Improved management of infrainguinal bypass graft infection with methicillin-resistant Staphylococcus aureus

Background: There is considerable debate over the management of infected in frainguinal grafts. This report describes recent experience in this field a nd documents the change in clinical practice needed to deal with methicilli n-resistant Staphylococcus aureus (MRSA). Methods: All infected infrainguinal grafts between January 1991 and July 19 97 were reviewed. In the light of the findings, clinical practice was modif ied considerably. A further 1 year was audited prospectively up to August 1 998. Results: Twenty-six patients were treated for 27 infrainguinal graft infect ions (25 prosthetic, two vein). Twenty were treated by complete graft excis ion as the initial therapy; graft preservation was attempted in six patient s. Before 1995, the infecting organisms were predominantly Pseudomonas aeru ginosa or methicillin-sensitive staphylococci. Subsequently all 14 patients treated up to 1997 had infection with MRSA. The overall amputation rate wa s 17 of 26; ten amputations were in patients with MRSA. Four patients died, all with MRSA sepsis. As a result of this experience a policy of complete isolation was adopted for all patients infected with MRSA. In the 12 months since this policy was introduced, 77 infrainguinal grafts (61 vein, 16 pro sthetic) have been inserted. Two grafts (3 per cent) have become infected, necessitating graft excision and amputation. Conclusion: MRSA infection of an infrainguinal graft is a serious complicat ion with high associated amputation and mortality rates. Isolation and barr ier nursing appeared to contain the problem.