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Background A groin wound associated with a vascular graft infection is associated with significant morbidity. Management of groin wounds is often challenging due to their anatomical location that renders them difficult to visualize and keep clean. Case This case report describes the use of a concentrated surfactant-based gel dressing for an infected groin wound. Conclusions Because of their location and complex topography, groin wounds are difficult to keep clean and maintain dressing integrity. This case study describes the use of a concentrated surfactant-based gel dressing that remained in place and promoted healing of an infected groin wound.

As infeções vasculares protésicas continuam a ser um desafio médico complexo. A evolução da flora hospitalar e o desenvolvimento da cirurgia vascular têm contribuído para uma mudança na realidade das infeções protésicas, tornando imperativo conhecer o contexto microbiológico atual destas infeções para o seu adequado tratamento. Estas infeções dependem de fatores endógenos e exógenos e variam consoante o tempo de apresentação, localização da prótese vascular e ambiente microbiológico do doente. A morbimortalidade associada a este diagnóstico é elevada e o tratamento deve ser adaptado ao doente em questão, sendo necessário conhecer o microrganismo e as várias possibilidades de tratamento existentes. O conhecimento dos fatores predisponentes da infeção protésica vascular, o seu reconhecimento precoce e prevenção deve ser realizada em todos os doentes e num contexto de cuidados de saúde multidisciplinares. Vascular graft infections are still to date a complex medical challenge. The evolution of the hospital flora and development of the vascular surgery field has led to a change in the reality of these infections, making it important to know their current microbiological context in order to provide better care. These infections depend on endogenous and exogenous factors and vary according to the timing of infection, localization and microbiological environment of the patient. There is a high morbidity and mortality associated with these conditions and the treatment must be tailored to patient in question, making it necessary to know the underlying bacteria and the variety of treatment options available. The knowledge of predisposing factors, the high index of suspicion and correct diagnosis and prevention must be performed in all patients and in a multidisciplinary matter.

Prosthetic vascular graft infection remains a great challenge in vascular surgery. Unsuccessful treatment of vascular prosthesis infection often results in limb amputations and death. A conservative treatment option – local wound irrigation with antiseptic solutions – it not yet a well established treatment method in clinical practice. Novel experimental in vitro and in vivo models of vascular graft infection were designed and disscussed in this dissertation. Three antiseptic solutions: 0.1% octenidine dihydrochloride, 10% povidone-iodine and 0.02% chlorhexidine digluconate, routinelly used in clinical practice, were used in the experiments. The experiments were performed with a woven polyester vascular graft, infected by biofilm-producing Staphylococcus aureus strains. In vitro experiments were designed to test antiseptics’ biofilm-disrupting activity and antimicrobial efficacy in a simulated wound environment. An innovative model of infected vascular graft was designed to test antiseptics’ ability to remove S. aureus biofilms from the surface of the vascular graft. In vivo experiments with Wistar rats were designed to evaluate antiseptics’ efficacy to treat prosthetic vascular graft infection by daily wound irrigations. The efficacy of different antiseptic solutions and the duration of the treatment needed to eradicate S. aureus from the wounds was evaluated and cytological and histological analysis of the perigraft tissues was performed.

Prosthetic vascular graft infection remains a great challenge in vascular surgery. Unsuccessful treatment of vascular prosthesis infection often results in limb amputations and death. A conservative treatment option – local wound irrigation with antiseptic solutions – it not yet a well established treatment method in clinical practice. Novel experimental in vitro and in vivo models of vascular graft infection were designed and disscussed in this dissertation. Three antiseptic solutions: 0.1% octenidine dihydrochloride, 10% povidone-iodine and 0.02% chlorhexidine digluconate, routinelly used in clinical practice, were used in the experiments. The experiments were performed with a woven polyester vascular graft, infected by biofilm-producing Staphylococcus aureus strains. In vitro experiments were designed to test antiseptics’ biofilm-disrupting activity and antimicrobial efficacy in a simulated wound environment. An innovative model of infected vascular graft was designed to test antiseptics’ ability to remove S. aureus biofilms from the surface of the vascular graft. In vivo experiments with Wistar rats were designed to evaluate antiseptics’ efficacy to treat prosthetic vascular graft infection by daily wound irrigations. The efficacy of different antiseptic solutions and the duration of the treatment needed to eradicate S. aureus from the wounds was evaluated and cytological and histological analysis of the perigraft tissues was performed.

Prosthetic vascular graft infection is devastating and frequently fatal. Cure requires removal of the graft and reperfusion by placement of a new graft. However, no evidence based guidelines exist for management where removal of the graft is not possible. We describe a patient who lived in a state of chronic infection suppression through outpatient parenteral antimicrobial therapy (OPAT) over a period of 32 months, and outline the challenges experienced and strategies used to suppress infection in the face of escalating antimicrobial resistance. To date there have been very few reports of OPAT used in the palliative context and this case illustrates the microbiological issues that can arise and the importance of the full OPAT multi-disciplinary team in managing these issues and optimising the patient's quality and length of life.

PurposeVascular graft infection (VGI) in central grafts is a rare but dreaded complication with a high mortality. Several imaging modalities are employed, all with pros and cons. Computed tomography is the standard, but lacks sensitivity for low-grade infections. There is still no consensus regarding the diagnostic modality of choice. The study objective was to assess the role of combined positron emission tomography and computed tomography with fluorodeoxyglucose (FDG-PET/CT) in the diagnostic workup of VGI in central grafts.MethodsA systematic review was conducted according to the PRISMA guidelines through a search in Embase, PubMed, and Cochrane databases. Meta-analysis on accuracy measures was carried out with random effects models for three parameters: focal uptake, visual grading scale (VGS), and maximum standardized uptake value (SUVmax). Heterogeneity among studies was assessed with the I-squared test.ResultsA total of 307 studies were identified and 9 were eligible for inclusion. The pooled estimates for sensitivity and specificity for focal uptake were 90.6% (95% CI 81.7–99.4%) and 82.8% (95% CI 71.3–94.3%), respectively, for VGS 86.8% (95% CI 59.3–100%) and 69.4% (95% CI 39.9–98.9%), respectively, for SUVmax 92.8% (95% CI 83.2–100%) and 69.7% (95% CI 52.4–86.9%), respectively. A single study employed tissue-to-background ratio (TBR) and found sensitivity and specificity of 71.8% (95% CI 54.6–84.4%) and 70.4% (95% CI 51.5–84.2%), respectively.ConclusionsAccording to this systematic review and meta-analysis, FDG-PET/CT performs well especially when using focal versus diffuse FDG uptake to diagnose VGI.

Background and objectives: Treatment of a prosthetic vascular graft infection (PVGI) remains a challenging problem in vascular surgery. The aim of this study was to design a novel rat model for treatment of peripheral vascular prosthesis infection caused by Staphylococcus aureus (S. aureus) and to determine the efficacy of different antiseptic solutions in suppressing or eradicating infection from the wound and the graft material itself. Materials and methods: A piece of Dacron vascular prosthesis was surgically implanted at the dorsum of 48 Wistar rats and the wounds were infected with 5 McFarland standard inoculum of S. aureus. Suppurating wounds were daily irrigated with different antiseptic solutions: octenidine dihydrochloride, povidone-iodine, chlorhexidine digluconate, and sterile saline. The antimicrobial action of antiseptics was defined according to their capability to eradicate bacteria from the graft surroundings and bacteriological examination of the graft itself. Extended studies on wound microbiology, cytology, and histopathology were performed with an additional group of 10 rats, treated with the most effective antiseptic-octenidine dihydrochloride. Results: Four-day treatment course with octenidine, povidone-iodine, and chlorhexidine resulted in 99.98% (p = 0.0005), 90.73% (p = 0.002), and 65.97% (p = 0.004) decrease in S. aureus colonies in wound washouts, respectively. The number of S. aureus colonies increased insignificantly by 19.72% (p = 0.765) in control group. Seven-day treatment course with octenidine eradicated viable bacteria from nine out of 10 wound washouts and sterilized one vascular graft. Conclusions: A reproducible rat model of PVGI with a thriving S. aureus infection was designed. It is a first PVGI animal model where different antiseptic solutions were applied as daily irrigations to treat peripheral PVGI. Seven-day treatment with octenidine eradicated bacteria from the wound washouts for 90% of rats and one vascular graft. Further studies are needed to investigate if irrigations with octenidine could properly cure vascular bed from infection to assure a successful implantation of a new synthetic vascular substitute.

Purpose . To develop a new in vitro model of prosthetic vascular graft infection (PVGI) and evaluate antimicrobial and biofilm-disrupting efficacy of 0.1% octenidine dihydrochloride, 10% povidone-iodine and 0.02% chlorhexidine digluconate against biofilm-producing Staphylococcus aureus ( S. aureus ). Methodology . The effect of antiseptics on the microscopic integrity and antimicrobial effect on S. aureus biofilms was tested by growing biofilms on glass coverslips, in the modified Lubbock chronic wound pathogenic biofilm (LCWPB) model and on the surface of vascular grafts using qualitive and quantitative methods as well as by scanning electron microscopy (SEM). Results . Chlorhexidine worked best on destroying the integrity of S. aureus biofilms (P=0.002). In the LCWPB model, octenidine and povidone-iodine eradicated all S. aureus colonies (from 1.79 × 109 c.f.u. ml−1 to 0). In the newly developed PVGI model, the grafts were successfully colonized with biofilms as seen in SEM images. All antiseptics demonstrated significant antimicrobial efficacy, decreasing colony counts by seven orders of magnitude (P=0.002). Octenidine was superior to povidone-iodine (P=0.009) and chlorhexidine (P=0.041). Conclusion . We implemented an innovative in vitro model on S. aureus biofilms grown in different settings, including a clinically challenging situation of PVGI. The strongest antimicrobial activity against S. aureus biofilms, grown on prosthetic vascular grafts, was showed by 0.1% octenidine dihydrochloride. We suggest that combinational therapy of antiseptics between chlorhexidine with either povidone-iodine or octenidine dihydrochloride should be tested in further experiments. Despite the need of further studies, our findings of these in vitro experiments will assist the management of vascular graft infection in clinical cases.

BACKGROUND To evaluate the diagnostic accuracy of positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (PET/CT), contrast-enhanced CT (CE-CT), and a combined imaging approach (CE-PET/CT) in patients with suspected vascular graft infection (VGI). METHODS PET/CT and CE-CT were performed prospectively in 23 patients with suspected VGI. Diagnostic accuracy for PET/CT was assessed by using previously suggested cut-off points for maximum standardized uptake values (SUVmax) measured in the vicinity of the graft. Using a new 4-point scale for visual grading, two readers independently assessed the diagnostic accuracy for CE-CT and combined CE-PET/CT. Microbiological culture, obtained after open biopsy or graft explantation, and clinical follow-up of the patients served as the standard of reference. RESULTS Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of PET/CT for the diagnosis of VGI was 100%, 50%, 100%, 72.2%, and 78.3%, using the most favorable SUVmax cut-off ≥ 4.9. Respective values for CE-CT were 100%, 50%, 100%, 72.2%, and 78.3% for reader 1, and 92.3%, 80%, 88.9%, 85.7%, and 86.9% for reader 2; while respective values for combined CE-PET/CT were 100%, 70%, 100%, 81.3%, and 86.9% for reader 1, and 100%, 80%, 100%, 86.7%, and 91.3% for reader 2. Additionally, imaging provided a conclusive clinical diagnosis in patients without graft infection (i.e., other sites of infection): five of ten patients with CE-CT, six of ten patients with PET/CT, and seven of ten patients with combined CE-PET/CT. CONCLUSION The diagnostic accuracy of combined CE-PET/CT in patients with suspected VGI is very high. The combination of the high sensitivity of PET/CT in detecting metabolically active foci in infection, and the high specificity of CE-CT in detecting anatomic alterations, appears to be the reason why combined imaging outperforms stand-alone imaging in diagnosing VGI and may be supportive in future decision-making of difficult cases of suspected VGI. Clinical Trials.gov Identifier: NCT01821664.

Q fever, a zoonotic infection caused by Coxiella burnetii, can present with a wide spectrum of clinical manifestations. The organism is typically transmitted from sheep, goats, or cattle to humans via contaminated aerosols. On average, 1–5% of patients with acute Q fever will develop chronic infection months to decades after their primary infections. We report a case of a chronic vascular graft infection due to Coxiella burnetii in a 61-year-old man without direct exposure to animals who presented with recurrent fever. Indium-111-labeled white blood cell scan with single-emission positron computed tomography demonstrated findings suggesting a graft infection. C. burnetii phase I and phase II IgG antibody titers were > 1:32,768 and polymerase chain reaction performed on the explanted graft was positive for C. burnetii. Q fever should be considered in the differential diagnosis of vascular infections in patients who have a pre-existing lesion such as an aneurysm, or vascular prosthesis even in the absence of a history of direct animal exposure.

Infections of vascular grafts are the most severe complications in vascular surgery. We present the case of a 73-year-old male with infection of a dacron prosthesis with a strain of Enterococcus faecalis. The patient was treated with replacement of a full prosthesis with a combined graft constructed from Biosynthetic Vascular graft Omniflow and autologous veins. This graft is recommended for implantation in patients with a higher risk of infection. Our case is one of the first reported usage of this kind of graft in the aortic region and in a 2 years observation period no recurrence of infection was observed.

Objective Vascular graft and endograft infection (VGEI) has high morbidity and mortality rates. Diagnosis is complicated because symptoms vary and can be nonspecific. A meta-analysis identified 18F-fluoro- d -deoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) as the most valuable tool for diagnosis of VGEI and favorable to computed tomography as the current standard. However, the availability and varied use of several interpretation methods, without consensus on which interpretation method is best, complicate clinical use. The aim of this study was to evaluate the diagnostic performance of different interpretation methods of 18F-FDG PET/CT in diagnosis of VGEI. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources included PubMed/MEDLINE, Embase, and Cochrane Library. A meta-analysis was conducted on the different interpretation methods for 18F-FDG PET/CT in diagnosis of VGEI, including visual FDG uptake intensity, visual FDG uptake pattern, and quantitative maximum standardized uptake (SUVmax). Results Of 613 articles, 13 were included (10 prospective and 3 retrospective articles). The FDG uptake pattern method (I2 = 26.2%) showed negligible heterogeneity, whereas the FDG uptake intensity (I2 = 42.2%) and SUVmax (I2 = 42.1%) methods showed moderate heterogeneity. The pooled sensitivity for FDG uptake intensity was 0.90 (95% confidence interval [CI], 0.79-0.96); for uptake pattern, 0.94 (95% CI, 0.89-0.97); and for SUVmax, 0.95 (95% CI, 0.76-0.99). The pooled specificity for FDG uptake intensity was 0.59 (95% CI, 0.38-0.78); for FDG uptake pattern, 0.81 (95% CI, 0.71-0.88); and for SUVmax, 0.77 (95% CI, 0.63-0.87). The uptake pattern interpretation method demonstrated the best positive and negative post-test probability, 82% and 10%, respectively. Conclusions This meta-analysis identified the FDG uptake pattern as the most accurate assessment method of 18F-FDG PET/CT for diagnosis of VGEI. The optimal SUVmax cutoff, depending on the vendor, demonstrated strong sensitivity and moderate specificity.

Presented in the article are advantages of various methods of treatment of periprosthetic infection which continues to be one of the most challenging problems in modern vascular surgery. We describe herein a clinical case report regarding a patient with late infection of a bifurcated aortofemoral bypass graft. The infectious complication manifested itself by a periprosthetic infiltrate in the area of the distal anastomosis. The stent-graft's limb was resected within the limits of the unaltered tissue. The infectious process then manifested itself as sequestration of the main branch. Staged complete anatomical reconstruction performed later on using a hybrid technique made it possible to achieve an optimal result and resolution of the infection. This case report demonstrated undeniable advantages of using hybrid techniques.В статье приводятся преимущества разных способов лечения парапротезной инфекции, которая является актуальной проблемой современной сосудистой хирургии. Нами представлено клиническое наблюдение больного с поздней инфекцией бифуркационного аорто-бедренного шунта. Инфекционное осложнение манифестировало с парапротезного инфильтрата в области дистального анастомоза. Выполнена резекция бранши в пределах неизмененной ткани. Затем инфекционный процесс проявился секвестрацией основной бранши. Проведенная далее этапная полная анатомическая реконструкция гибридным методом позволила достичь оптимального результата и разрешения инфекции. Данный случай демонстрирует неоспоримые достоинства применения гибридных технологий.

Background and Aims: To report the experience of a tertiary vascular surgery center using Omniflow II® biosynthetic vascular grafts for treatment of prosthetic aortic graft infection. Materials and methods: Retrospective analysis of all patients with prosthetic graft infections who underwent in situ aortic reconstruction using Omniflow II® grafts or other conduits between March 2015 and May 2017. Early and late mortality, perioperative complications, and reinfection rate were analyzed. Results: Sixteen patients (14 males, median age 68.5, range 57–89) with prosthetic aortic graft infection were treated at our center. Eight patients received an Omniflow II® biosynthetic graft, two patients silver-triclosan coated grafts, three patients bovine pericardial tube grafts, and three patients composite bovine pericardial tube grafts with Omniflow II® graft extensions. Perioperative complications occurred in seven patients (43.8%). Early mortality rate was 18.7% (n = 3). In addition, four patients died during follow-up after a median of 11 months (range 0–34 months). We did not observe any reinfections. Bypass grafts were patent in all patients. No major limb amputations were performed during follow-up. Conclusion: Treatment of prosthetic aortic graft infection with Omniflow II® vascular grafts is feasible. Graft material seems to have an excellent resistance to infection and might be a valuable alternative to traditional replacement materials. Especially long-term durability has to be continuously monitored and documented.

In Zurich in 2012, 2 cases of Mycobacterium chimaera endocarditis/vascular graft infection were identified. This led to an investigation where six patients (in total) were found to have M. chimaera infection, detected up to 3.6 years post-surgery. M. chimaera was cultured from both the air surrounding and the water from the heater-cooler units used during surgery and therefore was thought to be the source. Aim To investigate levels of heater-cooler unit colonisation and aerosolisation risk over time within a single UK centre Methods In 2015, guidance was released that required the surveillance of both waters from heater cooler unit’s post-use and air samples taken from during use. Mycobacterial culture of the water samples was undertaken using a modified BacTalert TB protocol (Biomerieux). Air sampling was undertaken as per the guidelines using Middlebrook 7 H11 agar, as well as standard microbiological culture. Results 66 water samples from three heater cooler units (cardioplegia and patient circuits) were taken between September 2015 and February 2017. 12 samples were positive for M. chimaera across all three units, no single unit, however, has been continuously detected as positive. Air samples were taken for monitoring both within the theatre environment and within the setup environment isolated M.mucogenicum. This then grew in a theatre mock-up when the machine was covered. All other air samples remained negative. Other Mycobacteria were isolated from 10 water samples and sequencing was required for identification. Conclusions Despite sporadic detection of M. chimaera within all three-heater cooler units utilised no M. chimaera has been detected within the air surrounding the units, thus indicating a low risk of transmission to patients undergoing surgery. Air was sampled in rooms that had between 10 and 25 air changes per hour and this may be the source of the decreased detection levels.

Objective: We aimed to assess the efficacy of preoperative antibiotic therapy for the treatment of prosthetic graft infection. Materials and Methods: We retrospectively analyzed the treatment strategies used for managing patients with prosthetic vascular graft infections between 2000 and 2016. The patients were divided into two groups: early antibiotic (EA) group, those who were administered with antibiotics ≥2 weeks preoperatively and late antibiotic (LA) group, those who were administered with antibiotics

Background: Vascular graft infection (VGI), a serious complication in vascular surgery, has a high morbidity and mortality rate. The diagnosis is complicated by non-specific symptoms and challenged by the variable accuracy of different imaging techniques. The objective of this study was to determine the diagnostic value of various imaging techniques to diagnose VGI. Methods: A systematic review was conducted according to the PRISMA guidelines. Data sources included PubMed/Medline, Embase, and Cochrane from January 1997 until October 2017. Observational cohort studies were included. A meta-analysis was conducted on several imaging modalities: computed tomography with or without angiography (CT(A)), F-18-fluoro-D-deoxyglucose positron emission tomography with or without low dose or contrast enhanced CT (FDG-PET(/CT)), and white blood cell scintigraphy with or without single photon emission computed tomography combined with low dose CT (WBC (SPECT/CT)). Results: Of 4259 papers, 14 articles were included, containing eight prospective and six retrospective articles. CTA (I-2 7.4%), FDG-PET (I-2 36.5%), and FDG-PET/CT (I-2 36.6%) showed negligible to moderate heterogeneity, while WBC scintigraphy +/- SPECT/CT (I-2 78.6%) showed considerable heterogeneity. Pooled sensitivity for CTA was 0.67 (95% CI 0.57-0.75), in contrast to FDG-PET of 0.94 (95% CI 0.88-0.98), FDG-PET/CT of 0.95 (95% CI 0.87-0.99), WBC scintigraphy of 0.90 (95% CI 0.85-0.94), and WBC scintigraphy with SPECT/CT of 0.99 (95% CI 0.92-1.00). The pooled specificities were for CTA 0.63 (95% CI 0.48-0.76), FDG-PET 0.70 (95% CI 0.59-0.79), FDG-PET/CT 0.80 (95% CI 0.69-0.89), WBC scintigraphy 0.88 (95% CI 0.81-1.94), and WBC scintigraphy SPECT/CT 0.82 (95% CI 0.57-0.96). Pre-and post-test results showed that WBC SPECT/CT favours FDG-PET/CT, with a positive post-test probability of 96% versus 83%. Conclusion: This meta-analysis suggests the diagnostic performance of WBC scintigraphy combined with SPECT/CT is the greatest in diagnosing VGI. However, it is a time consuming technique and not always available. Therefore FDG-PET/CT may be favourable as the initial imaging technique. The use of solitary CTA in diagnosing VGI seems to be obsolete. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

International audience; Vascular access infection is a frequent complication in hemodialysis patients. We report the second case worldwide of a prosthetic hemodialysis vascular graft infection by Coxiella burnetii, with intense hypermetabolism on PET-CT, Q fever serology consistent with persistent infection, and positive C. burnetii DNA in the blood and removed vascular graft.

Vascular graft insertion to treat aortic or peripheral aneurysm and lower limb occlusive disease is now commonplace [1]. A variety of synthetic materials, autologous veins, or a combination of the two can be used as the graft material depending on the anatomical location and clinical circumstance [2]. Although graft-related complications are uncommon, one of the most feared is graft infection and this remains a major surgical challenge [3]. This chapter will discuss the use of FDG PET/CT in the diagnosis of vascular graft infection.

Background The aim of this study was to evaluate the effectiveness of linezolid, teicoplanin, and vancomycin in prevention of prosthetic vascular graft infections in a vascular graft infection model. Material/Methods Fifty rats were divided into 5 groups. A polytetrafluoroethylene graft was implanted on the back of each rat. Methicillin-resistant Staphylococcus aureus (MRSA) strain was inoculated into all rats except Group 1. Group 2 was not given any treatment, Group 3 received linezolid, Group 4 received vancomycin, and Group 5 received teicoplanin. The grafts were removed for microbiological and histological examinations on the 7th day. In addition, C-reactive protein and prealbumin levels and leukocyte counts in obtained blood specimens were determined. Results Group 1 did not have infection. Group 2 had bacteria 5.7×104 CFU/cm2. Group 3 and Group 4 had less bacterial growth. Group 5 had no bacterial growth. The number of bacteria was significantly higher in Group 2 than in the other experimental groups and the control group (p

Sir,Making the diagnosis of vascular graft infection caused by rare and/or slow growing microorganisms poses significant difficulties. 2-[Fluorine-18] fluoro-2-deoxy-D-glucose-positron emission tom...

Pseudomonas stutzeri is infrequently isolated from clinical specimens, and if isolated, more likely represents colonization or contamination rather than infection. Despite this, there are dozens of case reports which describe clinically significant P. stutzeri infections at variable sites. A 69-year-old man had a P. stutzeri infection of a prosthetic vascular graft infection, which he received in Panama City. He was successfully treated with a single antipseudomonal agent for 6 weeks and the removal of the infected vascular graft. A 70-year-old man had a P. stutzeri infection of a prosthetic joint, which was successfully treated with a single anti-pseudomonal agent for 6 weeks. There is only one other documented case of a prosthetic vascular graft infection secondary to P. stutzeri. There are 5 documented cases of P. stutzeri prosthetic joint infections. The previous cases were treated with antibiotics and variably, source control with the removal of prosthetic material. Most cases of P. stutzeri infection are due to exposure in health care settings. Immunocompromised states such as HIV or hematological and solid tumor malignancies are risk factors for P. stutzeri infection. Infections caused by P. stutzeri are far less frequent and less fatal than those caused by P. aeruginosa. The etiology of a P. stutzeri infection could be exposure to soil and water, but also contaminated material in the health care setting or an immunocompromised state. Iatrogenic infections that are secondary to health care tourism are a potential cause of fever in the returned traveler.

Introduction. It is estimated up to 6 % of prosthetic vascular grafts become infected. Staphylococcus aureus is predominant in early infection and coagulase-negative staphylococci are predominant in late infections. Enterobacteriaceae cause 14–40 % of prosthetic vascular graft infections. This is, to our knowledge the first reported case of Salmonella gastroenteritis causing chronic prosthetic vascular graft infection (PVGI). Case presentation. A 57 years old lady presented with signs and symptoms of prosthetic vascular graft infection. Three years earlier, she had undergone a prosthetic axillo-femoral bypass graft for critical limb ischaemia. The infected prosthetic vascular graft was removed and Salmonella Typhimurium was isolated on culture. In the intervening period, Salmonella Typhimurium was isolated from a faecal specimen, collected during an episode of acute gastroenteritis. Whole-genome sequencing (WGS) showed that the respective Salmonella Typhimurium isolates differed by only a single nucleotide polymorphism (SNP). Salmonella Typhimurium was not isolated on culture of a faecal specimen collected five days following cessation of antimicrobial therapy. Six months after removal of the prosthetic graft, the patient remains under follow-up for her peripheral vascular disease, which currently requires no further surgical intervention. Conclusion. This case has clear implications for the management of chronic PVGI. It is vital to collect high-quality surgical specimens for microbiological analysis and empirical choices of antibiotics are unlikely to cover all potential pathogens. It may also be prudent to enquire about a history of acute gastroenteritis when assessing patients presenting with chronic PVGI.

Introduction In treatment of prosthetic vascular graft infection (PVGI), appropriate antimicrobial treatment is crucial for controlling the septic process and preventing re-infection of the new graft. Glycopeptides are the mainstay of treatment for device-related infections by methicillin-resistant Staphylococcus aureus strains, but with some limitations, especially concerning vancomycin-intermediate and glycopeptide-intermediate S. aureus. We report our experience using a high dose of daptomycin (DAP) for treatment of PVGI. Methods We reviewed medical reports of 26 patients treated with high doses of DAP (>8 mg/kg) and beta-lactams/aminosides for PVGI, defined as positive bacterial culture of intraoperative specimens or blood samples and/or clinical, biological, and radiological signs of infection. Clinical success was defined by resolution of all clinical signs at the end of follow-up, without the need for additional antibiotic therapy, and/or negative culture in case of new surgery. Results Cultures of intraoperative samples were positive in 21 patients (80.8%). Blood and intraoperative cultures were concomitantly positive in 10 patients. The main microorganism identified in microbiological samples was S. aureus (n = 18). Surgery was performed in 23 patients (88.4%). The mean duration of the DAP regimen was 12.3 ± 11.9 days. DAP was discontinued in 26 patients [need to switch to microbiological results (n = 19), bacterial pneumonia (n = 2), and increased creatine phosphokinase levels (n = 4)]. One patient had myalgia, while 9 received concomitant statins. Conclusion High-dose DAP therapy shows a satisfactory toxicity profile even in severely ill patients with multiple comorbidities, and may favorably compete with vancomycin, especially concerning the risk of induced nephrotoxicity. Electronic supplementary material The online version of this article (doi:10.1007/s40121-014-0035-9) contains supplementary material, which is available to authorized users.

Histoplasma infection of vascular grafts is extremely rare. To our knowledge, there are only 4 cases reported with Histoplasma capsulatum infection of the aortic graft. All had previous disseminated histoplasmosis and atherosclerotic peripheral vascular disease. They were treated surgically with explantation of the infected graft and reimplantation of new graft in extra-anatomic uninfected site. The authors present a new case of H capsulatum infection of aortofemoral bypass graft, but unlike the other cases, this case was managed without surgical intervention.

Objectives Prosthetic vascular graft infections (PVGIs) are associated with high mortality rates. To improve treatment outcome, an early and definite diagnosis is critical, and current diagnostic criteria are often insufficient. The accuracy of 2-deoxy-2-[fluorine-18]-fluoro- d -glucose positron emission tomography integrated with computed tomography (18F-FDG PET/CT) and white blood cell (WBC) scan for the diagnosis of PVGI were compared. Methods A retrospective single centre study was conducted on patients undergoing WBC scan and 18F-FDG PET/CT for a suspected PVGI between April 2013 and June 2016 at the Bordeaux University Hospital, France. The diagnostic value of both imaging tests was assessed for all grafts, using receiver operating characteristic (ROC) curve analysis. Images were independently interpreted by two nuclear medicine physicians blinded to the patients’ clinical and other imaging data. Results Thirty-nine patients were included, of whom 15 had PVGI. Antibiotic treatment was started before nuclear imaging for 16 patients, including nine patients with a PVGI. The 96 grafts of these patients were analysed, and 19 were infected. The diagnostic value of the WBC scan was significantly higher than 18F-FDG PET/CT (ROC AUC = 0.902, 95% CI 0.824–0.980, and 0.759, CI 95% (0.659–0.858), respectively, p = .0071). Interobserver agreement was good for 18F-FDG PET/CT and excellent for WBC scan (kappa value of 0.76, 95% CI 0.62–0.9, and 0.97, 95% CI 0.92–1, respectively). Only one patient had a false negative 18F-FDG PET/CT result under antibiotic therapy. Conclusion The WBC scan has a better diagnostic value than 18F-FDG PET/CT for PVGI diagnosis.

We investigated the efficacy of tigecycline and FS8, alone or combined, in preventing prosthesis biofilm in a rat model of staphylococcal vascular graft infection. Graft infections were established in the back subcutaneous tissue of adult male Wistar rats by implantation of Dacron prostheses followed by topical inoculation with 2 x 107 colony-forming units of Staphylococcus aureus, strain Smith diffuse. The study included a control group, a contaminated group that did not receive any antibiotic prophylaxis, and three contaminated groups that received: (i) intraperitoneal tigecycline, (ii) FS8-soaked graft, and (iii) tigecycline plus FS8-soaked graft, respectively. Each group included 15 animals. The infection burden was evaluated by using sonication and quantitative agar culture. Moreover, an in vitro binding-study was performed to quantify the how much FS8 was coated to the surface of the prosthesis. Tigecycline, combined with FS8, against the adherent bacteria showed MICs (2.00 mg/L) and MBCs (4.00 mg/L) four-fold lower with respect to tigecycline alone in in vitro studies. The rat groups treated with tigecycline showed the lowest bacterial numbers (4.4 x 104 ± 1.2 x 104 CFU/mL). The FS8-treated group showed a good activity and significant differences compared to control group with bacterial numbers of 6.8 x 104 ± 2.0 x 104 CFU/mL. A stronger inhibition of bacterial growth was observed in rats treated with a combined FS8 and tigecycline therapy than in those that were singly treated with bacterial numbers of 101 CFU/mL graft. In conclusion, the ability to affect biofilm formation as well, its property to be an antibiotic enhancer suggests FS8 as alternative or additional agent to use in conjunction with conventional antimicrobial for prevention of staphylococcal biofilm related infection.

Einleitung: Protheseninfektionen in der peripheren Bypasschirurgie stellen ein hochsignifikantes Risiko hinsichtlich Morbiditat und Extremitatenverlust dar. Bei fehlendem Venenmaterial stellt sich die Frage nach einem geeigneten Gefasersatz. Silberprothesen, Homografts bzw. die Verwendung tiefer Venen ist mit zusatzlichen Risiken behaftet. Die Verwendung einer biosynthetischen Prothese aus Schafskollagen auf einer Dacron-Matrix („Omniflow-II®“) wurde als Alternativverfahren untersucht und die Erlossituation analysiert. Material und Methoden: In der Zeit von Dezember 2010 bis Dezember 2011 wurden 8 Patienten aufgrund eines klinisch, laborchemisch und durch Bildgebung nachgewiesenen Infekts einer funktionell offenen bzw. akut verschlossenen Gefasprothese in peripherer Lokalisation zur Behandlung aufgenommen. Eingeschlossen wurden Patienten, bei denen eine In-situ-Rekonstruktion der infizierten Prothese moglich war. Das infizierte Material wurde in toto entfernt, eine mikrobiologische Probe gewonnen und bei fehlenden korpereigenen oberflachlichen Venen eine biosynthetische Kollagenprothese („Omniflow-II®“) implantiert. Das Follow-up der Patienten wurde anhand der Dokumentation aufgearbeitet. Die Erlossituation wurde vor und nach Optimierung untersucht. Ergebnisse: Die technische Durchfuhrbarkeit war in allen Fallen gegeben. Ein mikrobiologischer Nachweis von Erregern gelang in 5 von 8 Fallen. Bei einer mittleren Nachbeobachtungszeit von 8 Monaten zeigten 7 von 8 Patienten eine klinische Ausheilung des Infekts. Die primare Offenheitsrate betragt 63 %, die sekundare 75 %, der Beinerhalt liegt bei 88 %. Ein Patient musste bei drohender Sepsis oberschenkelamputiert werden, ein weiterer wurde nach 12 Monaten frustran thrombektomiert. Bei 4 PET-CT-Verlaufsuntersuchungen zeigte sich eine deutliche Minderung der Glukoseutilisation im betroffenen Bereich. Zur ausreichenden Erlosgenerierung ist differenziertes Kodierungswissen im DRG-Kontext notig. Diskussion: Die Behandlung des Protheseninfekts in der peripheren Bypasschirurgie stellt bei fehlendem korpereigenen Material in leicht zuganglicher Lokalisation hohe Anspruche an das zu verwendende Ersatzmaterial. Die vorliegende Untersuchung zeigt ermutigende Ergebnisse bei der Verwendung einer biosynthetischen Kollagenprothese. Bei fehlenden Langzeitergebnissen sollte das Verfahren jedoch nur nach entsprechender Aufklarung des Patienten durchgefuhrt werden. Der zu erreichende Erlos deckt die hoheren Kosten des Transplantats.

Introduction. Graft infection is rightly considered one of the severest complications of vascular reconstruction. Treatment is non­standardized and associated with high mortality and morbidity rates. The choice of therapeutic modality depends upon variety of factors. One increasingly used option is in situ replacement of the infected prosthesis with the arterial allograft. Objective. The aim of this prospective nonrandomized study was to evaluate the effectiveness and durability of fresh arterial allograft as in situ substitute for the infected vascular prosthesis. Methods. During period of 2002-2005, 18 patients with the synthetic vascular graft infection underwent partial or complete prosthesis removal and secondary in situ reconstruction using the fresh arterial allograft, preserved under hypothermic conditions in buffered saline solution with an addition of antibiotics. Results. In 14 male and 4 female patients, meanaged 62 years, 8 aortic and 10 peripheral arterial infected prostheses were partially or completely replaced with the allograft. Operative mortality was 27.8% and amputation rate was 22.2%. Systemic sepsis at initial presentation and highly virulent nature of causative microorganisms were identified as significant negative prognostic factors (χ² test, p

In recent years, there has been an increasing emphasis on efficient and accurate diagnostic testing, exemplified by the American Board of Internal Medicine’s “Choosing Wisely” campaign. Nuclear imaging studies can provide early and accurate diagnoses of many infectious disease syndromes, particularly in complex cases where the differential remains broad.This review paper offers clinicians a rational, evidence-based guide to approaching nuclear medicine tests, using an example case of methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia in a patient with multiple potential sources. Fluorodeoxyglucose-positron emission tomography (FDG-PET) with computed tomography (CT) and sulfur colloid imaging with tagged white blood cell (WBC) scanning offer the most promise in facilitating rapid and accurate diagnoses of endovascular graft infections, vertebral osteomyelitis (V-OM), diabetic foot infections, and prosthetic joint infections (PJIs). However, radiologists at different institutions may have varying degrees of expertise with these modalities.Regardless, infectious disease consultants would benefit from knowing what nuclear medicine tests to order when considering patients with complex infectious disease syndromes.

We present an unusual case of a 74-year-old woman who presented with a pseudoaneurysm at the site of a previous prosthetic femoro-popliteal bypass graft and underwent an urgent repair with pseudoaneurysm excision and extra-anatomic placement of an autologous venous graft. Microbiology examination revealed Aspergillus fumigatus infection of the graft, which is a very rare condition. Long-term antifungal medication has been administrated with positive outcome. Only a few cases have been reported in literature, mainly involving aortic grafts. Most patients are immunocompetent and with late presentation. Successful outcome can only be achieved with long-term antifungal treatment and extra-anatomic replacement of the graft.