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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
A Journal on Vascular and Endovascular Surgery
Giornale Italiano di Chirurgia Vascolare 2003 December;10(4):301-32
language: English, Italian
Prophylaxis of primary and secondary graft infections in vascular surgery. A review
Pedrini L., Pisano E., Ballestrazzi M. S., Sensi L.
Vascular Surgery Operative Unit C.A. Pizzardi General Hospital, Bologna, Italy
Graft infection in vascular surgery is a complication with incidence varying from 0.2% to 8% depending on the reconstruction site, and has high mortality (9-45%), morbidity and amputation rates (0-60%). Attempts have been made to prevent this complication both by modifying pre- and intraoperative conduct and surgical techniques, and through antibiotic prophylaxis. This review aims to verify the tools that are available to reduce graft infection, and when their use is appropriate. The literature search was extended well beyond the past 10 years, using many databases, and crossing the data they offered. Articles cited in the publications examined, where relevant, were also located and examined. From the available studies it emerged that graft infection does not only occur in the operating theatre, but also in the post-operative period, both immediate and during follow-up. The germs most frequently responsible are Staphylococcus aureus and coagu-lase-negative staphylococci such as S. epidermidis, with a recent dramatic increase in MRSA. Incidence of graft infection was found to be similar in many reports, even though different classes of antibiotics were utilised. At the same time, with the same antibiotic different incidences of infection were reported, testifying to the role played by local differences in infection pathogenesis. The choice of antibiotic must be guided by the infection that is determined in each individual medical centre. It is in any case clear that the protocols proposed to date use antibiotics that have long been ineffective against the germs responsible for the graft infections reported. The effectiveness of prophylaxis extended to the first few days post-surgery in reducing the incidence of graft and surgical site infection is not demonstrated in the few prospective studies reported, in which series are small, but it may be hypothesised from the lower incidence of surgical site infections reported in the specimens examined. In the presence of trophic lesions, antibiotic prophylaxis should be extended because of possible endogenous infection, reported in many studies. Surgical technique and patient preparation were found to be very important in preventing wound infection. The graft material (PTFE and polyester impregnated with antibiotics) appears to reduce the incidence of graft infection both in primary operations and in re-operations for infection. Invasive pre- and postoperative procedures and those during follow-up cause bacteremia, and graft infection has been shown experimentally to be possible. This bacteremia may explain late infections. In treating graft infections, the need for prolonged administration of antibiotics is confirmed, although no comparative studies exist. Prospective studies with sufficiently large series to guide the choice of antibiotic protocol for graft infection prophylaxis, and to demonstrate the advantages of prolonged antibiotic administration, are not to be found in the literature. The benefits of extended administration might be deduced by evaluating the short-term ineffectiveness of highly active antibiotics for prophylaxis, and the lower incidence of surgical site infections with prolonged administration. This phenomenon should be stratified by risks for associated diseases (ulcer, gangrene, diabetes, etc.) and by surgical site. There are no studies on the prevention of late infection, which do on the contrary exist for heart valves.