OUTPATIENT ANTIMICROBIAL THERAPY FOR ENDOVASCULAR AORTIC REPAIR INFECTION; A FIVE YEAR RETROSPECTIVE EVALUATION Dr. Niamh Allen (1), Dr. Mohamed Eltayeb (1), Dr. Grace O’Regan (1), Dr. Aoife Seery (1), Dr. Cora Mc Nally (1), Prof. Samuel McConkey (1)(2), Dr. Eoghan de Barra (1)(2) 1. Beaumont Hospital, Dublin, Ireland 2. Royal College of Surgeons (RCSI) , Dublin, Ireland
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OUTPATIENT ANTIMICROBIAL THERAPY FOR ENDOVASCULAR
AORTIC REPAIR INFECTION; A FIVE YEAR RETROSPECTIVE
EVALUATION
Dr. Niamh Allen (1), Dr. Mohamed Eltayeb (1), Dr. Grace O’Regan (1), Dr. Aoife Seery(1), Dr. Cora Mc Nally (1), Prof. Samuel McConkey (1)(2), Dr. Eoghan de Barra (1)(2)
1. Beaumont Hospital, Dublin, Ireland
2. Royal College of Surgeons (RCSI) , Dublin, Ireland
OVERVIEW
• 1% of endovascular aortic repair (EVAR) devices become infected- high mortality rate [1].
• OPAT database• 5-year period from 2014-2018; infected EVAR
• Median age 76 (65-85)
• Median Charleston co-morbidity index 6.5
• 11 abdominal aorta, 1 fem-pop
• At our centre 400 EVARs placed in that time period
OVERVIEW OF PRESENTATION
1. Brief description of 3 cases2. Case definitions - MAGIC criteria3. Clinical features4. Causative Organisms5. Management
a. General principlesb. Our cohort (medical/surgical)c. Commonly used antimicrobials on OPAT
6. Outcomes7. Take home points
CASE 1
• 70 yr old male
• BG: A fib, IHD, PVD
• Infra-renal EVAR 13/6/17 -elective
• Bilateral ax/fem grafts 21/7/17
• Day 3 post-op • fever, raised wcc, fast AF• Wound clinically infected• BC+ pseudomonas• Imaging: fluid and gas collection
R+ L groin• Femoral aspirate culture
positive pseudomonas
→ AGI; diagnosed, early (<4 months)
1. Lyons, O. T. A., Baguneid, M., Barwick, T. D., Bell, R. E., Foster, N., Homer-Vanniasinkam, S., … Price, N. M. (2016). Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC). European Journal of Vascular and Endovascular Surgery, 52(6), 758–763.
DIAGNOSTIC CRITERIA: MANAGEMENT OF AORTIC GRAFT INFECTION
COLLABORATION (MAGIC)
CASE 1 - MANAGEMENT AND PROGRESS
• 12 weeks piptaz (OPAT) → PO ciprofloxacin
• June 2018; collection axillary site → drainage + piptaz (OPAT)
• Mild erythematous rash on tazocin – continue and observe
• Oct 2018 - recurrence of collections
• Daptomycin added
• Elective admission for surgery
• Planned EVAR explant and later plan for removal of infected ax/fem grafts
CASE 1 – PROGRESS CONT.
• Stormy post-op course – prolonged ICU admission
• Further 4/12 IV antibiotics
• Eventually d/c to rehab April 2019 on PO cipro
• No further plans for ax/fem explant
• Life long suppression
CASE 1 HIGHLIGHTS
• Consensus approach of 6-12 weeks iv antibiotics followed by oral suppressive therapy
• Prolonged and recurrent use of IV antibiotics – induction and break-throughs on oral
• Surgical explantation with debridement + long term ABx is standard of care but
• Co-morbidity profile
• Nature of the devices- not made to be removed
• 2/11 had surgical explantation
1
2
4
1
3
1
0 1 2 3 4 >5
Number of Antimicrobial Switches
MANAGEMENT; MEDICAL
• Median days on OPAT 46, total 864
3
4
4
10
OPAT Antimicrobials
piptaz
cephalosporin
carbapenem
vancomycin
daptomycin
teicoplanin
caspofungin
>1 antimicrobial
OUTCOMES
• 10/12 (83.3%) re-admitted to hospital at least once, median 4, range 0-6
• Median bed days 67, range 9-199, total 922
10
2
Re-admitted post diagnosis
Yes
No
OUTCOMES
• 4/12 (33.3%) died - at 5, 10, 27 and 72 months• Multiple co-morbidities and older (Charlson 7-12,
median age 84)
• At median 29 months in published data – all dead who had no explantation (1).
• In our data 8/12 alive at median of 24 months follow up.
• Palliative care referral offered to ¾ who died
• 8/12 alive• 6 on long-term PO antibiotics (1 intermittently on
OPAT)
• 2 off antibiotics
TAKE HOME POINTS
• Prolonged antibiotic therapy, often complex• Polymicrobial infections requiring >1 anti-microbial• Long hospital stays and multiple re-admissions• High mortality rates• The role and optimal timing of surgical explanation unclear; technically difficult
and patient co-morbidities• Roles of OPAT• Temporizing measure• Bridge to graft explantation• Break-throughs on oral suppression• Palliative intervention in some cases
THANK YOU!
REFERENCES
1. Lyons, O. T. A., Patel, A. S., Saha, P., Clough, R. E., Price, N., & Taylor, P. R. (2013). A 14-year experience with aortic endograft infection: Management and results. European Journal of Vascular and Endovascular Surgery, 46(3), 306–313.
2. Lyons, O. T. A., Baguneid, M., Barwick, T. D., Bell, R. E., Foster, N., Homer-Vanniasinkam, S., … Price, N. M. (2016). Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC). European Journal of Vascular and Endovascular Surgery, 52(6), 758–763.
FURTHER EVALUATION NEEDED…
• Role and duration of OPAT where no oral option available• Complications• Line related• antimicrobial S/Es etc
ADDITIONAL PRESENTERS NOTES
• Antibiotici therapy – current status of those alive: 5 patients are currently on long term antibiotic and are all PO, and 2 off antibiotics the remaining 4 are dead.
• Explantation: 1/11 had surgical removal of the Femro-popliteal bybpass graft with primary outcome death after 72 months of follow up. 2/11 patients had undergone sinus excision and one died within 5 months after diagnosis of infection.
• Comparison of mortality: our series at median follow up of 24 months 4/11 dead (1 had explantation, 2 had temporising measures, 8 had no surgical management). Compared to literature A 14-year experience with aortic endograft infection: Management and results. In which the mortality rate is 100% without surgical explanation. (1) – at median f/u of 29 months
• Describing the results in 3 domains:
• 1- the case definitions using the MAGIC criteria ( 8 diagnosed), of those 8 patients there are 2 currently not antibiotics and no available data on one patient.
• 2- management: surgical definitive i.e Explantaion was not performed to any patient but other measures like sac aspiration were done for 3/11 2 of them are diagnosed based on MAGIC. All patients were under surveillance CT/US. Broad spectrum antibiotic were used in 10/11 with as initial management with one patient was put on fluconazole
• 3- primary out come death is 4/11, all were diagnosed cases, index indication was rupture in 2/4.
• To add further:
• MAGIC to be used as its easily applied to define the case.
• antibiotic choice in negative culture patients will be broad spectrum (what to choose first clinically in circumstances like aortoenteric fistula or thoracenteric fistula) and on the other hand should be guided with the sensitivity result.
• Surgical explantation with debridement + long term ABx is standard of care but given the com-morbidity profile the nature of the devices which isn’t made to be removed the best chance will be temporizing surgical measures in addition to long term suppressive therapy with antibiotic and consideration of palliative care referral earlier.