Systematic approach to diagnosis and management of infected prosthetic grafts in the proximal aorta.

OBJECTIVES: Management of infected prosthetic aortic grafts in the ascending and or root is complex and multifaceted. We report our diagnostic pathway, management and outcomes, identifying successful strategies. METHODS: This was a retrospective, single center, observational study. Consecutive patients who underwent management of infected aortic grafts in the ascending and/or root at our institution between October 1998 and December 2019 were included. The main outcome measures were: discharge from hospital alive with at least 1 year survival, operative mortality and success of primary treatment strategy. RESULTS: Twenty-six patients presented with infection of proximal aortic grafts and were managed through a number of strategies with an overall hospital-survival of 81% and 1 year survival of 69%. Twenty of them ultimately underwent redo surgery with 25% operative mortality (within 24 h of surgery). Five patients underwent washout and irrigation of which two were successfully treated and cured with adjunctive antibiotics and two went on to have staged explant and definitive surgery. Interval between surgery and infection was 42.5 ± 35.8 months. All patients had at least one major criterion and three minor criterions with no diagnostic uncertainty. The commonest primary strategy was 3a (definitive surgery), (13/26, 50%). CONCLUSIONS: Adopting a systematic and flexible patient specific approach to the diagnosis and management of patients with proximal aortic graft infections results in reasonable overall 1 year survival. In the majority of patients surgery is ultimately required in an attempt to achieve a curative treatment; however this comes with high operative mortality risk.

In vivo development of heterogeneous glycopeptide-intermediate Staphylococcus aureus (hGISA), GISA and daptomycin resistance in a patient with meticillin-resistant S. aureus endocarditis.

We report a patient who developed a meticillin-resistant Staphylococcus aureus (MRSA) central venous catheter infection complicated by infective endocarditis. The patient was initially treated with glycopeptides, which led to the development of heterogeneous glycopeptide resistance, the detection of which required the use of a macro Etest screening test. Subsequently, the causative strain, confirmed by PFGE as a UK epidemic MRSA-15, was treated with daptomycin, and again resistance developed in vivo. The development in vivo of resistance to both these agents suggests that the resistance mechanisms may be associated. We suggest that the clinician managing MRSA infection should anticipate daptomycin resistance when reduced glycopeptide susceptibility is detected.