1 00:00:03,120 --> 00:00:07,560 Sara Dong: Hey everyone, welcome to Febrile, a cultured podcast about all things infectious disease. 2 00:00:08,119 --> 00:00:13,350 We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management. 3 00:00:13,780 --> 00:00:16,530 I'm Sara Dong, your host and a MedPeds ID doc. 4 00:00:17,159 --> 00:00:19,749 We're back with a Febrile StAR episode. 5 00:00:20,180 --> 00:00:28,669 Today, we have a team all from the Division of Public Health, Infectious Diseases, and Occupational Medicine at Mayo Clinic in Rochester, Minnesota. 6 00:00:29,419 --> 00:00:31,110 So let me introduce our guest stars. 7 00:00:32,385 --> 00:00:33,425 First up, we have Dr. 8 00:00:33,425 --> 00:00:38,585 Hussam Tabaja, who is an assistant professor of medicine in the Division of ID. 9 00:00:38,905 --> 00:00:44,515 He completed his internal medicine residency at the Detroit Medical Center and Wayne State University. 10 00:00:45,104 --> 00:00:50,295 Following that, he moved to Rochester, where he completed his three year ID fellowship at Mayo Clinic. 11 00:00:50,475 --> 00:00:58,055 His clinical research is focused on hardware associated infections, including both cardiovascular device and orthopedic device infections. 12 00:00:58,900 --> 00:01:00,780 Hussam Tabaja: Hi, my name is Hussam Tabaja. 13 00:01:00,830 --> 00:01:02,890 I am very excited to be here today. 14 00:01:03,610 --> 00:01:04,740 Sara Dong: Next, we welcome Dr. 15 00:01:04,740 --> 00:01:05,790 Mac Chesdachai. 16 00:01:06,220 --> 00:01:09,219 He is an assistant professor of medicine in the Division of I. 17 00:01:09,219 --> 00:01:09,639 D. 18 00:01:10,020 --> 00:01:16,329 He completed his internal medicine residency at the University of Minnesota followed by his fellowship at Mayo Clinic. 19 00:01:17,209 --> 00:01:21,739 His interests include cardiovascular infections and infections in solid organ transplant recipients. 20 00:01:22,300 --> 00:01:24,320 Mac Chesdachai: Hi, my name is Mac Chesdachai. 21 00:01:24,380 --> 00:01:25,880 Thank you so much for having me. 22 00:01:26,609 --> 00:01:28,119 Sara Dong: And rounding out the team is Dr. 23 00:01:28,119 --> 00:01:29,199 Daniel DeSimone. 24 00:01:29,329 --> 00:01:32,829 He is a consultant and associate professor in the Division of ID. 25 00:01:32,869 --> 00:01:36,570 He also holds a joint appointment in the Department of Cardiovascular Diseases. 26 00:01:37,360 --> 00:01:43,679 He has chaired and vice chaired several American Heart Association scientific statements in cardiovascular infectious diseases. 27 00:01:44,220 --> 00:01:54,080 His clinical and research interests focus on the prevention, diagnosis, and management of infective endocarditis, cardiac implantable electronic device infections, and vascular graft infections. 28 00:01:54,670 --> 00:01:57,770 Daniel DeSimone: Hi, my name is Daniel DeSimone, and it's a pleasure to be here. 29 00:01:58,009 --> 00:01:58,449 Sara Dong: Great. 30 00:01:58,890 --> 00:02:09,889 So before we talk about your paper, I'd like to ask, as everyone's favorite cultured podcast, I'd love to hear a little piece of culture, basically just something non medical that has made you happy recently. 31 00:02:10,100 --> 00:02:15,910 Hussam Tabaja: So yeah, I mean, I consider myself a boring individual, so not too many interesting things have been going on. 32 00:02:16,809 --> 00:02:24,675 One interesting thing I've recently been playing pickleball, with Mac actually, and, uh, it's very new. 33 00:02:24,675 --> 00:02:29,075 I've never actually, uh, knew about this sport before just a couple of months ago. 34 00:02:29,135 --> 00:02:31,105 So that's, that's a new activity. 35 00:02:31,145 --> 00:02:32,184 And I think it's interesting. 36 00:02:32,244 --> 00:02:34,414 Sara Dong: Someone, someone else mentioned pickleball recently. 37 00:02:34,414 --> 00:02:38,224 I'm not actually sure if it's been released, but you're in good company. 38 00:02:38,445 --> 00:02:38,805 Hussam Tabaja: Yeah. 39 00:02:38,805 --> 00:02:39,695 Mac is a pro. 40 00:02:39,715 --> 00:02:40,715 I am a beginner. 41 00:02:44,035 --> 00:02:44,645 Sara Dong: What about you, Mac? 42 00:02:44,875 --> 00:02:53,204 Mac Chesdachai: Apart from playing pickleball with Hussam, actually one thing that I just want to share is that I'm from Thailand and then in Thai culture. 43 00:02:53,225 --> 00:02:58,244 I mean, the reason why my name is Mac is just because my parents gave me Mac as a nickname. 44 00:02:58,694 --> 00:03:04,394 And I just, I learned that all Thai people always has a nickname because their name is very complicated. 45 00:03:05,124 --> 00:03:09,225 And then the Mac is just from MacGyver, the series that my parents love. 46 00:03:10,270 --> 00:03:10,780 Sara Dong: Excellent. 47 00:03:11,280 --> 00:03:13,650 Daniel DeSimone: And I loved MacGyver growing up. 48 00:03:13,650 --> 00:03:15,470 So that's incredible. 49 00:03:15,470 --> 00:03:16,050 I didn't know that. 50 00:03:16,060 --> 00:03:17,920 Mac Chesdachai: I, I, I never watched this actually. 51 00:03:17,959 --> 00:03:18,109 So 52 00:03:19,669 --> 00:03:20,550 Daniel DeSimone: it's a classic. 53 00:03:20,730 --> 00:03:23,480 Sara Dong: I know it's one of those references that I think is starting to fade. 54 00:03:23,499 --> 00:03:25,319 Like people maybe don't know, but. 55 00:03:25,895 --> 00:03:26,865 That's a good nickname. 56 00:03:26,875 --> 00:03:27,255 Daniel DeSimone: I love that. 57 00:03:27,255 --> 00:03:28,415 I grew up on that show. 58 00:03:28,865 --> 00:03:40,765 And, you know, I never got that pickleball invite, so, uh, you know, but something that brings me joy is I love grilling and I've taken up doing a lot of smoking, not, not cigarettes or anything like that. 59 00:03:40,775 --> 00:03:41,404 That's unhealthy. 60 00:03:41,404 --> 00:03:41,875 Don't smoke. 61 00:03:42,285 --> 00:03:43,584 Smoking ribs. 62 00:03:43,674 --> 00:04:04,690 That's kind of been something I've done over the last, not so much in the winter here because it gets quite cold in Rochester, but definitely in the spring, summer, late fall, and fall I've gotten into trying smoking on my grill and you got these little smoker tubes and you can get different pellets and it's just like a whole nother subculture that like, I just got into it's dangerous. 63 00:04:04,690 --> 00:04:06,820 It's a rabbit hole, but it's fun. 64 00:04:06,830 --> 00:04:08,400 And, uh, I'm Italian. 65 00:04:08,400 --> 00:04:11,560 So we enjoy, we enjoy eating and we enjoy watching people eat. 66 00:04:12,070 --> 00:04:13,830 That's just my Italian call. 67 00:04:14,030 --> 00:04:17,690 That's what my Nana used to do is she would just make food and watch us eat. 68 00:04:17,920 --> 00:04:19,589 So I have that same passion. 69 00:04:20,365 --> 00:04:21,675 Sara Dong: That sounds very good. 70 00:04:22,305 --> 00:04:24,525 Well, I am excited to have you guys here. 71 00:04:24,525 --> 00:04:28,615 This is one of our StAR episodes, so we're talking about the state of the art reviews. 72 00:04:28,724 --> 00:04:33,484 And you guys created, along with your colleagues, a review article on vascular graft infections. 73 00:04:34,135 --> 00:04:48,575 And so I thought I'd actually start by opening up to give you an opportunity to just introduce the topic and actually the terminology because I think that sometimes the use of graft infection can be a bit broad and interpreted differently by various people. 74 00:04:48,744 --> 00:04:51,104 So yeah, would you guys introduce us to the topic? 75 00:04:51,145 --> 00:04:51,845 Hussam Tabaja: Yeah, sure. 76 00:04:51,925 --> 00:04:56,785 So I can take this actually and make two introductory points that I think will be important. 77 00:04:56,935 --> 00:05:01,215 So the first one is, what do we mean by vascular graft infection in this paper? 78 00:05:01,700 --> 00:05:05,719 And that will help clarify the patients that we think this review will apply to. 79 00:05:06,020 --> 00:05:11,159 And the second point is, what is the purpose and what are we trying to achieve through this review? 80 00:05:11,619 --> 00:05:19,189 So, to the first point, if I will give you a simple definition, it'll be an infection of a vascular graft used for vascular reconstruction. 81 00:05:19,189 --> 00:05:24,979 But of course, like you said, vascular reconstruction is a very broad terminology, so we need to be a bit more specific. 82 00:05:25,375 --> 00:05:45,250 In this review, what we are focusing on is an infection of any graft material, whether biologic or synthetic, that is used to repair arterial aneurysms or pseudoaneurysms through either an endovascular approach or an open surgical approach that involves arteries both intracavitary and extracavitary. 83 00:05:45,530 --> 00:05:51,989 In that definition, what I did is I actually defined five different aspects that I think are very important to help specify the patient. 84 00:05:51,989 --> 00:06:00,569 So we are saying that this review will focus and will be relative to both graft material types, which broadly there are two different graft materials. 85 00:06:00,569 --> 00:06:02,010 There is a biologic and synthetic. 86 00:06:02,440 --> 00:06:06,430 We are saying that this is going to be specifically about arteries, not veins. 87 00:06:06,740 --> 00:06:10,220 The pathology will be specifically aneurysms and pseudoaneurysms. 88 00:06:10,240 --> 00:06:13,700 This does not relate to hemodialysis graft, for example. 89 00:06:14,280 --> 00:06:18,400 We are saying that this document is relative to both surgical techniques. 90 00:06:18,400 --> 00:06:31,255 There are two different surgical techniques for vascular reconstruction, so both endovascular and open surgical, and this review will apply to that, and the last point is that we're covering both the intracavitary and the extracavitary arteries. 91 00:06:31,445 --> 00:06:33,935 And I think it's also important to clarify this further. 92 00:06:33,935 --> 00:06:42,904 So intracavitary means that the artery is inside a cavity, like an abdomen or a chest, and extracavitary means that the artery is outside. 93 00:06:42,905 --> 00:06:46,044 So it could be in the groin, in the thigh, in the leg. 94 00:06:46,505 --> 00:06:55,935 For this review specifically, we are including the entire arterial tree and arterial system, but we are excluding ascending aortas because ascending aortas are unique. 95 00:06:55,955 --> 00:07:00,555 They have different ways to diagnose and to manage, and so they do not fit in this review. 96 00:07:00,595 --> 00:07:03,285 This review is talking about the rest of the arterial system. 97 00:07:03,795 --> 00:07:05,484 So that's to point number one. 98 00:07:05,745 --> 00:07:08,395 Uh, point number two is what are we trying to achieve in this review? 99 00:07:08,405 --> 00:07:18,255 What we want to do is we want to describe a model of care that we think institutions can apply in order to ensure effective prevention, diagnosis, and management of vascular graft infection. 100 00:07:18,564 --> 00:07:23,365 And we are hoping to do that through the clinical vignettes that we're going to be discussing in this podcast. 101 00:07:23,875 --> 00:07:28,485 The central theme for this model of care is the multidisciplinary collaboration. 102 00:07:28,735 --> 00:07:36,025 If you look at the graphic abstract, we actually have a picture of a vascular graft infection and there is a ring around it. 103 00:07:36,144 --> 00:07:49,534 And on the ring, there are some bubbles or circles, and within those circles, we have listed different healthcare personnel or hospital teams that we think have an essential role in providing high quality care for the patient. 104 00:07:49,864 --> 00:07:55,114 So this is a very important collaborative network in order to be able to actually care for those patients. 105 00:07:55,134 --> 00:07:56,594 We need a lot of resources. 106 00:07:57,205 --> 00:07:58,724 This is a very complex condition. 107 00:07:59,390 --> 00:08:05,060 If you look at those circles, there are three that are highlighted with dark blue compared to the others which are light blue. 108 00:08:05,510 --> 00:08:09,429 So these three are the patient, the vascular surgeon, and the infectious disease provider. 109 00:08:09,429 --> 00:08:27,335 What we are trying to say here is that this collaborative network is put together, guided, and directed by those three, but it is a team effort, and so if any other members are missing, neither the vascular surgeon nor the infectious disease doctor will be able to provide high quality care for the patient. 110 00:08:27,624 --> 00:08:39,854 This is a very important point in this paper, and it brings me to one point that we actually make at the very end, which is for a center to be able to provide this good or high quality care for the patient, they have to have minimum capabilities. 111 00:08:40,194 --> 00:08:50,975 If they don't, then it's very important that this patient be transferred to a center that has all of these substantial and very important resources for providing high quality care for this patient. 112 00:08:50,975 --> 00:08:55,485 So this will be kind of an overview of what we're trying to do here in this paper. 113 00:08:55,655 --> 00:09:00,624 Sara Dong: That's been a common theme across all these reviews is thinking about the multidisciplinary teams. 114 00:09:00,625 --> 00:09:03,084 I'm glad you emphasized that right up front. 115 00:09:03,405 --> 00:09:08,644 So yeah, we're going to talk about a couple clinical stories to chat about vascular graft infections. 116 00:09:09,034 --> 00:09:10,204 So we'll meet our first patient. 117 00:09:11,210 --> 00:09:16,100 We have a 60 year old man who has a 6 centimeter abdominal aortic aneurysm. 118 00:09:16,630 --> 00:09:21,720 He is evaluated by vascular surgery for elective endovascular arterial repair. 119 00:09:22,280 --> 00:09:28,580 The patient is a tobacco smoker and has a history of diabetes, hypertension, and stage 2 CKD. 120 00:09:29,270 --> 00:09:32,050 He reports a childhood allergy to penicillin. 121 00:09:32,690 --> 00:09:42,605 In this pre op setting, what evaluations do we need to think about to help mitigate both his risk of surgical site infection and or vascular graft infection? 122 00:09:42,725 --> 00:09:53,134 Daniel DeSimone: This case is a classic case, something that providers or frontline clinicians are going to encounter in folks, I don't want to say on a frequent basis, but does come up quite often. 123 00:09:53,525 --> 00:10:07,405 If you look at this patient in this scenario, they have most of the risk factors that come into play here for vascular graft infection, as well as surgical site infection, so smoking, diabetes, high blood pressure, chronic kidney disease. 124 00:10:07,405 --> 00:10:09,355 These are all factors that come into play. 125 00:10:09,355 --> 00:10:15,155 Some other things to consider, again, not this patient, but in addition to what this patient has, malnutrition. 126 00:10:15,255 --> 00:10:21,615 So the patient's nutritional status, it's something that often is overlooked, but it's an elective procedure. 127 00:10:21,684 --> 00:10:29,105 If we have time to improve this patient's nutrition, if, if they were malnourished, that's very helpful from a healing standpoint, right? 128 00:10:29,105 --> 00:10:33,704 So they have to go through the surgery, survive the surgery, but then have to recover. 129 00:10:33,714 --> 00:10:42,554 And it's during that recovery phase where that wound that does not close or where just the substrate, this patient's substrate just doesn't have the ability to close. 130 00:10:42,555 --> 00:10:49,225 Well, now you have that open wound, depending on how it was repaired, that's now a potential portal of entry for organisms. 131 00:10:49,235 --> 00:10:51,735 So that's something that I feel is often overlooked. 132 00:10:51,775 --> 00:10:59,344 And again, in addition to diabetes, chronic renal disease, if there's underlying malignancy, and peripheral arterial disease. 133 00:10:59,354 --> 00:11:02,604 So these are some of your major risk factors related to the patient. 134 00:11:02,614 --> 00:11:06,944 Then you also have to factor in just the perioperative risk factors as well. 135 00:11:07,064 --> 00:11:15,885 And if you take a look at figure four in our document, you'll see we have this all kind of laid out nicely pre op, intra op, and post op things to consider. 136 00:11:16,344 --> 00:11:24,454 One thing to consider is if we can prevent vascular graft infections, that's always preferred than having to have to treat vascular graft infections. 137 00:11:24,464 --> 00:11:31,814 So there are some preventative measures we can take and in this patient, in this scenario, we have the luxury of time. 138 00:11:31,834 --> 00:11:35,185 So this is an elective endovascular arterial repair. 139 00:11:35,204 --> 00:11:45,205 So there's several things we can do pre-op to optimize this patient for surgery and hope to prevent vascular graft infection. 140 00:11:45,235 --> 00:11:52,535 And some of these things listed here could be in the, as I mentioned earlier about malnutrition, ensuring this patient is nutritional and functional optimization. 141 00:11:52,535 --> 00:11:54,275 And we talked about the multidisciplinary team. 142 00:11:54,275 --> 00:12:00,944 So this is something where possibly endocrinology or nutritionist evaluation may be helpful if we have the time. 143 00:12:01,455 --> 00:12:10,350 If there's any ongoing or active infection, let's say they had a diabetic foot ulcer or something like that, that'd be something you'd want to manage or optimize as best as possible. 144 00:12:10,680 --> 00:12:18,310 Diabetes, making sure their glucose control is under as tight of control as possible, particularly leading up to surgery. 145 00:12:18,525 --> 00:12:23,995 Also, one thing in this patient's history, which comes up a lot, is this childhood allergy to penicillin. 146 00:12:23,995 --> 00:12:35,024 So when this person was a child, you know, they got a penicillin or amoxicillin, and their, and their mother said, you know, never take penicillin again, you're allergic to it, and now it's 70 years later. 147 00:12:35,315 --> 00:12:47,455 And sure enough, a lot of data actually out of our institution, as well as others, looked at that classic history of penicillin allergy and found that that really was not a true allergy in that. 148 00:12:47,770 --> 00:12:53,240 You know, many of these patients, we've avoided any sort of penicillin or beta lactam based therapies. 149 00:12:53,350 --> 00:13:02,610 A lot of data out there that shows giving beta lactams prior to surgery, it does much better compared to non beta lactam therapy like vancomycin. 150 00:13:02,819 --> 00:13:13,970 So IV cefazolin prior to surgical incision has a much better rate of preventing surgical site infections, possibly even these leading forward to potential graft infections. 151 00:13:13,980 --> 00:13:21,130 So this is something where either consultation with an allergist to potentially form penicillin skin testing is something to consider here. 152 00:13:21,480 --> 00:13:36,050 Although even that practice is starting to change as well to where a history like this oftentimes just giving that one dose in a supervised setting pre op without even seeing allergy, having that skin test being performed, is something that a lot of centers are starting to do. 153 00:13:36,069 --> 00:13:45,095 So I think that's a nice area that there's a lot of data showing that beta lactam therapy is superior at preventing surgical site infections compared to something like vancomycin. 154 00:13:45,525 --> 00:13:47,595 Otherwise, at this point, those are probably the best thing. 155 00:13:47,595 --> 00:13:49,145 So we have the luxury of time. 156 00:13:49,145 --> 00:13:49,995 Let's use it. 157 00:13:50,244 --> 00:13:53,064 Let's get this patient as optimized as possible. 158 00:13:53,275 --> 00:14:05,015 And one more thing, as I mentioned, the tobacco smoking, any way we can prevent that, that will be not, not just for surgical site infection, vascular graft infection, as well as, you know, downstream, all the complications from cigarette smoking. 159 00:14:05,025 --> 00:14:08,724 Sara Dong: Some good PSAs, don't smoke, de label your penicillin allergies. 160 00:14:09,005 --> 00:14:09,525 Excellent. 161 00:14:09,875 --> 00:14:12,165 So we'll head to our second patient. 162 00:14:12,405 --> 00:14:20,265 We have a 67 year old woman who is admitted with fever and septic shock due to MSSA bacteremia from an unclear source. 163 00:14:21,014 --> 00:14:33,425 She has a history of open surgical repair, a abdominal aortic aneurysm with a Dacron graft five months prior to admission, as well as a permanent pacemaker that's been in place for about five years. 164 00:14:34,085 --> 00:14:39,245 She was started on cefazolin, has stabilized, and has a weaned off of pressors. 165 00:14:39,734 --> 00:14:43,134 But her Staph aureus bacteremia has persisted now for three days. 166 00:14:43,824 --> 00:14:53,685 So as ID consultants, we're often called to determine whether the source of Staph aureus bacteremia or really other bloodstream infections can be due to a vascular graft. 167 00:14:53,724 --> 00:14:56,034 So how should we approach these cases? 168 00:14:56,194 --> 00:14:57,394 Mac Chesdachai: I can take this one. 169 00:14:57,755 --> 00:15:04,220 As Sara mentioned, it is a very common scenario that we encounter as an ID provider. 170 00:15:04,740 --> 00:15:10,110 We often get calls about this patient presents with bloodstream infection. 171 00:15:10,140 --> 00:15:13,190 They have a graft in place, they have a pacemaker in place. 172 00:15:13,670 --> 00:15:14,939 What do I do with the graft? 173 00:15:15,480 --> 00:15:22,680 And it's very, very challenging question, not just only for the primary team, but for our infectious disease team as well. 174 00:15:22,819 --> 00:15:33,529 So when we think about the bloodstream infection in a patient who has a graft in place, we have to think whether the graft itself is a source of bloodstream infection. 175 00:15:34,240 --> 00:15:39,130 Is that bloodstream infection come from somewhere else and then now infected the graft? 176 00:15:39,479 --> 00:15:46,519 Or the bloodstream infection has just happened from somewhere else and then now the graft is still okay without infected? 177 00:15:47,109 --> 00:15:50,620 And sometimes it's very challenging to distinguish all of that. 178 00:15:51,275 --> 00:16:01,314 Apart from the investigation that we're going to obtain in the near future, we have to think about two factors that play a part in the bloodstream infection. 179 00:16:01,974 --> 00:16:06,325 The first factor is that what kind of organism causing bloodstream infection. 180 00:16:06,335 --> 00:16:11,065 For example, from this clinical vignette, the Staph aureus bacteremia. 181 00:16:11,465 --> 00:16:13,465 As we all know, it's scary. 182 00:16:13,555 --> 00:16:24,290 I think that this patient is in trouble because she has both pacemaker and vascular graft in place, which just recently placed months ago, which means it's very early. 183 00:16:24,310 --> 00:16:33,280 So the risk of infection is definitely higher than the patient who present with bacteremia in the later state of the vascular graft placement. 184 00:16:33,589 --> 00:16:44,910 This patient is in trouble, but it's quite obvious that when the patient present with the Staph aureus bacteremia, we really need to look for something else like, you know, graft infection, pacemaker infection. 185 00:16:45,340 --> 00:16:57,060 But it might not be obvious in the case that the patient present with other type of bloodstream infection, for example, Gram negative or other Gram positive other than Staph. 186 00:16:57,905 --> 00:17:05,155 Most of the time, the principle is that Staph aureus bloodstream infection has the highest risk of graft becoming infected. 187 00:17:05,985 --> 00:17:17,155 On the other hand, when the patient presents with urosepsis and Gram negative bacteremia, the chance of vascular graft becoming infected is relatively low compared to Gram positive. 188 00:17:17,695 --> 00:17:19,205 There is some in the middle risk. 189 00:17:19,685 --> 00:17:35,325 For example, in a patient who has like a Strep bloodstream infection, Enterococci, or even some other type of Gram negative like Pseudomonas or Serratia, all of these fall into the middle category, which means we also need other factors to consider. 190 00:17:35,354 --> 00:17:48,105 For example, whether the bacteremia is prolonged, whether this is a community onset, whether we could not identify any other source, or whether the bacteremia keep persisting even though we start the treatment. 191 00:17:48,465 --> 00:18:04,625 So if the patient has all of these factors, our thought about vascular graft infection, the chance of vascular graft infection need to be higher, and we also need to think that we should provide more investigation to look for the graft infection specifically. 192 00:18:05,045 --> 00:18:13,235 And one other point I just want to point out is early detection of the bloodstream infection in this group of patient is very important. 193 00:18:13,265 --> 00:18:24,815 For example, if we have some mechanism, for example, if the stewardship team or the microbiology team can alert the provider and say that, Hey, this is a bloodstream infection. 194 00:18:25,165 --> 00:18:37,895 Especially in the setting of the patient has a device or vascular graft, that would be very helpful because I think the early intervention, early infectious disease consult in this scenario, provide benefit in the patient outcome. 195 00:18:38,104 --> 00:18:38,524 Sara Dong: Great. 196 00:18:39,034 --> 00:18:50,895 So after going through that process, knowing that this patient is high risk for vascular graft infection, you recommend a CTA, which shows perigraft gas and some organized fluid. 197 00:18:51,354 --> 00:18:54,884 The TEE shows endocarditis. 198 00:18:54,885 --> 00:18:58,665 So at this point, we have a confirmation of vascular graft infection. 199 00:18:59,005 --> 00:19:10,955 We call up vascular surgery, who's consulted for graft explantation, along with consulting EP to talk about pacemaker removal and the setting of the Staph aureus bacteremia. 200 00:19:11,675 --> 00:19:15,525 And so this patient is considered fit for surgical intervention. 201 00:19:15,935 --> 00:19:23,750 You started to talk about it in the beginning, but what are the types of surgical approaches that are used to try and cure infection? 202 00:19:23,970 --> 00:19:27,929 Hussam Tabaja: I, I like to think about those, uh, scenarios through algorithms. 203 00:19:27,929 --> 00:19:35,710 And so there is actually an algorithm that we included in this review that discusses surgical approach for intra cavity vascular graft infection. 204 00:19:35,900 --> 00:19:40,750 I'll talk about it in a minute, but before that, there are some important points to make. 205 00:19:40,940 --> 00:19:49,600 If you look at intracavitary vascular graft infection, and even extracavitary really, the way I think about the surgical approach is under two umbrellas. 206 00:19:50,170 --> 00:19:53,510 There is the curative approach, and there is the suppressive approach. 207 00:19:53,949 --> 00:19:59,835 So curative approach means that you have to explant and remove the entire infected graft. 208 00:19:59,865 --> 00:20:00,675 It needs to come out. 209 00:20:00,685 --> 00:20:01,735 This is source control. 210 00:20:01,755 --> 00:20:03,925 We love this as infectious disease physicians, right? 211 00:20:03,935 --> 00:20:05,225 We always want source control. 212 00:20:05,245 --> 00:20:18,545 So that infected graft needs to come out and there needs to be plans for reconstruction because of course you will need to connect the proximal and distal ends again, but for cure, you have to remove the infected graft. 213 00:20:18,945 --> 00:20:21,145 The suppressive approach is anything other than that. 214 00:20:21,145 --> 00:20:27,375 So if you are not going to explant the entire graft, you are not going to cure this infection. 215 00:20:27,640 --> 00:20:29,340 And you can see a lot of different scenarios, right? 216 00:20:29,340 --> 00:20:38,960 Sometimes that patient does not have any form of surgery, sometimes they have only debridement, sometimes they have partial resection of the graft, but then the other part of the graft is still there. 217 00:20:38,970 --> 00:20:45,629 So anything outside of explanting the entire graft, in our opinion, is not going to really be a curative approach. 218 00:20:45,930 --> 00:20:55,350 Now, when you look at the literature, and of course, this is not going to be any high quality studies because vascular graft infection is not a very common condition, so it's not very well studied. 219 00:20:55,749 --> 00:21:01,950 But if you look at the literature, with the vascular graft explantation, this is a high risk procedure. 220 00:21:01,950 --> 00:21:18,520 It's a very complex procedure, and mortality can be between 18 percent to 30%, even though as infectious disease providers, we want to advocate for a curative approach, and we always push for that, you know, we're not the ones who are doing the surgery, so we really have to understand the point of 221 00:21:18,520 --> 00:21:26,209 view of the vascular surgeons who say, you know, this patient is not a good fit for surgery because he's gonna have a very high risk of complication. 222 00:21:26,210 --> 00:21:28,319 So we really need to be aware of that. 223 00:21:28,889 --> 00:21:35,940 But if you look at the suppressive approach in the literature there, there is actually some studies that show that mortality 100% after 2 years. 224 00:21:35,940 --> 00:21:50,540 So, we're saying that if you don't explant the graft and you do a suppressive approach for intracavitary vascular graft infection, specifically intracavitary, this suppressive approach is not a durable option and patients will eventually have a bad outcome. 225 00:21:50,760 --> 00:21:54,490 If there is any way you could advocate for a curative approach. 226 00:21:54,880 --> 00:21:57,310 then that should be the way you go about it. 227 00:21:57,570 --> 00:22:06,920 But at the same time, we have to understand when the surgeons tell us that this patient is particularly at high risk for surgery, and I don't think I can go in and explant the graft for this patient. 228 00:22:07,129 --> 00:22:09,619 Okay, so that's, those are a couple of points that I wanted to make first. 229 00:22:09,650 --> 00:22:15,119 Now, if you come to the algorithm that we have, it mainly talks about the curative approach, right? 230 00:22:15,119 --> 00:22:20,260 So there are two different pathways to explant the graft and do a curative approach. 231 00:22:20,620 --> 00:22:24,825 Both of these pathways actually include the explantation of the entire graft. 232 00:22:25,055 --> 00:22:30,575 But what distinguishes those pathways is how you're going to reconstruct after you explant. 233 00:22:30,885 --> 00:22:35,885 There is something called extra anatomic reconstruction, and there is something called in situ reconstruction. 234 00:22:36,385 --> 00:22:52,275 What in situ reconstruction means is that they go in, they explant the entire infected graft, they debride, clean, clean, clean, remove everything that looks infected, and then they, within that same surgery, they put in a new graft, whether this is a biologic or a synthetic graft, they put it at the same time. 235 00:22:52,495 --> 00:22:52,935 Okay? 236 00:22:52,935 --> 00:22:54,475 This is in situ reconstruction. 237 00:22:54,925 --> 00:23:00,355 Extranatomic reconstruction means that in the reconstruction, they will bypass the infected field. 238 00:23:00,595 --> 00:23:02,395 And this is usually done in two stages. 239 00:23:02,555 --> 00:23:09,515 Stage one, they go in, they form a bypass, and this usually is a synthetic graft for intracavitary VGIs. 240 00:23:09,855 --> 00:23:26,644 They do a bypass around the infected field, and then they bring the patient back a few days later for the second stage, where they resect the infected graft and debride and clean out the infection. 241 00:23:26,664 --> 00:23:28,444 They can't do them in the same stage because it will be a very long procedure, it will be a lot of ischemia, and the mortality rate will go up. 242 00:23:28,444 --> 00:23:33,735 And now in the past, extranatomic reconstruction was kind of the preferred approach by the surgeons. 243 00:23:34,255 --> 00:23:48,124 But now they are going more towards in situ reconstruction because there's data to show that in situ reconstruction actually has less complications, less mortality, better patency of the new graft, less ischemia, and even some studies showing that there is less recurrence 244 00:23:48,134 --> 00:23:55,745 of infection, even though it makes sense to think that extra-anatomic will have lower risk because you're bypassing the infected site. 245 00:23:56,204 --> 00:24:01,115 So these are the two surgical approaches within the curative category. 246 00:24:01,660 --> 00:24:04,470 And there is no gold standard in the literature. 247 00:24:04,770 --> 00:24:11,660 It all depends on the case, the anatomy of the vascular graft that's infected, and really the surgeon's preference. 248 00:24:11,920 --> 00:24:16,080 So as of now, we don't have a gold standard for what surgery should be done over the other. 249 00:24:16,470 --> 00:24:19,389 Both of them are still being applied until today. 250 00:24:19,739 --> 00:24:20,020 Sara Dong: All right. 251 00:24:20,030 --> 00:24:25,480 So for this patient, vascular surgery performs graft explantation and in situ reconstruction. 252 00:24:26,020 --> 00:24:30,829 EP has exchanged the pacemaker and you know, we're ID docs. 253 00:24:31,530 --> 00:24:33,470 We can dive into antibiotics now. 254 00:24:33,470 --> 00:24:36,300 What recommendations do you guys have for antimicrobial therapy? 255 00:24:36,640 --> 00:24:49,465 Daniel DeSimone: The surgery is the hard part, no doubt about it, but this is also a big challenge sometimes because number one, hopefully you have accurate microbiological diagnosis. 256 00:24:49,505 --> 00:24:53,885 That's the first step on our end, because a lot of these patients, okay, somebody like this is septic. 257 00:24:53,885 --> 00:24:55,205 Well, they started antibiotics. 258 00:24:55,235 --> 00:25:05,554 Luckily, we knew there was MSSA bacteremia, but let's say they're not septic and blood cultures are negative, or at least at the time of starting antibiotics, blood cultures were negative. 259 00:25:05,965 --> 00:25:07,115 We have to factor that in. 260 00:25:07,115 --> 00:25:11,275 So, okay, so accurate microbiological diagnosis is key. 261 00:25:11,805 --> 00:25:21,325 And before even getting into all that, what is very important here, in addition of, hey, what's the bug, is you have to tailor this. 262 00:25:21,325 --> 00:25:33,525 You have to individualize this therapy for that patient with that procedure and take all the medical comorbidities into account, take into account the surgical aspect as well. 263 00:25:34,185 --> 00:25:37,635 As Hussam mentioned earlier, we ideally want cure, right? 264 00:25:37,635 --> 00:25:42,115 I mean, I think everybody wants cure, but these are major high risk surgeries. 265 00:25:42,555 --> 00:25:50,985 Every patient in this group will be quite high risk and will be high risk for if they were to relapse or have a recurrence. 266 00:25:51,014 --> 00:25:55,144 So what I'm getting at here is this seems easy and it's like, oh, well, here's the bug. 267 00:25:55,155 --> 00:25:57,074 Here's the antibiotic for this long and that's it. 268 00:25:57,534 --> 00:26:03,755 But I always say have plan A, plan B, plan C, D, E, F in these patients. 269 00:26:03,775 --> 00:26:08,040 And I say that because what is it, what can go wrong, will go wrong. 270 00:26:08,720 --> 00:26:10,650 Yeah, so let's put them on IV for six weeks. 271 00:26:10,660 --> 00:26:20,620 So right up there front, you know, IV six weeks, some cases you may have, you could go oral, but for the most part, these folks are going to be six weeks IV up front. 272 00:26:20,840 --> 00:26:23,089 And then what do you do after that? 273 00:26:23,100 --> 00:26:38,625 So after that six weeks of IV antibiotics, the question gets to, do they need to be on some form of suppressive therapy, or in other words, a prophylactic three to six months, and in some cases even up to a year depending on the graft. 274 00:26:38,645 --> 00:26:41,795 But again, you have to tailor this to the individual. 275 00:26:42,174 --> 00:26:49,225 You have to take into account their risk of Okay, if this were to relapse or recur, what trouble are they in? 276 00:26:49,455 --> 00:26:51,075 What did they do at the time of surgery? 277 00:26:51,235 --> 00:26:56,605 Did they do in situ reconstruction and put a put a graft, a synthetic graft? 278 00:26:56,865 --> 00:27:04,950 Or did they put a a cryopreserved tissue graft, or do they do an ex anatomic bypass, which is going to be a synthetic? 279 00:27:05,210 --> 00:27:09,230 Those all factor into do I put this patient on for three to six months? 280 00:27:09,230 --> 00:27:10,150 Do I put them on a year? 281 00:27:10,150 --> 00:27:11,270 Do I put them on lifelong? 282 00:27:11,720 --> 00:27:12,990 And then also the organism. 283 00:27:12,999 --> 00:27:23,550 So if you have something like Staph aureus, Pseudomonas, multi drug resistant pathogens, you also may consider lifelong prophylactic or suppressive therapy, depending on on how they reconstruct it. 284 00:27:24,040 --> 00:27:26,655 But you also have to factor in that's not always easy. 285 00:27:26,895 --> 00:27:33,745 So if you have Pseudomonas, well, what's your, at the, you know, for the most part, what's your oral, what's your only oral option for suppression? 286 00:27:33,995 --> 00:27:35,204 Cipro or Levo? 287 00:27:35,205 --> 00:27:36,875 Well, what if they have a prolonged QT? 288 00:27:37,514 --> 00:27:39,165 Well, that kind of leaves that out. 289 00:27:39,214 --> 00:27:43,704 Do I put them on, uh, IV gentamicin therapy three times a week? 290 00:27:43,704 --> 00:27:51,740 I mean, these are things that where I was saying you kind of want to have those backup plans or contingency plans in place because something will go wrong. 291 00:27:52,210 --> 00:27:56,060 Now this patient in our center, in our scenario here is uh, 67. 292 00:27:56,510 --> 00:27:57,780 Well what if they're 35? 293 00:27:58,785 --> 00:28:03,555 Are you going to keep them on lifelong suppression if they're 35 with MSSA? 294 00:28:03,725 --> 00:28:10,735 Sure, you could try, but at some point, either the patient's going to develop some intolerance or, you know, let's say C. 295 00:28:10,765 --> 00:28:16,210 diff is a complication or the bug develops resistance and now it became, you know, MRSA. 296 00:28:16,210 --> 00:28:22,100 Again, I'm just throwing things out there that are possibilities, but, but these are all things you have to take into account. 297 00:28:22,110 --> 00:28:25,190 So, again, an individualized approach to each patient. 298 00:28:25,230 --> 00:28:28,970 None of this is a route where you just say, okay, everybody's gonna get this, this, and that's it. 299 00:28:29,030 --> 00:28:31,440 No, it's, you have to take everything into account. 300 00:28:31,560 --> 00:28:36,680 Their age, their comorbidities, and actually, this is where you want to do some shared decision making. 301 00:28:36,990 --> 00:28:52,450 This is where, you know, we talk about the multidisciplinary teams, and again, yeah, we're going to kind of be the deciding factor from an infection side, you know, antibiotics, but the patient's going to have to take this medicine for, let's say we go down the lifelong route, maybe 10, 20 years. 302 00:28:52,660 --> 00:28:56,435 Do they want to be on a fluoroquinolone for 10 years. 303 00:28:56,475 --> 00:28:57,665 Can they even tolerate it? 304 00:28:57,755 --> 00:28:59,995 You know, I mean, these are just things you have to factor in. 305 00:29:00,265 --> 00:29:02,425 So that's why it's not just one thing out there. 306 00:29:02,425 --> 00:29:08,585 What we have in figure seven, kind of in the antimicrobial course, realize that this has to be individualized. 307 00:29:08,585 --> 00:29:16,765 It's not just, just because someone goes for in situ reconstruction with a synthetic graft, that they're all going to get this program. 308 00:29:17,130 --> 00:29:20,040 I wish it was that easy, but it's actually quite the opposite. 309 00:29:20,390 --> 00:29:24,330 Cause then the other part to this is, well, how do we, okay, in the hospital, it's quite easy. 310 00:29:24,390 --> 00:29:33,280 Put them on IV antibiotics, get a PICC line in, set them up with lab monitoring and an OPAT or outpatient antimicrobial therapy monitoring, and we'll see in six weeks. 311 00:29:33,900 --> 00:29:34,370 Okay. 312 00:29:34,570 --> 00:29:36,470 Well, what happens at the six week mark? 313 00:29:36,520 --> 00:29:55,965 And, and, and as I mentioned, having those contingency plans, because there will be some drug drug interactions or side effects or intolerances, and that's, we're having that robust team with pharmacists, nursing, that support in the outpatient setting is critical because once the surgery is done, these patients have 314 00:29:55,965 --> 00:30:12,935 to recover and hopefully we can either prevent infection from coming back or keep it under control and suppress or hopefully cure and again, we I said the hard part was the surgery, but oftentimes the hard part is getting through those six weeks and then potentially another three to six months of oral prophylaxis or 315 00:30:12,935 --> 00:30:21,165 potentially lifelong suppression because, as Hussam mentioned a little while ago, some of these these infections carry high morbidity as well as high mortality. 316 00:30:21,535 --> 00:30:30,585 So, we want to be as aggressive as we can be, but always keep the patient at the center of your decisions and involve them in these decisions. 317 00:30:30,795 --> 00:30:31,645 discuss with them. 318 00:30:31,895 --> 00:30:33,295 This is not easy. 319 00:30:33,355 --> 00:30:38,215 There's not one cookbook recipe that, okay, this works for everybody. 320 00:30:38,515 --> 00:30:43,755 And I kind of prepare patients that, yeah, this, you know, certain things can fail or, or you may not tolerate it. 321 00:30:43,765 --> 00:30:47,225 And we have to do certain things that are outside of the box a little bit. 322 00:30:47,235 --> 00:30:52,015 So keep the patient focused, individualize this, talk with the surgeon. 323 00:30:52,245 --> 00:30:53,715 What happens if we fail? 324 00:30:54,020 --> 00:30:56,810 What if it's Pseudomonas and the only thing we have is IV options? 325 00:30:57,660 --> 00:31:01,000 Is there, what's this patient's chance of another surgical intervention? 326 00:31:01,010 --> 00:31:02,750 Let's say they went for a suppressive route. 327 00:31:03,400 --> 00:31:07,980 Perhaps, you know, does this patient need to go for an extra anatomic reconstruction? 328 00:31:08,040 --> 00:31:20,100 But if you, you know, the surgeon may say that's not possible, you know, it's so high risk, you know, it's not even So these are just things you, you gotta take all this into account because like I said, some of these decisions can be, they're, they're not easy and can be quite complex. 329 00:31:20,160 --> 00:31:31,080 Multidisciplinary team comes up quite often at this, you know, post surgery, a lot of times it's, it's a lot of discussions, a lot of close follow up to hopefully have, have success for this patient. 330 00:31:31,220 --> 00:31:31,550 Sara Dong: Yeah. 331 00:31:31,580 --> 00:31:38,975 Those conversations are hard, especially the lifelong suppression and like presenting that to the patient in a way that they can make the decision. 332 00:31:38,975 --> 00:31:46,805 I mean, that alone is challenging because sometimes describing what the risk first benefit is, it's not, you know, it's not easy to quantify that. 333 00:31:46,805 --> 00:31:48,385 And I think sometimes patients want that. 334 00:31:48,395 --> 00:31:48,725 Daniel DeSimone: Yeah. 335 00:31:48,945 --> 00:31:50,515 And I don't think there's a number, right? 336 00:31:50,525 --> 00:31:57,399 Like it's, and even for that patient, I usually tell my patients a lot of times, it's sometimes it's a, Hey, it's 50 50. 337 00:31:57,540 --> 00:31:59,910 either it worked or it didn't work for you, right? 338 00:31:59,940 --> 00:32:08,090 But, uh, you know, overall, the absolute risk may be low, you know, it's lower, but at the same time, for that patient, if it happens to them, yeah, it's not zero. 339 00:32:08,090 --> 00:32:12,280 It's either going to happen, it's either 50 50 or essentially it works or it doesn't work. 340 00:32:12,280 --> 00:32:14,380 So yeah, those are tough conversations. 341 00:32:14,380 --> 00:32:17,510 And again, this is, this is complex to us. 342 00:32:17,570 --> 00:32:30,475 So us trying to to translate this to our patients, to understand that the gravity of the situation, I think is important to do that because again, well, why do we want to put you on an antibiotic for the rest of your life? 343 00:32:30,495 --> 00:32:33,975 Well, there's some bad stuff that can happen if we don't. 344 00:32:34,045 --> 00:32:38,889 But again, just having these discussions throughout the process is very important. 345 00:32:39,070 --> 00:32:42,060 Sara Dong: All right, well, we have one more patient that's coming through. 346 00:32:42,410 --> 00:32:48,160 This time we have a 65 year old woman who's hospitalized because of pain and swelling in her right thigh. 347 00:32:48,870 --> 00:32:59,250 She had a percutaneous coronary intervention eight months ago, which is complicated by a large common femoral pseudo aneurysm requiring repair with a polyester graft. 348 00:32:59,780 --> 00:33:04,790 The ultrasound of the thigh demonstrates an organized fluid collection communicating with the graft. 349 00:33:05,310 --> 00:33:09,440 The patient is hemodynamically stable, so antibiotics are held. 350 00:33:10,580 --> 00:33:20,160 The patient goes for a percutaneous aspiration and then from that is shown to have purulent fluid which yielded polymicrobial growth and cultures. 351 00:33:20,630 --> 00:33:24,050 So vascular surgery and ID are involved. 352 00:33:24,430 --> 00:33:26,990 How would you talk about approaching this case? 353 00:33:27,680 --> 00:33:33,590 Mac Chesdachai: So when you have a fluid collection around a graft and also you aspirate and it's growing polymicrobial. 354 00:33:34,830 --> 00:33:36,000 It's definitely not good. 355 00:33:37,160 --> 00:33:45,350 In this scenario, I don't think the diagnosis is challenging because we know that the extra cavitary graft is involved. 356 00:33:45,770 --> 00:33:51,210 The more challenging thing that we need to discuss down the road is how to manage this patient. 357 00:33:51,230 --> 00:33:54,220 That will be the key of this clinical scenario. 358 00:33:54,820 --> 00:34:02,390 So when we encounter the extra cavitary vascular graft, I usually think about the Samson classification. 359 00:34:02,860 --> 00:34:08,795 So when we think about the Samson classification, it's divided into like five categories. 360 00:34:09,105 --> 00:34:15,145 The 1 and 2, skin and soft tissue infection around the graft that is not involved in the graft itself. 361 00:34:15,625 --> 00:34:20,065 When we talk about the graft infection, we talk about Samson 3, 4, and 5. 362 00:34:20,490 --> 00:34:26,010 So, 5 is the extreme, which means the patient is septic, has a bleeding, has a bacteremia. 363 00:34:26,100 --> 00:34:27,270 That's a SAMSON 5. 364 00:34:27,750 --> 00:34:38,520 And then SAMSON 3 and 4, uh, the category that graft is involved, but it also depends on whether it involves anatomosis or not, that would be SAMSON 3 and 4. 365 00:34:38,950 --> 00:34:50,050 In this category, I think the patient falls into category of SAMSON 3 and 4, because she has been hemodynamically stable, and we know that there's a fluid collection around the graft. 366 00:34:50,625 --> 00:34:55,935 So the reason why we want to know about the Samson category, because that would affect our management. 367 00:34:56,660 --> 00:35:08,000 For example, the, the Samson 1 and Samson 2, we usually do like aggressive debridement with the antibiotic because the infection is not involved in the graft, so we don't need to do any surgical approach. 368 00:35:08,290 --> 00:35:17,974 But when we talk about the Samson 3, 4, and 5, that's when the graft involvement, that's the reason why we also have a thought process the same way as the Sampson 1. 369 00:35:18,125 --> 00:35:30,155 When we're dealing with the intracavitary, which means are we doing surgical management, like for curative purpose, or we do the suppressive strategy, which I think the thought is the same. 370 00:35:30,495 --> 00:35:55,285 So when we talk about the SAMSON 3 and 4, we can either do debridement with preserve the graph, or we can do the debridement plus doing the surgical approach to exchange the graft, and then all of that, most of the time, the patient like this will need multiple debridement and muscle flap and prolonged antibiotic course, the same as Hussam and Dan mentioned. 371 00:35:55,705 --> 00:36:09,585 Let's say if the patient has like Samson 3 and 4 and they have like the easy to treat organism, sometimes the vascular surgeon will do the graft preservation, which means doing multiple debridement. 372 00:36:09,970 --> 00:36:21,270 Plus the antibiotic therapy for, you know, four to six weeks of IV followed by the oral suppression for three to six months in when we run into the easy to treat organism. 373 00:36:21,740 --> 00:36:33,260 When I say the easy to treat, mean the organism that is not fall into the category of, you know, Staph aureus, MRSA, Pseudomonas, or MDRO, or the multi drug resistant organism. 374 00:36:33,260 --> 00:36:44,385 All of those most of the time we will need a surgical approach to, you know, remove the graft and exchange and everything like that, followed by the prolonged antibiotic therapy. 375 00:36:44,595 --> 00:36:51,275 And again, this kind of case is very, very complicated, even with the infectious disease itself. 376 00:36:51,515 --> 00:36:54,985 So I think it is very important to involve multidisciplinary team. 377 00:36:55,005 --> 00:36:59,285 As Hussam mentioned that we are not the one who, you know, actually do the surgery. 378 00:36:59,595 --> 00:37:09,950 So we need to talk to the expert in this scenario and come up with a multidisciplinary conclusion to say that, okay, this patient may be suitable for this approach. 379 00:37:09,950 --> 00:37:20,805 This patient may need graft preservation, followed by the antibiotic, which requires multiple discussion and also multiple factor that need to take part in the discussion. 380 00:37:20,805 --> 00:37:30,384 And also, I think the patient preference is also the one that sometimes we, we didn't involve them because we think that, okay, we managed this after Samson 3, 4, 5. 381 00:37:30,385 --> 00:37:34,965 And when we talk to the patient, sometimes the patient say that, no, I don't want anything done or something like that. 382 00:37:34,965 --> 00:37:39,805 So I think patient centered decision is also very important in this situation. 383 00:37:40,075 --> 00:37:48,570 Sara Dong: And in addition to talking about multidisciplinary care, another key theme of a lot of these state of the art reviews is health disparities. 384 00:37:48,570 --> 00:37:53,250 And I was wondering if you could give a little insight into that related to vascular graft infection. 385 00:37:53,490 --> 00:37:53,770 Hussam Tabaja: Yes. 386 00:37:53,780 --> 00:38:10,090 So, you know, as, as expected, you're not going to, uh, find a lot of literature specific to vascular graft infection when it comes to healthcare disparities, but we know a lot about social determinants of health and healthcare disparities from other complex conditions. 387 00:38:10,590 --> 00:38:14,900 And you know, it makes sense to think that they all apply here in vascular graft infection. 388 00:38:15,475 --> 00:38:24,965 What we can do and what we have done in the paper is we listed at least one that we think is a very important factor, uh, where disparities could be seen. 389 00:38:25,435 --> 00:38:36,845 I'm hoping now towards the end of the podcast between myself, Dan, and Mac, we have already kind of highlighted the just extensive resources needed to take care of the patient. 390 00:38:36,845 --> 00:38:38,520 Itv truly needs like a village. 391 00:38:38,760 --> 00:38:39,550 What's the saying? 392 00:38:39,560 --> 00:38:41,890 Need a village to take care, to raise a child. 393 00:38:42,080 --> 00:38:44,370 It needs a village to take care of the patient as well. 394 00:38:44,600 --> 00:38:50,820 We have, you know, if you look at the review, we have mentioned almost everyone in the hospital and how everyone can have a role. 395 00:38:50,850 --> 00:38:55,860 We talked about surgeons, physicians, including specialists, and including hospitalists. 396 00:38:55,890 --> 00:39:03,500 We talked about social workers, nurses, pharmacists, OPAT, antimicrobial stewardship, and microbiology labs. 397 00:39:03,500 --> 00:39:05,380 So really extensive resources. 398 00:39:05,730 --> 00:39:09,810 And so do we expect that every hospital has those resources available? 399 00:39:10,220 --> 00:39:11,060 Of course not. 400 00:39:11,560 --> 00:39:15,640 There are certain centers that are able to provide this type of service. 401 00:39:15,920 --> 00:39:20,270 And so, the disparity here is access to this care, right? 402 00:39:20,520 --> 00:39:24,600 There is a lot of reasons why some patients might not be able to access this care. 403 00:39:24,690 --> 00:39:26,820 For example, your zip code, right? 404 00:39:26,850 --> 00:39:29,200 It's just a simple, you know, idea, right? 405 00:39:29,200 --> 00:39:40,170 The zip code of the patient can actually determine whether or not this patient is able to get access to the specialized care because not everyone lives somewhere that has a big hospital next to them that's able to do things like that. 406 00:39:40,710 --> 00:39:45,710 Access to specialized care is very, very important and, you know, how do we centralize this care? 407 00:39:45,720 --> 00:39:50,680 How do we refer those patients immediately or as soon as possible to those big centers? 408 00:39:50,900 --> 00:39:52,230 That is actually the trick. 409 00:39:52,690 --> 00:40:00,690 That is one of the major health care disparity and we kind of spoke again about the minimum capabilities that a center has to have in order to provide care. 410 00:40:00,690 --> 00:40:07,510 If that's not available, then really there should be efforts made to transfer the patient soon enough to a larger hospital. 411 00:40:07,890 --> 00:40:13,190 I can give you more examples about things that I think are important in this patient population. 412 00:40:13,210 --> 00:40:20,650 If you think about it, this is again a very complex condition and it actually requires a lot from the patient himself. 413 00:40:20,650 --> 00:40:29,670 You know, if you go back to that graphic abstract, we said that the patient was one of those three bubbles that was highlighted with dark blue because they really need to, to steer the ship. 414 00:40:29,860 --> 00:40:31,760 They need to be engaged in their care. 415 00:40:31,760 --> 00:40:33,050 They need to know what's going on. 416 00:40:33,330 --> 00:40:37,660 There is going to be a lot of treatment plans, follow up labs, and all of that. 417 00:40:37,660 --> 00:40:39,430 So the patient really needs to know what's going on. 418 00:40:39,880 --> 00:40:47,160 And so you think about patient education, you think about patient language barrier, and those things are additional stuff that could come in the way, right? 419 00:40:47,200 --> 00:40:57,105 And I think You know, unfortunately, as physicians become more and more busy, I don't think that we are making, you know, we're not, we're doing a good job educating those patients properly. 420 00:40:57,175 --> 00:41:00,605 You know, physicians need to know that they need to give them more time. 421 00:41:00,605 --> 00:41:01,865 There should be an interpreter. 422 00:41:01,865 --> 00:41:06,135 And even if the interpreter is with you in the room, you need to repeat what you've been saying to the patient. 423 00:41:06,135 --> 00:41:15,605 You need to give, just give them more time, make sure that they understand what's going on before they get out of the hospital and that there is a way for them to actually follow up with the care teams. 424 00:41:15,895 --> 00:41:21,855 So these are kind of some of the things that I can think of and that we have observed when we've taken care of those patients. 425 00:41:22,225 --> 00:41:30,745 Everything else that we know about social determinants of health and how they affect other complex conditions will probably also be applied applicable to, to vascular graft infections. 426 00:41:31,155 --> 00:41:33,085 Sara Dong: Well, we're approaching the end. 427 00:41:33,495 --> 00:41:45,510 To wrap up, I also like to leave a little space just to see if there are key take homes that you want to emphasize and or adding something that you think that is important that we didn't quite get a chance to touch on. 428 00:41:45,730 --> 00:41:53,960 Hussam Tabaja: We kind of mentioned briefly that there is not too much literature about vascular graft infection and it may, one of the reasons is because it's not very common. 429 00:41:54,500 --> 00:42:00,570 Now, this is important to also state that it is not common, but you know, as it's just like any other surgery. 430 00:42:01,100 --> 00:42:10,570 As the surgical cases increase, which they are, we know that more and more people are undergoing those procedures, we are going to see more and more infections or infection cases. 431 00:42:10,590 --> 00:42:13,280 And we are already seeing that in referral centers. 432 00:42:13,320 --> 00:42:15,550 We, we see a lot of vascular graft infections. 433 00:42:15,970 --> 00:42:17,780 So, and those are likely going to increase. 434 00:42:18,090 --> 00:42:25,560 So, I think we have to make all efforts that we can in order to talk more about this topic so that physicians are more aware of it. 435 00:42:25,960 --> 00:42:38,555 This is one of the reasons why we were even interested in making such a review, to kind of describe this topic because we think that it's going to be become more prevalent in the future as more and more patients undergo those procedures. 436 00:42:38,965 --> 00:42:47,045 Mac Chesdachai: Now because we are dealing with aging population, so more and more people will undergo both of the pacemaker and vascular graft and everything like that. 437 00:42:47,045 --> 00:42:49,075 So we're going to see this more and more. 438 00:42:49,510 --> 00:42:53,050 I would like to encourage everyone to, to read our paper. 439 00:42:53,450 --> 00:42:59,740 Most of the time when I get a consult on vascular graft infection, I am not the only one that can manage the patient. 440 00:42:59,740 --> 00:43:16,920 I need to talk to multiple people and I would encourage when we get consult about this very complex scenario, talk to your colleagues, talk to other people who often see this condition because I think it's very, very complicated and require, you know, the whole village to take care of the patient. 441 00:43:17,325 --> 00:43:26,445 One last thing is that I just want to also shout out to the co author who helped writing this paper, who didn't join the podcast this morning. 442 00:43:26,845 --> 00:43:37,555 Our paper also involves collaborative effort from pharmacy, from vascular surgery, from multiple people who helped writing this paper, I just want to say thank you to all of them. 443 00:43:37,585 --> 00:43:49,495 Daniel DeSimone: One last thing to take home from, from my standpoint would be, understand that the landscape of vascular graft surgery and vascular approach to these aneurysms are changing. 444 00:43:50,085 --> 00:43:52,515 And it's been changing over the last decade or so. 445 00:43:52,675 --> 00:43:53,875 And what, what do I mean by that? 446 00:43:54,165 --> 00:44:01,055 A lot of these aneurysms are now being replaced via endovascular repair rather than open surgical repair. 447 00:44:01,765 --> 00:44:03,065 And that changes. 448 00:44:03,290 --> 00:44:04,880 the landscape quite a bit. 449 00:44:05,040 --> 00:44:07,550 So, instead of having a big, large incision 450 00:44:07,970 --> 00:44:13,750 midline, now this can be performed with an incision in the groin region. 451 00:44:14,100 --> 00:44:34,275 So, instead of having these big, large incisions where the risk of the surgery definitely goes up, I mean, as I said, all these vascular surgery interventions are high risk, but open surgical repair versus endovascular repair has revolutionized this process of aneurysm repair. 452 00:44:34,685 --> 00:44:36,055 So what do I mean by that? 453 00:44:36,065 --> 00:44:37,215 Why do I say that? 454 00:44:37,535 --> 00:44:47,890 Is patients that may have been deemed too high risk, too sick to go for open surgical repair, are now being considered for endovascular repair. 455 00:44:48,240 --> 00:45:03,785 So think of this in the realm of TAVR, transcatheter arterial valve repair, where some patients were too high risk to go for open cardiac surgery, but they're not too sick to replace a valve through the patient's wrist or through the groin region. 456 00:45:04,065 --> 00:45:09,935 Compare that to vascular repair, even in emergent cases, as well as elective cases. 457 00:45:10,685 --> 00:45:34,165 Patients, as well as surgeons are starting to opt more towards endovascular repair compared to open surgical repair, which also opens up, broadens the pool of folks who would have been deemed, as I mentioned, too high risk or too sick to go for aneurysm repair, open surgical repair, who are now, you know, the risk is not that high to where they can undergo endovascular repair. 458 00:45:34,375 --> 00:45:41,390 So, so what happens there is you have patients with higher medical comorbidities, or air quotes, sicker. 459 00:45:41,840 --> 00:45:44,530 So the population is changing. 460 00:45:44,530 --> 00:46:01,050 So as Hussam mentioned, we're going to see more vascular graft infections, and I think he's right on that, but I will say that we do see a lower rate of graft infections with endovascular repair or replacement versus open surgical repair. 461 00:46:01,120 --> 00:46:12,860 However, that pool of patients with more comorbidities, the worry there would be, yes, even though the procedure itself has a lower risk of infection and the grafts that are repaired that way have a lower risk. 462 00:46:13,290 --> 00:46:22,960 However, the patient and their comorbidities being so high that changing in the pool risk could potentially lead to an increased infection. 463 00:46:22,970 --> 00:46:30,170 But again, that's what the, we'll see where things are in the next five to 10 years and on that, but, but I think Hussam is correct in that regard. 464 00:46:30,170 --> 00:46:34,610 So that's something else to keep in mind is that the surgical approach has changed. 465 00:46:34,800 --> 00:46:38,240 Therefore the pool or population is, is going to change as well. 466 00:46:38,300 --> 00:46:43,820 And ultimately, you know, I think if anything you've heard us say is throughout this podcast is individualized approach. 467 00:46:44,065 --> 00:46:59,935 Each patient come up with a plan with not just yourself, with a, with a multidisciplinary team of what's best for your patient at that moment in time and be flexible, involve them in the decision making, keep them in the center of that decision. 468 00:47:00,615 --> 00:47:04,235 In the end, that doing what's best for the patient, I think that's the best route here. 469 00:47:04,655 --> 00:47:09,005 Sara Dong: Well, you guys can come back in a couple of years and update us on how it's evolving. 470 00:47:10,565 --> 00:47:12,125 Well, thank you guys for joining. 471 00:47:12,265 --> 00:47:13,785 Daniel DeSimone: Sara, thank you so much for having us. 472 00:47:14,085 --> 00:47:15,065 Greatly appreciate it. 473 00:47:15,125 --> 00:47:18,665 Sara Dong: Thanks again to Hussam, Mac, and Daniel for joining Febrile today. 474 00:47:19,385 --> 00:47:31,205 You can find the article linked in the episode description and Consult Notes from CID entitled Fostering Collaborative Teamwork, A Comprehensive Approach to Vascular Graft Infection Following Arterial Reconstructive Surgery. 475 00:47:31,415 --> 00:47:33,875 Don't forget to check out the website, febrilepodcast. 476 00:47:33,895 --> 00:47:42,675 com, where you will find our consult notes, which are written complements to the episodes of links to references, our library of ID infographics, and a link to our merch store. 477 00:47:43,015 --> 00:47:47,375 Febrile is produced with support from the Infectious Diseases Society of America, IDSA. 478 00:47:48,115 --> 00:47:50,755 Editing and mixing was provided by Bentley Brown. 479 00:47:51,095 --> 00:47:55,285 Please reach out if you have any suggestions for future shows or want to be more involved with Febrile. 480 00:47:55,645 --> 00:47:56,465 Thanks for listening. 481 00:47:56,575 --> 00:47:58,085 Stay safe and I'll see you next time.