Use of antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary prosthetic vascular graft infections
Use of antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary prosthetic vascular graft infections
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DOI：
10.1016/j.jvs.2006.05.056
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发表时间：
2006-10-01
影响因子：
4.3
通讯作者：
Shames, Murray L.
中科院分区：
文献类型：
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作者：
Stone, Patrick A.;Armstrong, Paul A.;Shames, Murray L.
目的：本研究旨在评估载有抗生素的聚甲基丙烯酸甲酯 (PMMA) 珠在治疗下肢腔外假体动脉移植物感染中的疗效。方法：本研究对 34 名接受血管手术部位 (VSS) 感染的患者进行回顾性评价，涉及 36 个假体下肢动脉旁路，使用载有抗生素的 PMMA 珠和培养特异性肠外抗生素治疗 4 至 6 周。对移植物感染部位进行探查、清创和培养。根据VSS脓液的革兰氏染色结果确定，PMMA粉末与抗生素（万古霉素、达托霉素或妥布霉素/庆大霉素或组合）聚合，模制成珠链，并在清创和脉冲喷雾抗菌灌洗后植入到感染的移植物附近。所有伤口均主要通过计划探查进行闭合，以在移植物保存或原位置换手术之前验证灭菌情况。根据组织培养分离株、持续感染程序和无移植物感染情况，对包括伤口消毒在内的治疗结果进行分析。结果：培养物分离出 42 种病原体（32 种革兰氏阳性菌、9 种革兰氏阴性菌、1 种白色念珠菌）以及从 36 例手术部位感染中的 16 例（44%）培养的耐甲氧西林金黄色葡萄球菌 (MRSA)。根据初次手术革兰氏染色或之前的培养结果确定，在第一次手术时，36 例 VSS 感染中的 29 例植入了万古霉素 PMMA 珠；其余部分植入达托霉素 (n = 4) 或妥布霉素 (n = 3) 珠。重复 VSS 探查和培养结果导致在最终治疗前平均更换 2.5 个抗生素珠。在移植物保存 (n = 16) 或原位替换受感染移植物 (n = 20) 手术之前，87% 的病例实现了无菌（组织培养上无生长）VSS。没有发生患者死亡事件。早期和晚期保肢率为100%。在平均 23 个月的随访期间，有 4 例 (11%) VSS 出现感染复发，其中 1 例在 3 个月内复发，原因是与主动脉股动脉移植肢体原位置换相关的肠损伤未被识别。结论：载有抗生素的 PMMA 珠可能是涉及假体移植物的 VSS 感染的当代外科治疗中的有用辅助手段。大多数 VSS 均在移植物保存或原位置换手术之前实现了伤口消毒，包括由 MRSA 引起的感染，MRSA 是一种在一半的腔外假体移植物感染中分离出的病原体。这项初步试验显示了这项新技术的潜在好处，但需要进一步研究来证明其有效性。
Purpose: This study was conducted to assess the efficacy of antibiotic-loaded polymethylmethacrylate (PMMA) beads in the management of lower extremity extracavitary prosthetic arterial graft infection.Methods: This was a retrospective review of 34 patients treated for vascular surgical site (VSS) infections involving 36 prosthetic lower extremity arterial bypasses using antibiotic-loaded PMMA beads and culture-specific parenteral antibiotics for 4 to 6 weeks. Sites of graft infection were explored, debrided, and cultured. As determined from the results of Gram's stains of VSS purulence, PMMA powder was polymerized with an antibiotic (vancomycin, daptomycin, or tobramycin/gentamicin, or a combination), molded into a chain of beads, and implanted adjacent to the infected graft after debridement and pulsed-spray antibacterial lavage. All wounds were closed primarily with planned exploration to verify sterilization before a graft preservation or in situ replacement procedure. Treatment outcomes, including wound sterilization, were analyzed based on tissue culture isolates, procedures for persistent infection, and freedom from graft infection.Results: Cultures isolated 42 pathogens, (32 gram-positive, 9 gram-negative, 1 Candida albicans) with methicillin-resistant Staphylococcus aureus (MRSA) cultured from 16 (44%) of 36 surgical site infections. As determined from the initial operative Gram's stain or a prior culture result, vancomycin PMMA beads were implanted in 29 of 36 VSS infections at the first procedure; daptomycin (n = 4) or tobramycin (n = 3) beads were implanted in the rest. Repeat VSS exploration and culture results led to an average of 2.5 antibiotic bead replacements before definitive treatment. A sterile (no growth on tissue culture) VSS was achieved in 87% of cases before a graft preservation (n = 16) or in-situ replacement of an infected graft (n = 20) procedure. No patient deaths occurred. Early and late limb salvage was 100%. Infection recurred in 4 (11%) VSSs during a mean 23-month follow-up period, one within 3 months owing to unrecognized bowel injury associated with in situ replacement of an aortofemoral graft limb.Conclusion: Antibiotic-loaded PMMA beads may be a useful adjunct in the contemporary surgical management of VSS infection involving a prosthetic graft. Wound sterilization was achieved in most VSSs before graft preservation or an in-situ replacement procedure, including infections caused by MRSA, a pathogen isolated in half of the extracavitary prosthetic graft infections. This preliminary trial shows the potential benefit of this new technique, but further study is required to prove efficacy.