title: Antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary vascular surgical site infections.
abstract: OBJECTIVE
  This study assessed the efficacy of antibiotic-loaded polymethylmethacrylate (PMMA) beads in the treatment of lower extremity vascular surgical site infections (VSSIs).
  
  
  METHODS
  This was a retrospective review of all patients with a VSSI of a lower extremity bypass treated with antibiotic-loaded PMMA beads and culture-specific antibiotics during a 4.5-year period. Data collected included patient demographics, comorbidities, site of initial graft infection, symptoms and signs at presentation, initial and additional surgical debridement, wound culture results, type of antibiotic beads implanted, and graft treatment strategy, comprising conduit preservation or in situ replacement, with associated soft tissue management by muscle flap or vacuum-assisted closure. Primary outcome measures included death, recurrent infection, and limb salvage.
  
  
  RESULTS
  Forty patients developed 42 extracavitary lower extremity VSSIs (bilateral groin infections in two). Patients were treated according to our treatment algorithm with antibiotic-impregnated PMMA beads. Previous reconstructions included nine aortofemoral bypasses (groin infection only), 20 infrainguinal bypasses, five extra-anatomic bypasses, five femoral interpositions, two combined inflow-outflow bypass procedures, and one patch angioplasty with VSSI. Cultures isolated 59 pathogens (39 gram-positive, 18 gram-negative, 2 Candida spp). Methicillin-resistant Staphylococcus aureus was cultured from 10 VSSs (23.8%) overall and from 27.7% of those patients with attempted graft preservation or in situ reconstructions. Two patients (4.8%) had no growth despite clinical signs of infection. Repeat VSS exploration and culture results led to an average of 1.4 bead replacements before definitive treatment. Final treatment strategy included graft preservation of patent bypasses in 28, partial graft excision with in situ replacement in eight, graft removal only with residual graft remaining at implant site (ie, incorporated anastomotic conduit, 11.9%) in five, and extra-anatomic reconstruction in one. Sartorius muscle flap was performed in 14 groin infections (37.8%). The 30-day mortality was 0%, and limb loss was 7.1% (n = 3). At the median follow-up of 17 months, the limb loss was 21.4% and the recurrent infection rate was 19.4% (seven of 36) in those with attempted graft preservation or in situ replacement.
  
  
  CONCLUSIONS
  Antibiotic-loaded PMMA beads may serve as an adjunct in the management of VSSIs and may also expand treatment options for graft preservation or in situ reconstruction, with expected recurrent infection rate approaching 20%. Further experience with this adjunct may help elucidate its role in the management of this complicated problem, including the need for bead exchanges, until perigraft cultures are free of microbes.
authors.affiliation: Department of Vascular Surgery, West Virginia University, Charleston, WVA 25304, USA. pstone0627@yahoo.com
authors.forename: Patrick A
authors.initials: PA
authors.lastname: Stone
authors.forename: Albeir Y
authors.initials: AY
authors.lastname: Mousa
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Hass
authors.forename: D Daniel
authors.initials: DD
authors.lastname: Dearing
authors.forename: James R
authors.initials: JR
authors.lastname: Campbell
authors.forename: Ashley
authors.initials: A
authors.lastname: Parker
authors.forename: Stephanie
authors.initials: S
authors.lastname: Thompson
authors.forename: Ali F
authors.initials: AF
authors.lastname: AbuRahma
mesh_terms: D000671:Amputation, Surgical; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D001807:Blood Vessel Prosthesis / Q000009:adverse effects*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D002626:Chemistry, Pharmaceutical; D003131:Combined Modality Therapy; D003646:Debridement; D004337:Drug Carriers; D006801:Humans; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D054843:Negative-Pressure Wound Therapy; D019904:Polymethyl Methacrylate; D016459:Prosthesis-Related Infections / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality / Q000601:surgery; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps; D013530:Surgical Wound Infection / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome; D014903:West Virginia
chemical_list: D000900:Anti-Bacterial Agents; D004337:Drug Carriers; D019904:Polymethyl Methacrylate