What is the management for a right femoral incision infection after femoral-femoral (fem-fem) bypass surgery?

Management of Right Femoral Incision Infection After Femoral-Femoral Bypass

Immediately open and drain the infected incision widely, initiate empiric broad-spectrum antibiotics covering both Gram-positive organisms (including MRSA) and Gram-negative bacteria, and assess for graft involvement to determine if graft excision is necessary. 1

Initial Surgical Management

All incisional surgical site infections (SSIs) require prompt and wide opening of the surgical incision, with drainage, irrigation, and debridement. 1 This is the cornerstone of treatment and should not be delayed.

• Inspect for fascial disruption and deep tissue involvement - if suspected, formal operative drainage must be performed immediately 1
• Assess for graft involvement - this is critical as graft infection carries 26.5% risk of major amputation and 50% one-year amputation-free survival 2
• Consider percutaneous drainage, wound irrigation, and negative pressure-assisted wound management as alternatives to reduce need for complete open management 1

Antibiotic Therapy Indications and Selection

Initiate empiric broad-spectrum antibiotics immediately if any of the following are present: 1

• Any SIRS criteria (fever, tachycardia, tachypnea, leukocytosis)
• Signs of organ failure (hypotension, oliguria, decreased mental alertness)
• Immunocompromised status
• Deep incisional or graft involvement

Empiric Antibiotic Coverage

The groin region requires coverage beyond typical skin flora - while clean surgical procedures typically involve Staphylococcus aureus, vascular bypass procedures in the groin can be infected by Gram-negative bacteria due to enteric flora colonization of groin skin. 1

Recommended empiric regimen for infected femoral bypass:

• Vancomycin 30 mg/kg IV (infused over 120 minutes) PLUS a Gram-negative agent (cefepime, piperacillin-tazobactam, or carbapenem) 1
• This covers MRSA (most common pathogen at 55.9% in bypass graft infections), methicillin-sensitive S. aureus, and Gram-negative organisms 2
• Polymicrobial infections occur in 14.7% of cases 2

MRSA Risk Factors Requiring Vancomycin

Use vancomycin if patient has any of these risk factors: 1

• Long-stay care facility residence
• Hospitalization within preceding 30 days
• Charlson score >5 points
• Recent antibiotic therapy (beta-lactams, carbapenems, or quinolones in preceding 30 days)
• Age ≥75 years
• Current hospitalization >16 days
• Prosthetic graft material (which this patient has)

Assessment for Graft Infection

Graft infection is a surgical emergency requiring immediate vascular surgery consultation. 2

Signs suggesting graft involvement:

• Purulent drainage from deep tissues
• Exposed graft material
• Pulsatile mass or pseudoaneurysm
• Systemic sepsis despite superficial wound management
• Persistent fever despite appropriate antibiotics and drainage

If graft infection is confirmed, surgical options include: 2

• Graft excision without reconstruction (35.3% of cases) - results in amputation
• Graft excision with in-line reconstruction (32.4% of cases)
• Graft excision with extra-anatomic reconstruction (5.9% of cases)
• Incision and drainage alone (20.6% of cases) - only if graft not involved

Risk Factors Present in This Case

Prosthetic grafts carry 3.73-fold increased risk of infection compared to autogenous vein. 2 Femoral-femoral bypass by definition uses prosthetic material, placing this patient at higher baseline risk.

Monitor for these associated complications that increase infection risk: 2

• Postoperative hematoma (3.44-fold increased risk of graft infection)
• Lymphocele or lymphorrhea
• Need for 30-day readmission (2.75-fold increased risk)

Culture and Antibiotic Adjustment

• Obtain deep tissue cultures before initiating antibiotics if possible - however, do not delay treatment if patient is systemically ill 1
• Adjust antibiotics based on culture results and sensitivities 1
• Continue antibiotics for duration appropriate to depth of infection - superficial SSIs may require shorter courses, while graft infections require 4-6 weeks 1

Common Pitfalls to Avoid

• Do not treat with antibiotics alone without drainage - this will fail 1
• Do not assume only Gram-positive coverage is needed - groin location requires Gram-negative coverage 1
• Do not delay graft assessment - early recognition of graft involvement is critical to limb salvage 2
• Do not continue prophylactic antibiotics beyond 24 hours postoperatively - this does not prevent SSI and increases resistance 1, 3

Wound Management After Drainage

• Once infection clears, the wound can be closed secondarily 1
• Negative pressure wound therapy is effective for managing these complex wounds 1
• Superficial incisional SSIs that have been opened can usually be managed without antibiotics if no systemic signs present 1