented by members of the ESVS. However, under no circumstances should these guidelines be seen as the legal standard of care in all patients. As the word guidelines states in itself, the document is a guiding principle, but the care given to a single patient is always dependent on the individual (symptom variability, comorbidities, age, etc.) and treatment setting (techniques available, local expertise). The members of this guidelines Writing Committee (WC) were selected by the ESVS, the European Association of Nuclear Medicine (EANM), and the Groupe de Recherche sur les Infections de Prothèses, to represent physicians involved in the management of patients with VGEI. They include vascular surgeons, radiologists, and infectious disease specialists. WC members have provided disclosure statements of all relationships that might be perceived as real or potential sources of conflicts of interest, which are kept on file at the ESVS headquarters. No ESVS reviewers or individual WC members received any financial support from third parties in direct or indirect relation to this guideline, and all WC members and reviewers signed declarations of interest. The purpose, list of topics, and tasks and methods regarding the construction of the guidelines were agreed and distributed among the WC members in an initial meeting held in Strasbourg on 30 June 2017. All WC members performed a systematic literature search strategy for each of their assigned sections, carried out in PubMed, Scopus, Cardiosource Clinical Trials Database, and the Cochrane Library databases, first from January 1997 to November 2017, with a later update to February 2019 for relevant papers published in English. Reference checking and a hand search added other relevant literature. Abstracts were excluded. Single case reports or case series were included if they were of paramount importance to these guidelines to enlighten the manuscript. Selection of the literature was performed based on information provided in the title and abstract of the retrieved studies. Only peer reviewed published literature and studies presenting pre-defined outcomes were considered. The selection process followed the pyramid of evidence, with aggregated evidence at the top of the pyramid (systematic reviews, meta-analysis), followed by randomised controlled trials (RCTs), then observational studies, leaving expert opinion at the bottom. The level of evidence per section in the guidelines is dependent on the level of evidence available on the specific subject. To define the current guidelines, members of the WC reviewed and summarised the selected literature. Conclusions were drawn based on the availability and quality of the scientific evidence, and recommendations for the evaluation and treatment of patients with VGEI were formulated based on the analysis of the evidence and through consensus when evidence was scarce. The European Society of Cardiology (ESC) grading system was used for evidence and recommendation rating. The letter A, B, or C reflects the level of current evidence (Table 1), and weighing the level of evidence and expert opinion, each recommendation is graded as class I, IIa, IIb, or III (Table 2). For those recommendations tables of evidence were built and are available as supplementary material. The goals behind patient participation in healthcare decision making can be categorised as democratisation and increased quality of decisions. Patient engagement improves the validity of clinical guidelines and is encouraged by international and national groups. In order to better understand patient feedback, European patients were interviewed: representatives of patient associations in the field of aortic dissection and infectious diseases; and patients treated for abdominal VGEI (patients operated on by surgeons of the WC). The main questions that arose from discussions were: (1) Did you feel your physician provided enough information about the risk of infection at the time of the initial procedure? (2) What did you think about the management once the diagnosis of VGEI was made? and (3) Did you think that your physician provided enough information on the risks related to VGEI? Patients were interviewed with a focus on these three open questions. The guidelines document, merged and harmonised by the co-chairmen of the WC, underwent internal review. Once approved by every WC member, it moved on to external revision by the ESVS Guidelines Committee (GC) members and chosen external experts in the field. Each draft was revised by the WC and the final document, approved by all WC and GC members and external reviewers, was submitted to the European Journal of Vascular and Endovascular Surgery on 20 July 2019. As technology and disease knowledge in this field changes rapidly, current recommendations can become outdated. It is an aim of the ESVS to revise the guidelines when important new insights in the evaluation and management of VGEI become available or every five years at the latest. Studies dealing with VGEI are mostly case series rather than randomised studies. Diagnosis of VGEI is usually related to clinical findings, imaging studies, and microbiological examinations.1Lyons O.T. Baguneid M. Barwick T.D. Bell R.E. Foster N. Homer-Vanniasinkam S. et al.Diagnosis of aortic graft infection: a case definition by the management of aortic graft infection collaboration (MAGIC).Eur J Vasc Endovasc Surg. 2016; 52: 758-763Abstract Full Text Full Text PDF PubMed Google Scholar Criteria for incisional surgical site infections (SSI), which can be both superficial and deep, have been described by the Centers for Disease Control and Prevention (CDC) and can be applied to the description of VGEI (Table 3).2Horan T.C. Andrus M. Dudeck M.A. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting.Am J Infect Control. 2008; 36: 309-332Abstract Full Text Full Text PDF PubMed Scopus (3413) Google ScholarTable 3Centers for Disease Control and Prevention criteria for superficial and deep surgical site infections (SSI)2Horan T.C. Andrus M. Dudeck M.A. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting.Am J Infect Control. 2008; 36: 309-332Abstract Full Text Full Text PDF PubMed Scopus (3413) Google ScholarCriteriaSuperficial SSIDeep SSIDiagnostic criteria∗For diagnosis of SSI, diagnostic criteria 1, 2, and 3 must all be true.1Infection occurs within 30 days after the operative procedureInfection occurs within 30 days after the operative procedure if no implant is left in place, or within one year if implant is in place and the infection appears to be related to the operative procedureand 2Infection involves only skin and subcutaneous tissue of the incisionInfection involves deep soft tissues (e.g., fascia and muscle layers) of the incisionand 3Patient has at least one of the following:Patient has at least one of the following:•Purulent drainage from the superficial incision•Purulent drainage from the deep incision but not from the organ/space component of the surgical site•Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision•A deep incision spontaneously dehisces or is deliberately opened by a surgeon and is culture positive or not cultured when the patient has at least one of the following signs or symptoms: fever (>38°C), or localised pain or tenderness. A culture negative finding does not meet this criterion•At least one of the following signs or symptoms of infection: pain or tenderness, localised swelling, redness or heat, and superficial incision is deliberately opened by surgeon and is culture positive or not cultured. A culture negative finding does not meet this criterion•An abscess or other evidence of infection involving the deep incision is found on direct examination, during re-operation, or by histopathological or radiological examination•Diagnosis of superficial incisional SSI by a surgeon or attending physician•Diagnosis of a deep incisional SSI by a surgeon or attending physicianTypes Incisional primaryA superficial incisional SSI that is identified in the primary incision in a patient who has had an operation with one or more incisionsA deep incisional SSI that is identified in a primary incision in a patient who has had an operation with one or more incisions Incisional secondaryA superficial incisional SSI that is identified in the secondary incision in a patient who has had an operation with >1 incision (e.g., donor site [leg] incision to harvest autologous veins for in situ reconstruction of an abdominal vascular graft infection)A deep incisional SSI that is identified in the secondary incision in a patient who has had an operation with >1 incision (e.g., donor site [leg] incision to harvest autologous veins for in situ reconstruction of an abdominal vascular graft infection)Reporting instructionsDo not report a skin suture abscess with minimal inflammation and discharge confined to the points of suture penetration, as an infectionClassify infection that involves both superficial and deep incision sites as deep incisional SSIDo not report a localised stab wound infection as SSI; instead, report as skin or soft tissue infection, depending on its depthIf the incisional site infection involves or extends into the fascial and muscle layers, report as a deep incisional SSI∗ For diagnosis of SSI, diagnostic criteria 1, 2, and 3 must all be true. Open table in a new tab While the CDC definitions2Horan T.C. Andrus M. Dudeck M.A. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting.Am J Infect Control. 2008; 36: 309-332Abstract Full Text Full Text PDF PubMed Scopus (3413) Google Scholar differentiate between superficial and deep incisional SSIs without placing emphasis on vascular grafts (VGs), the Szilagyi classification and the Samson classification specifically also consider VG involvement, while the extent of graft involvement can be described using the Bunt classification (Table 4).3Szilagyi D.E. Smith R.F. Elliott J.P. Vrandecic M.P. Infection in arterial reconstruction with synthetic grafts.Ann Surg. 1972; 176: 321-333Crossref PubMed Google Scholar, 4Bunt T.J. Synthetic vascular graft infections. Graft infections.Surgery. 1983; 93: 733-746PubMed Google Scholar, 5Samson R.H. Veith F.J. Janko G.S. Gupta S.K. Scher L.A. A modified classification and approach to the management of infections involving peripheral arterial prosthetic grafts.J Vasc Surg. 1988; 8: 147-153Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Furthermore, aortic VGEI can also be divided into early (< 4 months) or late (> 4 months) onset, which, in many cases, is also extrapolated to other VGEl.6Back M.R. Local complications: graft infection.in: Cronenwett J.L. Johnston K.W. Rutherford’s vascular surgery. 2014: 654-662Google Scholar However, the clinical relevance of differentiation between early and late infections remains a matter of debate.Table 4Classifications for wound and vascular graft infections with respect to wound infection (Szilagyi, Samson) and to the extent of graft involvement (Bunt)3Szilagyi D.E. Smith R.F. Elliott J.P. Vrandecic M.P. Infection in arterial reconstruction with synthetic grafts.Ann Surg. 1972; 176: 321-333Crossref PubMed Google Scholar, 4Bunt T.J. Synthetic vascular graft infections. Graft infections.Surgery. 1983; 93: 733-746PubMed Google Scholar, 5Samson R.H. Veith F.J. Janko G.S. Gupta S.K. Scher L.A. A modified classification and approach to the management of infections involving peripheral arterial prosthetic grafts.J Vasc Surg. 1988; 8: 147-153Abstract Full Text Full Text PDF PubMed Scopus (0) Google ScholarSzilagyi classification: Grade I: cellulitis involving the wound Grade II: infection involving subcutaneous tissue Grade III: infection involving the vascular prosthesisSamson classification: Group 1: no deeper than dermis Group 2: subcutaneous tissue, no direct contact with the graft Group 3: body of graft but not anastomosis Group 4: exposed anastomosis, no bleeding, no bacteraemia Group 5: anastomosis involved, bleeding, bacteraemiaExtent of graft involvement (Bunt classification modified) Peripheral graft infection:P0 graft infection: infection of a cavitary graft (e.g., aortic arch; abdominal and thoracic aortic interposition; aorto-iliac, aortofemoral, iliofemoral graft infections)P1 graft infection: infection of a graft whose entire anatomical course is non-cavitary (e.g., carotid–subclavian, axillo-axillary, axillofemoral, femorofemoral, femorodistal, dialysis access bridge graft infections)P2 graft infection: infection of the extracavitary portion of a graft whose origin is cavitary (e.g., infected groin segment of an aortofemoral or thoracofemoral graft, cervical infection of an aortocarotid graft)P3 graft infection: infection involving a prosthetic patch angioplasty (e.g., carotid and femoral endarterectomies with prosthetic patch closure) Graft-enteric erosion Graft-enteric fistula Aortic stump sepsis after excision of an infected aortic graft Open table in a new tab To overcome the numerous shortcomings of current classifications, the Management of Aortic Graft Infection (MAGIC) group has developed a list of major and minor criteria with respect to clinical, surgical, radiological, and laboratory findings (Table 5).1Lyons O.T. Baguneid M. Barwick T.D. Bell R.E. Foster N. Homer-Vanniasinkam S. et al.Diagnosis of aortic graft infection: a case definition by the management of aortic graft infection collaboration (MAGIC).Eur J Vasc Endovasc Surg. 2016; 52: 758-763Abstract Full Text Full Text PDF PubMed Google Scholar Once VGEI is suspected, an exhaustive evaluation of the clinical status, signs of infection, and comorbidities of the patient according to the MAGIC criteria is recommended.Table 5The MAGIC classification1Lyons O.T. Baguneid M. Barwick T.D. Bell R.E. Foster N. Homer-Vanniasinkam S. et al.Diagnosis of aortic graft infection: a case definition by the management of aortic graft infection collaboration (MAGIC).Eur J Vasc Endovasc Surg. 2016; 52: 758-763Abstract Full Text Full Text PDF PubMed Google ScholarCriterionClinical/surgicalRadiologyLaboratoryMajorPus (confirmed by microscopy) around graft or in aneurysm sac at surgeryPerigraft fluid on CT scan ≥ 3 months after insertionOrganisms recovered from an explanted graftOpen wound with exposed graft or communicating sinusPerigraft gas on CT scan ≥ 7 weeks after insertionOrganisms recovered from an intra-operative specimenFistula development, e.g., aorto-enteric or aortobronchialIncrease in perigraft gas volume demonstrated on serial imagingOrganisms recovered from a percutaneous, radiologically guided aspirate of perigraft fluidGraft insertion in an infected site, e.g., fistula, mycotic aneurysm, or infected pseudo-aneurysmMinorLocalised clinical features of graft infection, e.g., erythema, warmth, swelling, purulent discharge, painOther, e.g., suspicious perigraft gas/fluid soft tissue inflammation; aneurysm expansion; pseudo-aneurysm formation: focal bowel wall thickening; discitis/osteomyelitis; suspicious metabolic activity on FDG-PET/CT; radiolabelled leukocyte uptakeBlood culture(s) positive and no apparent source except graft infectionFever ≥38°C with graft infection as most likely causeAbnormally elevated inflammatory markers with graft infection as most likely cause, e.g., erythrocyte sedimentation rate, C reactive protein, white cell countCT = computed tomography; FDG-PET/CT = 18F-fluoro-D-deoxyglucose positron emission tomography/computed tomography Open table in a new tab CT = computed tomography; FDG-PET/CT = 18F-fluoro-D-deoxyglucose positron emission tomography/computed tomography According to the MAGIC criteria, VGEI is suspected in the presence of one major or two minor criteria of the three different categories, and VGEI is diagnosed when there is at least a single major criterion and any other criterion from another category. For example, a fever ≥ 38°C is considered non-specific for VGEI and therefore it is required that no other clinical cause is apparent. Sepsis and systemic inflammatory response syndrome may be caused by something other than VGEI and is defined as combinations of different findings. Anorexia, lethargy, and malaise may accompany aortic graft and endograft (EG) infection, but are also considered insufficiently specific.1Lyons O.T. Baguneid M. Barwick T.D. Bell R.E. Foster N. Homer-Vanniasinkam S. et al.Diagnosis of aortic graft infection: a case definition by the management of aortic graft infection collaboration (MAGIC).Eur J Vasc Endovasc Surg. 2016; 52: 758-763Abstract Full Text Full Text PDF PubMed Google Scholar Intra-operative fluids around a graft can represent pus, but despite a yellowish or cloudy appearance may be present for non-infective reasons and microbiological culture will be negative. Therefore, pus cells must be proven by direct microscopy to be considered a major criterion. Furthermore, a direct communication between non-sterile sites and a prosthesis indicates graft infection: aorto-enteric fistula (AEnF), aorto-bronchial fistula (ABF), deployment of a stent graft in an already infected field (e.g., infected aneurysm), and exposed grafts in deep open wounds. VGEI are usually multifactorial and result from the complex involvement of patient, surgical, and environmental factors, making the real incidence difficult to assess. Reported incidences of VGEI by type and anatomical location will be developed in specific sections. Multiple risk factors contribute to VGEI and are listed in Table 6. The pathogenesis of VGEI is multifactorial. Presumably, early VGEI are mostly caused by a breach in sterility during implantation or the presence of bacteria in the aneurysmal thrombus, while late VGEI are mostly caused by haematogenous seeding from a bacteraemia (mostly arising from the urinary or respiratory tract), or from bacterial translocation or iatrogenic contamination during catheterisation.6Back M.R. Local complications: graft infection.in: Cronenwett J.L. Johnston K.W. Rutherford’s vascular surgery. 2014: 654-662Google Scholar, 7Tatterson M.R. Homer-Vanniaskinkam S. Infections in vascular surgery.Injury. 2011; 42: 35-41Abstract Full Text PDF Scopus (14) Google Scholar, 8Laohapensang K. Arworn S. Orrapin S. Reanpang T. Orrapin S. Management of the infected aortic endograft.Semin Vasc Surg. 2017; 30: 91-94Crossref PubMed Scopus (8) Google Scholar The pathogenesis of AEnF, aorto-oesophageal (AEsF), and ABF remains unclear. Ischaemia of the visceral wall due to occlusion of the feeding arteries, and mechanical erosion by the aneurysm or of a suture line pseudo-aneurysm, especially when still under pressure due to presence of an endoleak, have all been suggested. Fistula can occur as a result of direct trauma related to surgical injury, poor tunnelling, erosion by direct contact, or by the penetration of an oversised EG. Previous adjacent or remote infection in any site is considered to be a causative or contributing factor.9Hance K.A. Hsu J. Eskew T. Hermreck A.S. Secondary aortoesophageal fistula after endoluminal exclusion because of thoracic aortic transection.J Vasc Surg. 2003; 37: 886-888Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar,10Porcu P. Chavanon O. Sessa C. Thony F. Aubert A. Blin D. Esophageal fistula after endovascular treatment in a type B aortic dissection of the descending thoracic aorta.J Vasc Surg. 2005; 41: 708-711Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar The quality of material incorporation related to tissue ingrowth and healing also plays a role, explaining that VEGI might even be more frequent than VG infection (VGI), as there is no tissue ingrowth in the wall of the EG fabric that is surrounded only by thrombotic material, contrary to VG.11Lejay A. Georg Y. Dieval F. Heim F. Tartaglia E. thaveau F. et al.Properties and challenges in materials used as vascular and endovascular devices.J Cardiovasc Surg. 2013; 54: 167-182PubMed Google Scholar As mentioned in the MAGIC criteria, the clinical presentation of patients with VGEI varies between mild symptoms (redness of the skin, non-purulent effusion from a wound) to severe and evident symtoms such as sepsis or anastomotic rupture with hypovolaemic shock.1Lyons O.T. Baguneid M. Barwick T.D. Bell R.E. Foster N. Homer-Vanniasinkam S. et al.Diagnosis of aortic graft infection: a case definition by the management of aortic graft infection collaboration (MAGIC).Eur J Vasc Endovasc Surg. 2016; 52: 758-763Abstract Full Text Full Text PDF PubMed Google Scholar Fever of unclear origin and an unexplained leukocytosis with concomitant increase of C reactive protein (CRP) and fever may be the only clinical or laboratory sign of VGEI. In other cases the clinical manifestations may include abscess, mass, septic embolisation, septic shock, bleeding, melaena, haematemesis, haematuria, ileus, or abdominal distension. When VGEI is suspected, a complete clinical and biochemical evaluation of the patient is required in order to provide a sufficient analytical overview.12Teebken O.E. Bisdas T. Assadian O. Ricco J.B. Recommendations for reporting treatment of aortic graft infections.Eur J Vasc Endovasc Surg. 2012; 43: 174-181Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Post-implantation syndrome, characterised by transitory fever associated with elevated leukocytes and CRP may be observed following endograft implantation, but might also be distinguishing from an actual infection.13Corfield L. Chan J. Chance T. Wilson N. Early pyrexia after endovascular aneurysm repair: are cultures needed?.Ann R Coll Surg Engl. 2011; 93: 111-113Crossref PubMed Scopus (0) Google Scholar Micro-organism identification is a key issue in order to provide the patient with the best treatment. Using the different available sampling techniques, micro-organisms can be isolated in about 75% – 98% of cases.14Legout L. D’Elia P.V. Sarraz-Bournet B. Haulon S. Meybeck A. Senneville E. et al.Diagnosis and management of prosthetic vascular graft infections.Med Mal Infect. 2012; 42: 102-109Crossref PubMed Scopus (42) Google Scholar, 15Erb S. Sidler J.A. Elzi L. Gurke L. Battegay M. Widmer A.F. et al.Surgical and antimicrobial treatment of prosthetic vascular graft infections at different surgical sites: a retrospective study of treatment outcomes.PLoS One. 2014; 9e112947Crossref PubMed Scopus (33) Google Scholar, 16Antonios V.S. Noel A.A. Steckelberg J.M. Wilson W.R. Mandrekar J.N. Harmsen W.S. et al.Prosthetic vascular graft infection: a risk factor analysis using a case-control study.J Infect. 2006; 53: 49-55Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar Responsible pathogens are Gram positive bacteria in up to 58% of VGEI (including enterococci, Staphylococcus aureus, and coagulase negative staphylococci); Gram negative bacteria account for about 34% of VGEIs and and anaerobes 8%.14Legout L. D’Elia P.V. Sarraz-Bournet B. Haulon S. Meybeck A. Senneville E. et al.Diagnosis and management of prosthetic vascular graft infections.Med Mal Infect. 2012; 42: 102-109Crossref PubMed Scopus (42) Google Scholar, 15Erb S. Sidler J.A. Elzi L. Gurke L. Battegay M. Widmer A.F. et al.Surgical and antimicrobial treatment of prosthetic vascular graft infections at different surgical sites: a retrospective study of treatment outcomes.PLoS One. 2014; 9e112947Crossref PubMed Scopus (33) Google Scholar, 16Antonios V.S. Noel A.A. Steckelberg J.M. Wilson W.R. Mandrekar J.N. Harmsen W.S. et al.Prosthetic vascular graft infection: a risk factor analysis using a case-control study.J Infect. 2006; 53: 49-55Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 17Batt M. Feugier P. Camou F. Coffy A. Senneville E. Caillon J. et al.A meta-analysis of outcomes after in situ reconstructions for aortic graft infection.Angiology. 2018; 69: 370-379Crossref PubMed Scopus (3) Google Scholar In a recent meta-analysis, the risk of re-infection has been studied according to different infecting micro-organisms.17Batt M. Feugier P. Camou F. Coffy A. Senneville E. Caillon J. et al.A meta-analysis of outcomes after in situ reconstructions for aortic graft infection.Angiology. 2018; 69: 370-379Crossref PubMed Scopus (3) Google Scholar Staphylococcus aureus, Enterobacteriaceae, Pseudomonas aeruginosa, and beta haemolytic streptococci were classified as virulent, while bacteria belonging to the skin colonising flora such as Staphylococcus epidermidis, corynebacterial, and Cutibacterium acnes were classified as non-virulent agents. The results of this meta-analysis established that virulent organisms were significantly associated with an increased risk of re-infection. Antimicrobial resistance of the causative bacteria is another factor that may reduce the chance of healing, but this relationship has not been clearly established in the setting of VGEIs.14Legout L. D’Elia P.V. Sarraz-Bournet B. Haulon S. Meybeck A. Senneville E. et al.Diagnosis and management of prosthetic vascular graft infections.Med Mal Infect. 2012; 42: 102-109Crossref PubMed Scopus (42) Google Scholar The susceptibility of bacteria to the few antibiotics that exhibit a sustained activity in the environment of a biofilm (e.g., rifampicin combinations for staphylococcal implant infections) is another element that may lead to re-infection in patients treated for VGEIs.18Zimmerli W. Widmer A.F. Blatter M. Frei R. Ochsner P.E. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. F
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