1. Treatment and Prophylaxis Guidelines – Where are we up to? Dr Jonathan Sandoe, Consultant Microbiologist, Leeds Management of infections in the vascular patient

2. Competing interests Paid by Pfizer to deliver a lecture on infections in vascular surgical patients in 2011 Research funding, sponsorship to attend conferences or deliver lectures from Novartis, Pfizer and Merck Sharp and Dohme, Biomet.

3. Infections in vascular patients Aim To persuade you that guidelines have a role in the management of infections in vascular surgical patients… BUT Only if used in the correct context and as part of a comprehensive infection service.

4. Infections in vascular patients Plan Part 1 – Treatment guideline update Part 2 – What do we want from guidelines? Part 3 – Prophylaxis guideline update

5. Part 1 Treatment guideline update

6. Guidelines for diagnosis and management of infected vascular grafts…

8. Guidelines for radiological diagnosis and management of infected (mycotic) aneurysms….

11. Infections in vascular patients Where are all the guidelines?

13. Part 2 What do we want from guidelines?

14. Infections in vascular patients The aim of treatment To cure patients of infection with minimal risk of harm in the most efficient way possible. Secondary aim…to suppress infection…

15. Infections in vascular patients The aim of guidelines To standardise and optimise the care of vascular patients with infection?

16. Infections in vascular surgery The aim of guidelines Is standardisation possible in complex infection?

17. Infections in vascular patients The aim of guidelines Can anything be standardised? Diagnostic criteria Initial investigations Microbiological processing Empirical antimicrobial therapy Directed antimicrobials Surgery?

18. Infections in vascular patients Guideline criticisms Too many Conflicting Unhelpful Difficult to follow Ignored Hard to find Out of date …….

19. IDSA: Antibiotic choice for DFI Adapted from Lipsky (2004) IDSA guidelines: diabetic foot infection.Clin Infect Dis 39: 885–910

20. Infections in vascular patients Guideline criticisms NICE: AB - Diabetic foot infection (DFI) NICE are unable to make any recommendations on individual agents Each hospital should have DFI guidelines.

21. Infections in vascular patients Making the task manageable Infections can be viewed as “specialty- specific” and “general” In the assessment of a vascular surgery inpatient with infection, the differential diagnosis may be broad...

22. Infections in vascular patients “Specialty specific” infections 1.Surgical site infection (wound, stump, early graft infection) 2.Vascular graft infection (early/late) 3.AV fistula infection 4.Mycotic aneurysms 5.Diabetic foot infection 6.Cellulitis/ulcer infection

25. 8179 Jan 2011692 July 2008 “Hits” on antimicrobial guidelines per month

26. Infections in vascular patients Contrasting - situations Mycotic aneurysmVascular graft infection Microbiologymonomicrobialpolymicrobial Microbiological diagnosis (Blood culture) reliableunreliable ComorbidityIE, IVDU, noneDM, PVD, CKD Prosthetic materialabsentpresent

27. Infections in vascular patients Infected aneurysms yearlocationCauseIntervention 12012cerebralStrep gordoniiNone 2.2011splenicStrep oralisRadiological embolisation 3.2011brachialStrep agalactiaeResection/repair

28. Vascular graft infection Guideline – “top level recommendations” Antimicrobial strategy determined by surgical strategy Surgical strategy determined by location of graft, patient choice/suitability for surgery…. Removal of infected graft and debridement of infected tissue appears to be necessary for cure?

29. Vascular graft infection Success of surgical strategy for infection 1. Removal and extra-anatomical bypass 2. Removal with replacement with autologous vessel 3. Partial removal and replacement 4. Endovascular arterial reconstruction 5. No surgery

30. Vascular graft infection Duration of therapy vs surgical strategy 1.Removal/extra anatomical 6/52 IV 2.Removal/ in situ autologous 6/52 IV/po 3.Partial removal 6/52 IV + suppression? 4.EVAR 6/52 IV + suppression 5.No surgery IV + suppression

31. Vascular graft infection Guideline – Antimicrobial treatment Is it appropriate to draw parallels between prosthetic valve endocarditis and vascular graft infection? Prolonged (6/52) IV antimicrobials can cure PVE Trial data needed

32. Vascular graft infection Empirical therapy 1.Vancomycin + piperacillin/tazobactam (appropriate spectrum, low CDI risk, low MRSA colonisation risk)* 2.Vancomycin + ciprofloxacin +metronidazole (penicillin allergic patient)* (antifungals?) *Empirical regimen should consider previous microbiology

33. Part 3 Guidelines for antimicrobial prophylaxis in vascular (surgery) patients

35. Infections in vascular patients Prophylaxis Peripheral arterial reconstruction (EL 1+)

36. Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery (!) DO for all implant surgery Infections in vascular patients Prophylaxis

37. single dose prophylaxis IV on starting anaesthesia (earlier for operations in which a tourniquet is used). Infections in vascular patients Prophylaxis

38. No recommendations on choice of agent “see local formulary” Infections in vascular patients Prophylaxis

39. Infections in vascular patients Summary Guidelines do have a role in the management of infections in vascular surgical patients… BUT Only if used in the correct context and as part of a comprehensive infection service. More data are needed – high quality observational studies if trials impractical.