What is the treatment for infected vascular anastomosis?

Treatment of Infected Vascular Anastomosis

Infected vascular anastomoses require immediate surgical resection of infected tissue combined with broad-spectrum intravenous antibiotics, as these infections are potentially lethal and antibiotics alone are inadequate. 1, 2

Immediate Management Algorithm

Emergency Assessment and Stabilization

• Initiate broad-spectrum IV antibiotics immediately covering both Gram-positive (including MRSA) and Gram-negative organisms, typically vancomycin plus an aminoglycoside or piperacillin-tazobactam 1, 2
• Obtain blood cultures and wound cultures before antibiotics if possible, but do not delay treatment 2
• Assess for systemic sepsis (fever, hypotension, tachycardia) and limb viability (distal pulses, capillary refill, signs of ischemia) 2
• Cease all cannulation at the infected site immediately 2

Urgent Surgical Consultation

• Vascular surgery consultation is mandatory within hours, not days 2
• Infections at the AV anastomosis are potentially lethal in dialysis patients with impaired immunity and require aggressive surgical management 1, 2

Definitive Surgical Management

For Arteriovenous Fistula Anastomotic Infections

• Immediate surgical resection of infected tissue is required 1
• If arterial segment requires resection, reconstruction options include:
  • Interposition graft using autogenous vein 1
  • Creation of more proximal new AV anastomosis using exclusively degradable suture material 1
• Fistula takedown is required if septic emboli are present 1

For Arteriovenous Graft Infections

Superficial infections (not involving the graft itself):

• Treat with broad-spectrum antibiotics based on culture results 1
• Incision and drainage may be beneficial 1
• Initial coverage must include Gram-negative, Staphylococcal, Streptococcal, and Enterococcal organisms 1

Extensive infections involving the graft:

• Surgical exploration and removal of infected graft material combined with antibiotic therapy is necessary for complete resolution 1
• Total resection of the graft is required 1

Newly placed grafts (within 1 month):

• Remove the entire graft regardless of infection extent, as new grafts are not incorporated into surrounding tissue 1

Antibiotic Therapy Duration

• Primary AV fistula infections require 6 weeks of IV antibiotic therapy, analogous to subacute bacterial endocarditis 1, 2
• Tailor antibiotics based on culture and sensitivity results once available 1, 2
• For graft infections requiring surgical resection, prolonged antibiotic therapy is necessary following removal 1

Critical Pitfalls to Avoid

• Never continue oral antibiotics (such as doxycycline) as monotherapy for vascular access infections—this provides inadequate coverage and risks treatment failure with potential for sepsis and death 2
• Do not delay surgical consultation while attempting medical management alone for anastomotic infections 2
• Do not underestimate severity in dialysis patients—they have impaired immunity and high risk for metastatic complications including endocarditis and septic emboli 1, 2
• Do not plan short-course antibiotics—primary AV fistula infections require 6 weeks of IV therapy, not typical 7-10 day courses 2
• Do not probe or manipulate dehisced wounds to search for fistula tracts, as this causes iatrogenic complications 2
• Arrange alternative dialysis access immediately, as the infected access cannot be used 2

Special Considerations for Graft Preservation

While graft preservation may be considered in highly selected cases of superficial graft infections, anastomotic infections are not candidates for preservation and require resection 1. The American Heart Association notes that graft preservation should not be attempted with MRSA, Pseudomonas aeruginosa, or multidrug-resistant organisms 1.