Is it acceptable to use antibiotic beads around an infected femoropopliteal (fem-pop) bypass graft in a 55-year-old male with peripheral vascular disease instead of removing the graft?

From the Guidelines

Placing antibiotic beads around an infected femoral-popliteal bypass graft is not recommended as a standalone treatment. The standard of care for an infected vascular graft is complete removal of the infected graft material (graft excision) combined with appropriate systemic antibiotics, as supported by the most recent and highest quality study 1. Antibiotic beads alone are insufficient because the prosthetic material serves as a nidus for biofilm formation, which shields bacteria from both systemic antibiotics and local antibiotic delivery systems. The infection will likely persist despite antibiotic beads, leading to ongoing sepsis, anastomotic breakdown, and potentially life-threatening hemorrhage.

Key Considerations

• The prosthetic material of the graft acts as a foreign body, making it difficult for the immune system to clear the infection, as noted in 1 and 1.
• The use of antibiotic beads may provide temporary relief but does not address the underlying issue of the infected graft, as suggested by 1 and 1.
• Management should include graft excision with either extra-anatomic bypass (such as axillofemoral bypass) or in-situ reconstruction using autologous vein, antibiotic-soaked prosthetic, or cryopreserved allograft, depending on the extent of infection and patient factors, as recommended by 1.

Treatment Approach

• Systemic antibiotics should be tailored to culture results and continued for 4-6 weeks, as is standard practice in treating vascular infections 1.
• Attempting to salvage an infected graft with antibiotic beads alone carries high risk of treatment failure and serious complications including limb loss and death, emphasizing the need for a more comprehensive approach as outlined in 1 and supported by the principles of infection management in 1.

From the Research

Graft Infection Treatment Options

• The treatment of infected femoropopliteal bypass grafts can be challenging, and the decision to remove the graft or attempt to preserve it depends on various factors, including the extent of the infection and the patient's overall health 2, 3.
• Some studies suggest that aggressive local treatment, including drainage, debridement, and muscle transposition, may be effective in treating infected lower extremity bypass grafts without the need for graft removal, with superior limb salvage rates compared to excisional therapy 3.
• However, other studies recommend graft removal as the primary treatment for infected prosthetic grafts, especially in cases of severe infection or when the graft is exposed 4, 5.

Use of Antibiotic Beads

• The use of antibiotic beads in the treatment of infected prosthetic grafts is a topic of interest, with some studies suggesting that it may be a useful adjunct to surgical treatment 4.
• Antibiotic beads can be placed in the infected region to provide localized antibiotic delivery and help eradicate the infection 4.
• However, the effectiveness of antibiotic beads in preventing recurrent infection and promoting limb salvage is not well established, and further studies are needed to determine their role in the treatment of infected prosthetic grafts.

Risks and Complications

• Infected femoropopliteal bypass grafts are associated with significant morbidity and mortality, including the risk of limb loss, sepsis, and death 2, 6.
• The risk of recurrent infection and graft failure is also high, especially if the underlying causes of the infection are not addressed 6.
• Therefore, prompt and effective treatment of infected prosthetic grafts is crucial to prevent these complications and improve patient outcomes.