GUIDELINES [ back to index ]
17. Management of graft infection after 1st month of placement (1)
*1 Signs of graft infection
• Clinical signs of infection are tenderness, erythema, warmth, induration, local serous or purulent drainage and skin breakdown. However, even in the absence of these clinical signs, infection might be present, especially in cases of unexplained sepsis, leukocytosis or fever of unknown origin.
• Old clotted grafts may be a silent source of infection, which should be investigated by indium scanning since infected grafts show a marked indium uptake 1. These occult infections of old non-functioning grafts can be a cause of chronic inflammation and resistance to erythropoetin in haemodialysis patients.
• In cases of graft infection, a re-evaluation of precautionary measures to prevent infections, e.g. the correct puncture technique and treatment of nasal S. aureus carriers, must be performed (see Algorithm „Routine Management of A/V Fistula and Graft“ *8).
• If laboratory parameters, e.g. an elevated CRP, suggest an infection, other sources of infection, e.g. infection of a diabetic foot, should be excluded also.
*2 Assess for other causes
• It is important to distinguish infection from skin changes due to allergic dermatitis, venous hypertension, central stenosis, inflammation or lymph/fluid collections (peri-graft seroma) secondary to the creation of the subcutaneous tunnel.
*3 Systemic antibiotic treatment for 4 - 6 weeks plus surgical intervention
• Treatment of graft infections should always include surgical intervention in combination with systemic antibiotic treatment for 3 - 4 weeks 2 3. Only mere superficial infection, which does not involve the graft, may respond to antibiotic therapy alone (see appendix “Antibiotic Treatment”).
• Infection of the graft
must be considered in case of suppuration or bleeding from a
former needle site. The patient should be hospitalised
immediately, blood and wound
cultures taken, and systemic antibiotic therapy instituted
(see appendix “Antibiotic Treatment”).
After local control of inflammation,
resection of the infected graft segment, if possible, or
complete graft removal should be performed
4 5 6 .
In cases of heavy bleeding, urgent surgery is inevitable.
*4 Anastomotic / complete graft infection
• Extensive infections present with purulent discharge, abscess or infected aneurysmal dilatation 2. They require resection of the total graft and systemic antibiotic therapy in order to prevent bacteraemia, sepsis, haemorrhage and death 3 6. In these patients, a delayed tunnelled central venous access should be placed, and the next access should be constructed on the other arm after complete resolution of local and/or systemic signs of infection.
*5 Local puncture site infection
• Localised soft tissue or graft infections after complete healing (after the first month) can occur due to bacterial inoculation during puncture for haemodialysis at a frequency of 5 % per year 4.
• If possible, segmental resection of the infected part should be performed. Otherwise, resection of the complete graft becomes necessary. Conservative excision of the graft has a high recurrence rate and needs close follow-up. Nevertheless, if segmental graft excision/bypass is performed, several authors recommend leaving some parts of the old graft in place, so that this segment can be used for haemodialysis, thereby avoiding the need for dialysis through a central venous catheter 4 5.
*6 Superficial infections without graft involvement
• Superficial soft tissue inflammation around a well incorporated graft can be treated with antibiotics alone (see *3 ).
*7 Pseudoaneurysm infection
• Graft pseudo-aneurysms with parietal thrombus are prone to blood-borne or needling-induced infection. There is a high risk of septicaemia and of bleeding due to skin erosion. Treatment consists of antibiotics and surgical segmental graft excision / bypass.