Nosocomial infection during ECMO

Nosocomial infection during ECMO

Severe Patient Translation Group

The purpose of the review

The purpose of the review was to provide evidence of the most recent stage

Latest discoveries

The latest elaboration data from the study from the In Vitro Life Support Agency (ELSO) and the Single Center have been published

summary

ECMO is a salvage treatment

keyword

In vitro life support, extracorporeal membrane oxygenation, nosocomial infections, ventilator-associated pneumonia

introduce

In recent years, extracorporeal membrane oxygenation (ECMO) has resulted in a salvage treatment

ECMO is a highly invasive technique that requires the insertion of large catheters in the middle and cardiovascular systems, the support of circulating blood with centrifugal pumps and polymettene oxygenators for in vitro pathways, V-A support can be maintained for days without accidents, and V-V support can be maintained for several weeks

A data analysis from in vitro life support (ELSO) from 1998 to 2008 showed that culture-confirmed adult infection rates were 20.

To date, there is not a broad evidence that provides general management information

The scope of this review represents the most recent evidence

Epidemiology and results

The rates of nosocomial infection reporting vary widely from study series to

The main source of data on ECMO-related infections is the ELSO Registry

Regardless of the structure supported, the most common respiratory isolates (excluding yeast colonization) are Staphylococcus aureus, Pseudomonas spp.

A detailed single-center study of special infections has been published

The most common pathogenic microorganisms for BSI are Gram-negative bacilli and Candida spp.

The exact role of ECMO pathways, catheterization strategies, or coexisting central venous catheters (CVCs) on BSI is unclear

Risk factors

Patients requiring ECMO support are significantly more likely to develop nosocomial infection than other ICU patients, and even post-extubation [15] exposure is at constant risk of

Inter-hospital transport is also a sensory risk factor for non-ECMO patients [28].

diagnosis

Since most clinical and similar signs of complications can be masked by in vitro therapy, the diagnosis of infection during ECMO support is challenging
.
Since heat exchangers are often used to maintain a normal body temperature by replacing heat loss in the surrounding environment through the circuit, fever is usually not manifested
.
Moreover, exposure to blood in the extracorporeal circulation pipeline can lead to activation of cellular and fluid systems, leading to a waterfall of inflammatory response that can mimic similar signs of infection [2].

Distinguishing between infections in inflammation through common diagnostic tests, such as C-reactive protein and procalcitonin, is limited, and conflicting results have been found in many studies [30,31,32].

Moreover, the underlying disease can hinder the interpretation
of underlying images such as X-rays.
For these reasons, the diagnosis of infection during ECMO support requires a high degree of suspicion and a positive attitude
towards performing specific radiographic tests such as tracheoscopy or intra-hospital transport.

According to an ELSO survey, routine blood culture monitoring is routine,[33] although past studies have not shown support for this practice,[34] and there has been no concern about the potential risk posed by inappropriate use of antibiotics, and there has been no concern
about the increased need for transfusions due to repeated blood draws.
However, a recent single-center retrospective study of 150 patients requiring V-AECMO support showed that even conventional blood cultures identified significantly fewer BSI outcomes than clinically prescribed blood cultures, and that on-demand cultures alone resulted in one-third missed BSI [35].

On-demand culture sensitivity is improved
after patient identification and removal with positive risk factors.
Given these risks, a balanced approach to routine culture and on-demand culture based on positive risk factors may make sense and should be tested
in prospective studies.
Urgent techniques in the field of cultivation, independent rapid diagnostic experiments [36] are promising and beneficial
to this population.

prophylaxis

A recent single-center study of post-heart surgery ICUs, including 3396 admitted patients and 288 ECMO patients, despite the same level of standardized protocols to reduce hospital perception, showed a higher
prevalence of ECMO infection in patients [15].
These results suggest that general nosocomial infection precautions are inadequate and that special measures
should be designed for ECMO patients.
Extensive disinfection of exposed ECMO circuits with chlorhexidine on a daily basis has been proposed as a measure to reduce BSI and ECMO casing colonization and has shown effectiveness in pre- and post-study studies that are not controlled by a single center [37].

The ELSO Working Group on Infectious Diseases recommends surgery or percutaneous catheterization as standard surgical prophylaxis, and prophylactic antibiotics are not routinely used in the absence of specific cultures or physiological evidence of infection due to lack of data support [38
].
Despite this recommendation, antibiotic prophylaxis is frequent during ECMO support, although antibiotic use varies greatly from centre to centre and case, and in many cases no protocols or reviews are in place
.
According to data reported by a survey conducted in the United States, 50% of centers use preventive measures; The most common protocols include ampicillin plus aminoglycosides or cephalosporins [33].

In a survey conducted in Japan, 39% of centers used antimicrobial prophylaxis
.
The most common drug is the first-generation cephalosporin, followed by a combination of penicillin or penicillin-derived [39].

Shah et al.
evaluated the effects of implementing two successive versions of the antimicrobial prophylaxis regimen on antimicrobial use and nosocomial infection rates, and demonstrated a reduction in broad-spectrum antimicrobial use in the absence of evidence of increased infection rates [40].

A recent retrospective cohort study with a preference score match, including data from 9615 patients in Japan who received ECMO support, hinted at a reduced risk of hospital mortality and ventilator-associated pneumonia in patients receiving antibiotic prophylaxis [41
].
However, these findings also need to be confirmed
by prospective trials.
Current diagnostic and management guidelines of the European Society of Clinical Microbiology and Infectious Diseases target nonneutropenia in adult candidiasis, slightly support the recommendation of prophylactic antifungals in patients requiring mechanical ventilation, hospitalization ≥ 3 days of antibiotics, insertion of a central venous catheter, and satisfaction of at least other risk factors [42].

Given the high incidence of candidemia in ECMO patients and their association with poor prognosis, it may be worthwhile to evaluate the effectiveness of antifungal prophylaxis in patients with ECMO targeted
.
In addition, it is reasonable
to include antifungal therapy in patients suspected of infection in combination therapy.

The ELSO Task Force on Infectious Diseases recommends early tracheostomy and mild sedation strategies to reduce the risk of VAP and promote cough and airway cleaning [38].

Extubation is feasible during ECMO support under the appropriate conditions [43].

A single-center and single-center observational study of 57 patients with V-AECMO showed improved 30-day survival and a decrease in VAP cases [44], but these findings were not confirmed in a recent single-center study of 344 patients [45].

However, patients with extubation experienced a significant increase
in the number of days they did not stay in the ICU for 30 days after extubation.

treat

Critically ill patients often exhibit significant pharmacokinetic variability, and conventional antibiotic doses may lead to treatment failure and microbial resistance, or to increased
exposure and toxicity.
Changes in pharmacokinetics may manifest as alterations in volume distribution (due to venous fluid load, capillary leakage, hypoalbuminemia) and increased or decreased
renal clearance [46].
The presence of ECMO circuits may further alter the volume of distribution, thereby reducing the concentration
of hydrophilic antibiotics.
Lipophilic and protein-binding antibiotics are easily isolated by ECMO circuits, resulting in lower concentrations [47,48
].
The formation of bacterial biofilms has been observed in ECMO cannula, a known risk factor for antibiotic resistance and treatment failure, but its clinical significance has not been established [49,50].

Patients with ECMO are likely to benefit
from therapeutic drug monitoring.
The general recommendation for critically ill patients is routine therapeutic drug monitoring of aminoglycosides, lactam antibiotics, linezolid, ticopram, vancomycin, and voriconazole, if possible [51].

A recent review by Abdul-Aziz et al.
is an excellent summary of current knowledge about the pharmacokinetics of antibiotics in ECMO-supported patients [52].

conclusion

Nosocomial infections during ECMO support are common and associated
with increased morbidity and mortality.
Due to the unique characteristics of patient-loop interactions, diagnosis and treatment is a significant challenge
.
Current scientific understanding lags behind conventional clinical practice
.

Key knowledge points

Patients requiring ECMO support are at greater
risk of infection than the general intensive care unit population.

Nosocomial infections during ECMO support are associated
with an increase in length of hospital stay and mortality.

Despite the lack of evidence, diagnostic and preventive measures such as routine blood cultures and antibiotic prophylaxis remain common
.

.
Patients with ECMO are likely to benefit
from therapeutic drug monitoring.

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