Home > Journals > Italian Journal of Vascular and Endovascular Surgery > Past Issues > Giornale Italiano di Chirurgia Vascolare 2003 December;10(4) > Giornale Italiano di Chirurgia Vascolare 2003 December;10(4):301-32



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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.

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