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Puges M, Caradu C, Svahn I, Gontier E, Mzali F, Vignals C, Cazanave C, Bérard X. An ex vivo study of infections of vascular grafts and endografts with scanning electron microscopy. J Vasc Surg 2024; 80:554-563.e4. [PMID: 38608967 DOI: 10.1016/j.jvs.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/19/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Vascular graft and endograft infections (VGEIs) are complicated by high morbidity, mortality, and recurrence rates, notably due to biofilm formation on the graft surface, hardly dislodgeable by the sole anti-infectious treatment. The characteristics of this biofilm are still poorly documented. The aim of this study was to evaluate ex vivo biofilm on removed infected vascular grafts and endografts (VGEs). METHODS Explanted VGEs were prospectively collected from 2019 to 2022 at Bordeaux University Hospital, France. Two samples per graft were used for scanning electron microscopy imaging; one was sonicated, and both grafts' sides were imaged. RESULTS A total of 26 patients were included, 18 with VGEI, eight without any infection (endoleak and/or thrombosis), and 29 VGEs were collected. Microbial documentation was obtained in 83% of VGEIs. A thick layer of fibrin was visible on almost all grafts, mixed with a dense biofilm matrix on infected grafts visible as early as 1 month after the onset of infection. Bacteria were not always visualized on infected grafts' surface (80% on outer side and 85% on luminal side) but were surprisingly present on one-third of non-infected grafts. There was no significant difference between biofilm, fibrin, and microorganisms' distribution between the two grafts' sides. However, there were clear differences between infected and non-infected grafts, since immune cells, bacteria and biofilm were more frequently visualized on both sides of infected grafts (P < .05). Bacteria and immune cells although still visible, were significantly less present after sonication; the number of other elements including biofilm was not significantly different. CONCLUSIONS The persistence of a thick layer of fibrin and biofilm embedding microorganisms on both sides of infected VGE even after 1 month of infection could be the explanation for the low success rates of conservative management and the usual need for graft removal to treat VGEIs.
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Affiliation(s)
- Mathilde Puges
- Infectious and Tropical Diseases Department, CHU de Bordeaux, Bordeaux, France; University of Bordeaux, UMR 5234 CNRS, ARMYNE, Bordeaux, France.
| | - Caroline Caradu
- Department of Vascular Surgery, CHU de Bordeaux, Bordeaux, France
| | - Isabelle Svahn
- Bordeaux Imaging Center, CNRS, INSERM, University of Bordeaux, Bordeaux, France
| | - Etienne Gontier
- Bordeaux Imaging Center, CNRS, INSERM, University of Bordeaux, Bordeaux, France
| | - Fatima Mzali
- Aquitaine Microbiologie, University of Bordeaux, Bordeaux, France
| | - Carole Vignals
- Infectious and Tropical Diseases Department, CHU de Bordeaux, Bordeaux, France
| | - Charles Cazanave
- Infectious and Tropical Diseases Department, CHU de Bordeaux, Bordeaux, France; University of Bordeaux, UMR 5234 CNRS, ARMYNE, Bordeaux, France
| | - Xavier Bérard
- Department of Vascular Surgery, CHU de Bordeaux, Bordeaux, France
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Azad MA, Patel R. Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections. Clin Microbiol Rev 2024; 37:e0010423. [PMID: 38506553 PMCID: PMC11237642 DOI: 10.1128/cmr.00104-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.
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Affiliation(s)
- Marisa Ann Azad
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robin Patel
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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3
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Puges M, Carrer M, Caradu C, Bérard X, Cazanave C. Sonicate Fluid Inoculation Into Blood Culture Bottles for Vascular Graft and Endograft Infection Microbiological Diagnosis. Eur J Vasc Endovasc Surg 2024; 67:518-519. [PMID: 37923190 DOI: 10.1016/j.ejvs.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/28/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Mathilde Puges
- CHU de Bordeaux, Infection and Tropical Diseases Department, Bordeaux, France; Univ. Bordeaux, UMR 5234 CNRS, ARMYNE, Bordeaux, France.
| | - Mathilde Carrer
- CHU de Bordeaux, Infection and Tropical Diseases Department, Bordeaux, France
| | - Caroline Caradu
- CHU de Bordeaux, Vascular Surgery Department, Bordeaux, France
| | - Xavier Bérard
- CHU de Bordeaux, Vascular Surgery Department, Bordeaux, France. https://twitter.com/XavierBerardMD
| | - Charles Cazanave
- CHU de Bordeaux, Infection and Tropical Diseases Department, Bordeaux, France; Univ. Bordeaux, UMR 5234 CNRS, ARMYNE, Bordeaux, France. https://twitter.com/charles_cazanav
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Mitsuishi A, Miura Y, Arakawa Y, Noguchi T. Distinguishing sterile inflammation from graft infection. J Cardiothorac Surg 2024; 19:22. [PMID: 38263206 PMCID: PMC10804788 DOI: 10.1186/s13019-024-02504-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 01/14/2024] [Indexed: 01/25/2024] Open
Abstract
We describe the case of a 68-year-old man who underwent ascending aortic replacement and thoracic endovascular aortic repair. Four years later, the patient developed neck pain on the right side and chest computed tomography showed expansion of fluid in the mediastinum which had extended to the neck. Echocardiography revealed advanced severity of aortic regurgitation and decreased ejection fraction. Given the progression of aortic regurgitation, decreased cardiac function, and rapidly expanding fluid accumulation causing neck pain, reoperation was indicated. All microbiological test including polymerase chain reaction were negative indicating absence of any infection. The patient is being followed-up without antibiotics and CT has not shown peri-graft fluid 2 years postoperatively. Since infection cannot be excluded completely, it is important to assess the condition with selective medium, extended culture periods, genetic testing, and consultations with microbiology laboratories when normal culture tests for general bacteria, and fungi are negative which can help avoid drug-resistant bacteria count, elevated medical costs, and drug side effects due to the improper use of antibiotics through proper diagnosis.
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Affiliation(s)
- Atsuyuki Mitsuishi
- Department of Cardiovascular Surgery, School of Medicine, Kochi University, 185-1, Kohasu, Nankoku-shi, Okohmachi, Kochi Prefecture, 783-8505, Japan.
| | - Yujiro Miura
- Department of Cardiovascular Surgery, Kochi Medical School, 185-1, Kohasu, Nankoku-shi, Okohcho, Kochi Prefecture, 783-8505, Japan
| | - Yu Arakawa
- Department of Clinical Infectious Diseases, Kochi Medical School, 185-1, Kohasu, Nankoku-shi, Okohcho, Kochi Prefecture, 783-8505, Japan
| | - Tatsuya Noguchi
- Department of Cardiology and Geriatrics, Kochi Medical School Hospital, 185-1, Kohasu, Nankoku-shi, Okohcho, Kochi Prefecture, 783-8505, Japan
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5
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Del Fabro G, Volpi S, Fumarola B, Migliorati M, Bertelli D, Signorini L, Matteelli A, Meschiari M. Actinomyces spp. Prosthetic Vascular Graft Infection (PVGI): A Multicenter Case-Series and Narrative Review of the Literature. Microorganisms 2023; 11:2931. [PMID: 38138076 PMCID: PMC10745418 DOI: 10.3390/microorganisms11122931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/26/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Actinomycosis represents a challenging and under-reported complication of vascular surgery. Optimal management of Actinomyces spp. prosthetic vascular graft infection (PVGI) is highly uncertain because of the paucity of reports on this disease. METHODS We conducted a retrospective case-series of Actinomyces-PVGI that occurred in the last five years in two major university hospitals in northern Italy. We searched for previously published cases in the scientific literature. RESULTS We report five original cases of Actinomyces spp. prosthetic vascular graft infection following aortic aneurysm repair. Our literature review retrieved eight similar cases. Most patients were immunocompetent males. Most infections were polymicrobial (11/13 cases), with a prevalence of A. odontolyticus involvement (3/13 cases were associated with. Salmonella spp. infection). All cases had a late presentation (≥4 months from graft placement), with 61% associated with an aorto-enteric fistula. All patients received antibiotic therapy, but the duration was highly heterogeneous (from two weeks to life-long antibiotics). The patients without surgical revision experienced septic recurrences (2/13), permanent dysfunction (1/13), or a fatal outcome (2/13), while of the remainder who underwent vascular graft explant, six recovered completely and one developed a periprosthetic abscess. In two cases follow-up was not available. CONCLUSIONS This case-series aims to raise the diagnostic suspicion and to describe the current management of Actinomyces-PVGIs. We highlight a high heterogeneity in antibiotic duration, choice of the antibiotic regimen, and surgical management. Higher reporting rate is advisable to produce better evidence and optimize management of this rare complication of vascular surgery.
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Affiliation(s)
- Giovanni Del Fabro
- Department of Infectious Diseases, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Sara Volpi
- Clinic of Infectious Diseases, University Hospital of Modena, 41124 Modena, Italy
| | - Benedetta Fumarola
- Department of Infectious Diseases, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Manuela Migliorati
- Department of Infectious Diseases, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Davide Bertelli
- Department of Infectious Diseases, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Liana Signorini
- Department of Infectious Diseases, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Alberto Matteelli
- Department of Infectious Diseases, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Marianna Meschiari
- Clinic of Infectious Diseases, University Hospital of Modena, 41124 Modena, Italy
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Puges M, Bérard X, Vilain S, Pereyre S, Svahn I, Caradu C, Mzali F, Cazanave C. Staphylococcus aureus Adhesion and Biofilm Formation on Vascular Polyester Grafts are Inhibited In Vitro by Triclosan. Eur J Vasc Endovasc Surg 2023; 66:577-586. [PMID: 37482281 DOI: 10.1016/j.ejvs.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/22/2023] [Accepted: 07/17/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE This study evaluated Staphylococcus aureus adhesion and biofilm formation on vascular grafts, which has seldom been investigated. METHODS Adhesion and biofilm formation capabilities of three methicillin susceptible S. aureus strains (one biofilm forming reference strain and two clinical isolates) on five different vascular biomaterials were evaluated in vitro, including polyester (P), P + gelatin (PG), P + collagen (PC), PC + silver (PCS), and PCS + triclosan (PCST). Staphylococcus aureus adhesion on grafts was evaluated after one hour of culture and biofilm formation after 24 hours of culture by four different methods: spectrophotometry after crystal violet staining; sonicate fluid culture; metabolic assay; and scanning electron microscopy (SEM). Optical density was compared using Mann-Whitney pairwise test, and bacterial counts using Wilcoxon pairwise test. RESULTS PCST grafts were most efficient in preventing S. aureus adhesion and biofilm formation, regardless of the method used. Bacterial counts and metabolic activity were significantly lower on PCST grafts after 24 hours (5.65 vs. 9.24 [PCS], 8.99 [PC], 8.82 [PG], and 10.44 log10 CFU/mL [P]; p < .015), and only PCST grafts were bactericidal. Biofilm formation was significantly diminished on PCST grafts compared with all other grafts (p < .001). Bacterial viability and metabolic activity after 24 hours were more impaired on PG compared with PC graft, and were surprisingly higher on PCS compared with PC grafts. Biofilm biomass formed after exposure to P, PG, PC, and PCS grafts was also reduced after 24 hours of incubation with PCST grafts (p < .001). After 24 hours, few bacteria were visible by SEM on PCST grafts, whereas bacterial biofilm colonies were clearly identified on other graft surfaces. CONCLUSION Triclosan impregnated PCST grafts appeared to interfere with S. aureus adhesion from early stages of biofilm formation in vitro. Silver impregnation was not efficient in preventing biofilm formation, and collagen coating promoted S. aureus biofilm formation more than gelatin coating.
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Affiliation(s)
- Mathilde Puges
- Infectious and Tropical Diseases Department, CHU de Bordeaux, Bordeaux, France; Univ. Bordeaux, UMR 5234 CNRS, ARMYNE, Bordeaux, France.
| | - Xavier Bérard
- Vascular Surgery Department, CHU de Bordeaux, Bordeaux, France. https://twitter.com/Drake1128
| | - Sébastien Vilain
- Univ. Bordeaux, CNRS, Bordeaux INP, CBMN, UMR 5248, Pessac, France
| | - Sabine Pereyre
- Univ. Bordeaux, UMR 5234 CNRS, ARMYNE, Bordeaux, France; Bacteriology Department, CHU de Bordeaux, Bordeaux, France
| | - Isabelle Svahn
- Univ. Bordeaux, Bordeaux Imaging Centre, UAR 3420 CNRS US4 INSERM, Bordeaux, France
| | - Caroline Caradu
- Vascular Surgery Department, CHU de Bordeaux, Bordeaux, France
| | - Fatima Mzali
- Univ. Bordeaux, UMR 5234 CNRS, Aquitaine microbiologie, Bordeaux, France
| | - Charles Cazanave
- Infectious and Tropical Diseases Department, CHU de Bordeaux, Bordeaux, France; Univ. Bordeaux, UMR 5234 CNRS, ARMYNE, Bordeaux, France. https://twitter.com/Drake1128
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7
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Puges M, M'Zali F, Pereyre S, Bébéar C, Cazanave C, Bérard X. A Narrative Review of Experimental Assessment to Study Vascular Biomaterials Infections and Infectability. EJVES Vasc Forum 2023; 59:49-55. [PMID: 37408851 PMCID: PMC10319211 DOI: 10.1016/j.ejvsvf.2023.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 03/23/2023] [Accepted: 05/09/2023] [Indexed: 07/07/2023] Open
Abstract
Objective Many experimental studies have been conducted to evaluate vascular and endovascular graft infections (VGEIs) and infectability in order to elaborate strategies to prevent or to treat their occurrence. A systematic literature search was conducted to collect and summarise key features of infection and infectability assessment techniques in VGEI experimental models. Methods The literature search was conducted using the Medline and Cochrane databases, with no limit on the date of publication, until 10 August 2021. Ex vivo, in vitro, and in vivo animal studies on VGEIs, published in English or French, were selected. Cross references retrieved from selected articles on PubMed database were also included in the search. Data were collected on the techniques and the protocols performed for vascular graft infection and infectability assessment. Results A total of 243 studies were included in the review: 55 in vitro studies, 169 animal studies, 17 combining the two models, and two ex vivo studies. Many experimental techniques were performed, with a lot of protocol discrepancies. The main experiments conducted were bacterial culture, with (n = 82 studies) or without sonication (n = 120), histopathology (n = 69), scanning electron microscopy (n = 36), and graft diffusion tests (n = 28). These techniques were used to answer different research questions corresponding to different graft infection steps, such as microbial adhesion and/or viability, biofilm biomass or organisation, human cell reaction, or antimicrobial activity. Conclusion Many experimental tools are available to study VGEIs, but to improve their reproducibility and scientific reliability research protocols must be standardised and include sonication of grafts before microbiological culture. Moreover, the key role of the biofilm in VGEI physiopathology must be taken into account in future studies.
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Affiliation(s)
- Mathilde Puges
- Department of Infectious and Tropical Diseases, CHU de Bordeaux, Bordeaux, France
| | - Fatima M'Zali
- Aquitaine Microbiologie, UMR 5234 CNRS, University of Bordeaux, Bordeaux, France
| | - Sabine Pereyre
- Mycoplasma and Chlamydia Human Infections, University of Bordeaux, USC EA 3671, Bordeaux, France
- Department of Bacteriology, CHU de Bordeaux, Bordeaux, France
| | - Cécile Bébéar
- Mycoplasma and Chlamydia Human Infections, University of Bordeaux, USC EA 3671, Bordeaux, France
- Department of Bacteriology, CHU de Bordeaux, Bordeaux, France
| | - Charles Cazanave
- Department of Infectious and Tropical Diseases, CHU de Bordeaux, Bordeaux, France
- Mycoplasma and Chlamydia Human Infections, University of Bordeaux, USC EA 3671, Bordeaux, France
| | - Xavier Bérard
- Department of Vascular Surgery, CHU de Bordeaux, Bordeaux, France
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Kumins NH, Wogsland AA, Smith J, Patel A, Cho JS, Colvard B, Kashyap VS. Management and Outcome of Non-Aneurysmal Primary Aortic Infection. Vasc Endovascular Surg 2023; 57:222-229. [PMID: 36453193 DOI: 10.1177/15385744221143659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Aortic infection without prior intervention or aneurysm is exceedingly rare. We report the presentation, diagnosis, management, and outcome of patients with this unusual entity. METHODS Retrospective chart and imaging review of patients with primary aortic infection. RESULTS 5 patients (3 male, mean age 71.2 years) presented between 2014 and 2022. All had abdominal, back, or flank pain. Four had constitutional symptoms. All were evaluated with a complete blood count; 3 had leukocytosis. Both serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were elevated in the 4 patients evaluated with these tests. All were studied with peripheral blood culture on the first hospital day prior to any antibiotic administration. Blood culture was positive in only 1 patient. Computed tomography (CT) scan showed periaortic inflammation without aneurysm in all. Fluorodeoxyglucose positron emission tomography (PET) was obtained in 3 and a radiolabeled leukocyte single-photon emission CT (SPECT) scan was performed in 2. All demonstrated periaortic concentration of the radioisotope consistent with inflammation or infection. Intraoperative cultures were positive in 3. One patient who had a negative intraoperative culture was examined with broad range polymerase chain reaction (PCR) and DNA sequencing which identified a causative bacterium. The other patient with a negative intraoperative culture had periaortic abscess but was on antibiotics preoperatively, potentially confounding the culture. All patients underwent in-situ repair with rifampin impregnated polyester (N = 2), cryopreserved aortic allograft (N = 2), or autogenous femoral vein (N = 1). No patient developed recurrent infection or aortic related complications following surgery with an average follow up of 31.8 months (range 8-88 months). CONCLUSIONS Patients with primary aortic infection present similarly with the triad of abdominal or back pain, laboratory markers of infection, and imaging demonstrating periaortic inflammation. Patients were treated successfully with in-situ repair. Preoperative identification of a causative organism was difficult, and PCR may be useful to help identify an organism.
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Affiliation(s)
- Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Aric A Wogsland
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Justin Smith
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Avkash Patel
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Braams L, Vlaspolder G, Boiten K, Salomon E, Winter R, Saleem B, Wouthuyzen-Bakker M, van Oosten M. Sonication of Vascular Grafts and Endografts to Diagnose Vascular Graft Infection: a Head-To-Head Comparison with Conventional Culture and Its Clinical Impact. Microbiol Spectr 2023; 11:e0372222. [PMID: 36847571 PMCID: PMC10100911 DOI: 10.1128/spectrum.03722-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/09/2023] [Indexed: 03/01/2023] Open
Abstract
Vascular graft and endograft infection (VGEI) is a severe complication associated with high mortality and is often challenging to diagnose. For the definitive microbiological diagnosis, sonication of vascular grafts may increase the microbiological yield of these biofilm-associated infections. The objective of this study was to determine whether sonication of explanted vascular grafts and endografts results in a higher diagnostic accuracy than conventional culture methods and aids in clinical decision-making. A prospective diagnostic study was performed comparing conventional culture with sonication culture of explanted vascular grafts in patients treated for VGEI. Explanted (endo)grafts were cut in halves and were either subjected to sonication or conventional culture. Criteria based on the Management of Aortic Graft Infection Collaboration (MAGIC) case definition of VGEI were used for definitive diagnosis. The relevance of sonication cultures was assessed by expert opinion to determine the clinical impact on decision-making. Fifty-seven vascular (endo)graft samples from 36 patients (four reoperations; 40 episodes) treated for VGEI were included; 32 episodes were diagnosed with VGEI. Both methods showed a positive culture in 81% of the cases. However, sonication culture detected clinically relevant microorganisms that went unnoticed by conventional culturing in 9 out of 57 samples (16%, 8 episodes) and provided additional relevant information regarding growth densities in another 11 samples (19%, 10 episodes). Sonication of explanted vascular grafts and endografts improves the microbiological yield and aids in the clinical decision-making for patients with a suspected VGEI compared to conventional culture alone. IMPORTANCE Sonication culture of explanted vascular grafts was shown to be a noninferior method compared to conventional culturing in diagnosing vascular graft and endograft infection (VGEI). Moreover, sonication culture has probable additional value in microbiological characterization of VGEI by giving more detailed information on growth densities, especially when the conventional culture shows intermediate growth. In this prospective design, for the first time, a direct comparison is made between sonication culturing and conventional culturing in VGEI, while taking clinical interpretation into account. Therefore, this study is another step toward a more accurate microbiological diagnosis of VGEI, influencing clinical decision-making.
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Affiliation(s)
- Lisanne Braams
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Gro Vlaspolder
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Kathleen Boiten
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Elisa Salomon
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Rik Winter
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ben Saleem
- Division of Vascular Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marleen van Oosten
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Infection of Vascular Prostheses: A Comprehensive Review. PROSTHESIS 2023. [DOI: 10.3390/prosthesis5010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Vascular graft or endograft infection (VGEI) is a complex disease that complicates vascular-surgery and endovascular-surgery procedures and determines high morbidity and mortality. This review article provides the most updated general evidence on the pathogenesis, prevention, diagnosis, and treatment of VGEI. Several microorganisms are involved in VGEI development, but the most frequent one, responsible for over 75% of infections, is Staphylococcus aureus. Specific clinical, surgical, radiologic, and laboratory criteria are pivotal for the diagnosis of VGEI. Surgery and antimicrobial therapy are cornerstones in treatment for most patients with VGEI. For patients unfit for surgery, alternative treatment is available to improve the clinical course of VGEI.
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11
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Wouthuyzen-Bakker M, van Oosten M, Bierman W, Winter R, Glaudemans A, Slart R, Toren-Wielema M, Tielliu I, Zeebregts CJ, Prakken NHJ, de Vries JP, Saleem BR. Diagnosis and treatment of vascular graft and endograft infections: a structured clinical approach. Int J Infect Dis 2023; 126:22-27. [PMID: 36375692 DOI: 10.1016/j.ijid.2022.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/09/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
A vascular graft or endograft infection (VGEI) is a severe complication that can occur after vascular graft or endograft surgery and is associated with high morbidity and mortality rates. A multidisciplinary approach, consisting of a team of vascular surgeons, infectious diseases specialists, medical microbiologists, radiologists, nuclear medicine specialists, and hospital pharmacists, is needed to adequately diagnose and treat VGEI. A structured diagnostic, antibiotic, and surgical treatment algorithm helps clinical decision making and ultimately aims to improve the clinical outcome of patients with a VGEI.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Marleen van Oosten
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Wouter Bierman
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Rik Winter
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andor Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Riemer Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marlous Toren-Wielema
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ignace Tielliu
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Niek H J Prakken
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jean Paul de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ben R Saleem
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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12
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Oliva A, Miele MC, Al Ismail D, Di Timoteo F, De Angelis M, Rosa L, Cutone A, Venditti M, Mascellino MT, Valenti P, Mastroianni CM. Challenges in the Microbiological Diagnosis of Implant-Associated Infections: A Summary of the Current Knowledge. Front Microbiol 2021; 12:750460. [PMID: 34777301 PMCID: PMC8586543 DOI: 10.3389/fmicb.2021.750460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/04/2021] [Indexed: 12/14/2022] Open
Abstract
Implant-associated infections are characterized by microbial biofilm formation on implant surface, which renders the microbiological diagnosis challenging and requires, in the majority of cases, a complete device removal along with a prolonged antimicrobial therapy. Traditional cultures have shown unsatisfactory sensitivity and a significant advance in the field has been represented by both the application of the sonication technique for the detachment of live bacteria from biofilm and the implementation of metabolic and molecular assays. However, despite the recent progresses in the microbiological diagnosis have considerably reduced the rate of culture-negative infections, still their reported incidence is not negligible. Overall, several culture- and non-culture based methods have been developed for diagnosis optimization, which mostly relies on pre-operative and intra-operative (i.e., removed implants and surrounding tissues) samples. This review outlines the principal culture- and non-culture based methods for the diagnosis of the causative agents of implant-associated infections and gives an overview on their application in the clinical practice. Furthermore, advantages and disadvantages of each method are described.
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Affiliation(s)
- Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Claudia Miele
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Dania Al Ismail
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Federica Di Timoteo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Massimiliano De Angelis
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Luigi Rosa
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antimo Cutone
- Department of Biosciences and Territory, University of Molise, Pesche, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Teresa Mascellino
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Piera Valenti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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13
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Berard X, Battut AS, Puges M, Carrer M, Stenson K, Cazanave C, Stecken L, Caradu C, Ducasse E. Fifteen-year, single-center experience with in situ reconstruction for infected native aortic aneurysms. J Vasc Surg 2021; 75:950-961.e5. [PMID: 34600030 DOI: 10.1016/j.jvs.2021.08.094] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/24/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The purpose of the present study was to evaluate the survival and freedom from reinfection for patients with infected native aortic aneurysms (INAAs) treated with in situ revascularization (ISR), using either open surgical repair (OSR) or endovascular aneurysm repair (EVAR), and to identify the predictors of outcome. METHODS Patients with INAAs who had undergone ISR from January 2005 to December 2020 were included in the present retrospective single-center study. The diagnosis of INAAs required a combination of two or more of the following criteria: (1) clinical presentation, (2) laboratory results, (3) imaging findings, and (4) intraoperative findings. The primary endpoint was 30-day mortality. The secondary endpoints were in-hospital mortality, estimated survival, patency, and freedom from reinfection using the Kaplan-Meier method. The predictive factors for adverse outcomes were evaluated using the Mann-Whitney U test or the Fisher exact test and multivariate regression analysis. RESULTS A total of 65 patients (53 men [81.5%]; median age, 69.0 years; interquartile range, 61.5-75.0 years) were included, 31 (47.7%) were immunocompromised, 60 were symptomatic (92.3%), and 32 (49.2%) had presented with rupture, including 3 aortocaval fistulas (4.6%) and 12 aortoenteric fistulas (18.5%). The most common location was infrarenal (n = 39; 60.0%). Of the 65 patients, 55 (84.6%) had undergone primary OSR with ISR, 3 (4.6%) had required EVAR as a bridge to OSR, and 8 (12.3%) had undergone EVAR as definitive treatment. The approach was a midline laparotomy for 44 patients (67.7%), mostly followed by reconstruction and aortic-aortic bypass (n = 28; 40.6%) and the use of a silver and triclosan Dacron graft (n = 30; 43.5%). Causative organisms were identified in 55 patients (84.6%). The 30-day and in-hospital mortality rates were 6.2% (n = 4) and 10.8% (n = 7). The median follow-up was 33.5 months (interquartile range, 13.6-62.3 months). The estimated 1- and 5-year survival rates were 79.7% (95% confidence interval [CI], 67.6%-87.7%) and 67.4% (95% CI, 51.2%-79.3%). The corresponding freedom from reinfection rates were 92.5% (95% CI, 81.1%-97.1%) and 79.4% (95% CI, 59.1%-90.3%). On multivariate analysis, in-hospital mortality increased with uncontrolled sepsis (P < .0001), rapidly expanding aneurysms (P = .008), and fusiform aneurysms (P = .03). The incidence of reinfection increased with longer operating times (P = .009). CONCLUSIONS The selective use of ISR and OSR combined with targeted antimicrobial therapy functioned reasonably well in the treatment of INAAs, although larger, prospective, multicenter studies with appropriately powered comparative cohorts are necessary to confirm our findings and to determine the best vascular substitute and precise role of EVAR as a bridge to OSR or definitive treatment.
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Affiliation(s)
- Xavier Berard
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France.
| | - Anne-Sophie Battut
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Mathilde Puges
- Department of Infectious Diseases, Bordeaux University Hospital, Bordeaux, France
| | - Mathilde Carrer
- Department of Infectious Diseases, Bordeaux University Hospital, Bordeaux, France
| | | | - Charles Cazanave
- Department of Infectious Diseases, Bordeaux University Hospital, Bordeaux, France
| | - Laurent Stecken
- Department of Anesthesiology, Bordeaux University Hospital, Bordeaux, France
| | - Caroline Caradu
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Eric Ducasse
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France
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14
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Gaudric J, Couture T, Arzoine J, Chiche L. Response to "Comment on 'Short- and Mid-term Outcomes of Cryopreserved Abdominal Aortic Allografts Used as a Substitute for Infected Prosthetic Grafts in 200 Patients'". Eur J Vasc Endovasc Surg 2021; 62:494. [PMID: 34312073 DOI: 10.1016/j.ejvs.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Julien Gaudric
- Sorbonne Université, Department of Vascular Surgery, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, France.
| | - Thibault Couture
- Sorbonne Université, Department of Vascular Surgery, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, France
| | - Jeremy Arzoine
- Sorbonne Université, Department of Anaesthesiology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, France
| | - Laurent Chiche
- Sorbonne Université, Department of Vascular Surgery, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, France
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15
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Linares-Palomino JP, Lopez-Espada C. Infectious Complications of EVAR are Deadlier than Those of Conventional Surgery. Eur J Vasc Endovasc Surg 2018; 57:137. [PMID: 30206015 DOI: 10.1016/j.ejvs.2018.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 08/16/2018] [Indexed: 11/19/2022]
Affiliation(s)
| | - Cristina Lopez-Espada
- University Hospital Virgen de las Nieves, Department of Vascular Surgery, Granada, Spain
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