Outpatient parenteral antimicrobial therapy (OPAT) for aortic vascular graft infection; a five-year retrospective evaluation

Niamh Allen,Cora McNally,Eoghan de Barra,Aoife Seery,Mohamed Adam,Samuel McConkey,Grace O’Regan,Aisling Brown

doi:10.1186/s12879-021-06373-4

Abstract

ObjectivesAn estimated 1% of endovascular aneurysm repair (EVAR) devices become infected, carrying a high mortality rate. Surgical explantation is recommended and prognosis is guarded. This retrospective cohort analysis focuses on the role of outpatient parenteral antimicrobial therapy (OPAT) in the management of aortic vascular graft infections following EVAR.MethodsPatients who received OPAT for aortic graft infections (AGI) following EVAR from 2014 to 2018 inclusive were identified using the OPAT database. Clinical, microbiological and radiological data were collected. Survivors were followed up for a median of 36 months (range 25–60) after first presentation with infection. Outcomes were assessed.ResultsEleven cases with 20 OPAT episodes were identified: 10/11 male, median age 76 (IQR 71–81). Median time to presentation was 7 months (range 0–81 months) after EVAR. OPAT lead to a 55% reduction in length of hospital stay. One patient had graft explantation; four others had temporising measures. Eight of 11 were alive a median of 36 months after presentation with infection, having had a median of 2 re-treatments on OPAT (range 1–3). Seven of the eight survivors were on continuous suppressive oral antimicrobials; three were also intermittently on intravenous antibiotics for flares of infection. Patient/ infection outcomes were cure (1/11), improved (7/11), failure (3/11).ConclusionAGI following EVAR usually presents in the first year after graft deployment. OPAT has an important peri-operative role in patients suitable for curative surgery. OPAT followed by oral suppressive antimicrobial therapy can be a feasible long-term treatment for non-curative management of AGI. Survival in our cohort was longer than expected, and OPAT was feasible despite the complexity of these infections. OPAT can avoid multiple and lengthy hospital admissions and maximise time at home and quality of life in this cohort with life-limiting infection.

Highlights

Aortic graft infection (AGI) can follow open aortic aneurysmal repair or endovascular aneurysm repair [1]
We examined the presenting features, management, and outcomes of a cohort of patients with AGI following endovascular aneurysm repair (EVAR), with specific focus on the role of outpatient parenteral antimicrobial therapy (OPAT) followed by oral suppressive antimicrobial treatment in treating or suppressing these infections
OPAT may be used as a temporizing measure in those awaiting radical surgery, as induction therapy in those AGIs for medical management, and for treatment of clinical ‘flares’ in patients otherwise well-maintained on oral suppressive therapy

Summary

Introduction

Aortic graft infection (AGI) can follow open aortic aneurysmal repair or endovascular aneurysm repair [1]. Surgical explantation followed by appropriate antimicrobial therapy may be curative in select cases, it is technically difficult, and the role and optimal timing of surgery is unclear [3, 6]. Three meta-analyses of aortic graft infections have been published, one of which focuses on infected EVAR [3, 5, 10]. To the best of our knowledge there is no published data focusing on the use of outpatient parenteral antimicrobial therapy (OPAT) for AGI. We examined the presenting features, management, and outcomes of a cohort of patients with AGI following EVAR, with specific focus on the role of OPAT followed by oral suppressive antimicrobial treatment in treating or suppressing these infections

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