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Improved management of infrainguinal bypass graft infection with methicillin-resistant Staphylococcus aureus
R T Chalmers1, J H Wolfe, N J Cheshire
1Regional Vascular Unit, St Mary's Hospital, London, UK.
Background:
There is considerable debate over the management of infected infrainguinal grafts. This report describes recent experience in this field and documents the change in clinical practice needed to deal with methicillin-resistant Staphylococcus aureus (MRSA).
Methods:
All infected infrainguinal grafts between January 1991 and July 1997 were reviewed. In the light of the findings, clinical practice was modified considerably. A further 1 year was audited prospectively up to August 1998.
Results:
Twenty-six patients were treated for 27 infrainguinal graft infections (25 prosthetic, two vein). Twenty were treated by complete graft excision as the initial therapy; graft preservation was attempted in six patients. Before 1995, the infecting organisms were predominantly Pseudomonas aeruginosa or methicillin-sensitive staphylococci. Subsequently all 14 patients treated up to 1997 had infection with MRSA. The overall amputation rate was 17 of 26; ten amputations were in patients with MRSA. Four patients died, all with MRSA sepsis. As a result of this experience a policy of complete isolation was adopted for all patients infected with MRSA. In the 12 months since this policy was introduced, 77 infrainguinal grafts (61 vein, 16 prosthetic) have been inserted. Two grafts (3 per cent) have become infected, necessitating graft excision and amputation.
Conclusion:
MRSA infection of an infrainguinal graft is a serious complication with high associated amputation and mortality rates. Isolation and barrier nursing appeared to contain the problem.
Insights
Managing methicillin-resistant Staphylococcus aureus (MRSA) infrainguinal graft infections requires specific strategies. Complete graft excision and isolation protocols are crucial for reducing amputation and mortality rates in these serious cases.
Area of Science:
- Vascular Surgery
- Infectious Disease Management
- Surgical Site Infections
Background:
- Infected infrainguinal grafts present complex management challenges.
- The rise of methicillin-resistant Staphylococcus aureus (MRSA) necessitates updated clinical practices.
- Existing literature offers limited guidance on MRSA infrainguinal graft infections.
Purpose of the Study:
- To review clinical experience with infected infrainguinal grafts.
- To document changes in management strategies prompted by MRSA.
- To evaluate the impact of modified practices on patient outcomes.
Main Methods:
- Retrospective review of infected infrainguinal grafts (1991-1997).
- Prospective audit of clinical practice changes for one year (until 1998).
- Analysis of causative organisms, treatment modalities, and outcomes (amputation, mortality).
Main Results:
- MRSA became the predominant pathogen in later years (14/14 patients by 1997).
- High amputation (10/14) and mortality (4/4) rates were observed in MRSA cases.
- Post-policy implementation, only 2/77 (3%) new grafts became infected, leading to excision and amputation.
Conclusions:
- MRSA infrainguinal graft infection is a severe complication with significant morbidity and mortality.
- Complete graft excision and isolation nursing are effective in controlling MRSA spread.
- Updated clinical protocols are essential for managing these challenging infections.