Treatment of vascular graft and stent infections
Chakfe, 2020Niaz, Rao, Abidia, , 2020Niaz, Rao, Carey, , 2020Sorelius, 2019Wilson, 2016
Management of vascular graft and stent infections is complex and should be undertaken by a multidisciplinary team that includes a vascular surgeon, a radiologist, and an infectious diseases physician or clinical microbiologist. The nature of the graft (whether constructed from native venous or arterial tissue, or prosthetic material [eg Gore-Tex]) influences the likelihood of success with medical therapy and the need for surgical resection. Identification of the responsible pathogen is a key priority.
Patients with vascular graft or stent infections may have sepsis or septic shock. For patients with sepsis or septic shock, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock. Antibiotics should be administered immediately after blood samples are taken for culture. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.
Before starting antibiotic therapy, take 3 sets of blood samples for culture (from separate venipuncture sites). A suitable empirical regimen for vascular graft and stent infections in adults and children isAbdul-Aziz, 2024Dulhunty, 2024:
vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children. Loading doses are recommended for critically ill adults. See advice on modification and duration of therapy vancomycin vancomycin vancomycin
PLUS one of the following
1ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, daily for 2 weeks. For patients with septic shock or requiring intensive care support, use 1 g (child 1 month or older: 50 mg/kg up to 1 g) intravenously, 12-hourly. See advice on modification and duration of therapy ceftriaxone ceftriaxone ceftriaxone
OR
1cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly for 2 weeks. For patients with septic shock or requiring intensive care support, use 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see cefotaxime dosage adjustment. See advice on modification and duration of therapy cefotaxime cefotaxime cefotaxime
OR
patients without septic shock and not requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) 6-hourly
patients with septic shock or requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) administered as a loading dose over 30 minutes. After 3 hours, start a continuous infusion of 16+2 g (child: 400+50 mg/kg up to 16+2 g) administered over 24 hours1.
Administer vancomycin after ceftriaxone, cefotaxime or piperacillin+tazobactam due to the long infusion time required.
Pharmacokinetics may be altered in patients who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure in patients with vascular graft and stent infections who have septic shock or require intensive care support, modified dosages of ceftriaxone, cefotaxime and piperacillin+tazobactam are recommended. Once the critical illness has resolved, consider switching to the standard dosage.
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use the ceftriaxone or cefotaxime plus vancomycin regimen above.
For patients who have had a severe immediate2 hypersensitivity reaction to a penicillin, the ceftriaxone or cefotaxime plus vancomycin regimen (at the dosages above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).
For patients who have had a severe immediate2 hypersensitivity reaction to a penicillin in whom the ceftriaxone or cefotaxime plus vancomycin regimen is not used, or for patients who have had a severe delayed3 hypersensitivity reaction to a penicillin, seek expert advice.