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Pasteurella multocida-Infected Expanded Polytetrafluoroethylene Hemodialysis Access Graft
Pasteurella multocida-Infected Expanded Polytetrafluoroethylene Hemodialysis Access Graft Joseph R. Schneider,1 G. Wesley White,2 and Ernest F. DeJesus,3 Winfield, Illinois
Infections are among the risks related to prosthetic hemodialysis access grafts. However, dialysis access graft infections caused by Pasteurella multocida have not been reported previously. We report a case of a P. multocida-infected nonfunctioning expanded polytetrafluoroethylene graft in the forearm after a cat bite. At surgery, the graft was completely unincorporated and was completely excised. Operative culture results were positive for P. multocida, a common oral flora found in cats and dogs. The patient was treated with intravenous ceftriaxone, and the wounds healed with local care.
Infections have been observed after placement of prosthetic hemodialysis access grafts. These have typically been due to common skin flora and less often due to other organisms. We encountered a patient with a Pasteurella multocida-infected prosthetic forearm hemodialysis access graft. This report documents the course and treatment of this patient.
CASE REPORT A 43-year-old woman complained of 1 week of progressive left forearm pain and ultimately spontaneous drainage of purulent fluid from the midulnar volar left forearm on the morning of the day of her presentation. The patient had been diagnosed with systemic lupus erythematosus at age 19 years and had initiation of hemodialysis at age 20 years. She had renal transplants at age 26 years and again at age 31 years, but both of these failed, and she returned to hemodialysis at age 35 years. She 1 Vascular and Interventional Program of Cadence Healthcare, Winfield, IL. 2 Section of Infectious Diseases of Cadence Healthcare, Winfield, IL. 3
Section of Nephrology of Cadence Healthcare, Winfield, IL.
Correspondence to: Joseph R. Schneider, MD, PhD, Vascular and Interventional Program of the Cadence Medical Group, Outpatient Services Building Suite 201, 25 North Winfield Road, Winfield, IL 60190, USA; E-mail: [email protected] Ann Vasc Surg 2012; 26: 1128.e15e1128.e17 DOI: 10.1016/j.avsg.2012.03.007 Ó Annals of Vascular Surgery Inc. Published online: July 26, 2012
had undergone previous vascular access for hemodialysis in the left forearm, and we were consulted for evaluation and treatment. All hemodialysis access procedures (at least two on the right and four on the left arm) had been performed elsewhere. Current access was a left transposed upper basilic vein fistula. There was a U-shaped area of erythema in the left volar forearm, extending from two antecubital well-healed surgical scars proximally to another well-healed surgical scar distally just superior to the wrist, typical for the course of a prosthetic brachial artery-based forearm dialysis bridge graft. There was a 5mm-diameter open wound draining cloudy fluid over the ulnar side of this, and what appeared to be a graft could be observed in the base of this draining ulcer. The patient stated that the graft had been placed about 8 years earlier and was never accessed owing to early thrombosis. There was a small scab on the dorsal left hand adjacent to the fourth metacarpophalangeal joint. On further questioning, the patient recalled that her cat had bitten her at this site 1 week before presentation at our hospital. She reported no fever, chills, or other signs suggestive of sepsis, and she was afebrile, with a normal pulse rate and blood pressure. She was not taking any corticosteroids or other immunosuppressive medications. Her leukocyte count was 7,400/mm3 with 77% neutrophils. The patient had already received 1 g of vancomycin intravenously. The patient was taken to surgery, with the diagnosis of infected prosthetic graft. The graft was confirmed to be expanded polytetrafluoroethylene (ePTFE) with the characteristic manufacturer’s blue markings. No portion of the graft, including the anastomoses, was
1128.e15
1128.e16 Case reports
incorporated into the surrounding tissue. The graft was excised completely; the arterial and venous anastomotic sites were oversewn; and the wounds were left open and treated with dressing changes. Operative culture results were positive for P. multocida, and antibiotic coverage was changed to 1 g of ceftriaxone given intravenously every 24 hours. The erythema cleared rapidly, and the patient was discharged home on the third postoperative day with continued ceftriaxone therapy as an outpatient. Wounds had all closed at 5 weeks after surgery.
COMMENT The ePTFE bridge grafts were first used and popularized for hemodialysis access in the mid-1970s,1 and by the late 1970s, infections had been recognized as a significant problem with these grafts.2,3 Such infections are most often due to skin flora including Staphylococcus aureus and Staphylococcus epidermidis and less frequently due to other organisms, all most likely introduced during cannulation for dialysis.4 One can easily understand how a functioning prosthetic arteriovenous graft could be infected during episodes of bacteremia. However, even nonfunctioning thrombosed grafts may become infected.4 A hematogenous mechanism for infection is less satisfying in such cases, and an alternative mechanism of lymphatic seeding is also plausible. Three blood cultures obtained from our patient before graft excision tested negative for organisms, although it is still possible that the patient had bacteremia and that graft seeding was hematogenous. However, the most common P. multocida infections in humans occur after cat or dog bites or scratches, classically associated with rapidly progressive cellulitis/lymphangitis,5 and the hand is a common site of initial infection.6 Our patient presumably had bacteria in the lymphatic fluid draining from the bite wound on the hand at least transiently, and this may have been the route of graft infection. P. multocida is found in the oral flora of most cats and dogs.5,7 More than 50% of cat bites become infected with P. multocida,7 likely related to puncture wounds from cats’ small teeth. P. multocida is usually susceptible to penicillins and higher-generation cephalosporins, but is generally resistant to firstgeneration cephalosporins.8 b-Lactamase-producing strains are rare. P. multocida has been described as the causative organism in a number of prosthetic orthopedic infections, prosthetic heart valve, and even in breast prostheses.6,9e23 A Medline search using a variety of search terms and a review of bibliographies of the identified previous publications found only four
Annals of Vascular Surgery
previous case reports of P. multocida infection of prosthetic vascular grafts. Kalish and Sands reported a case of a P. multocida-infected aortofemoral graft thought to be related to a dog licking an open toe amputation wound.24 Sannella et al reported a case of an infected aortofemoral graft presumed to be related to frequent dog bites, and cultures collected from the mouth of the culprit dog were positive for the same strain of P. multocida as had been cultured from the patient’s infection.25 Kessler reported a case of a P. multocida-infected aortofemoral graft after a lower extremity cat bite.26 Finally, Silberfein et al reported a case of a P. multocida-infected aortic endograft thought to be related to a bite from a household pet rabbit.27 Rivera et al reported a case of an infection of an aortobifemoral graft in a patient who had suffered dog bites, and cultures collected from the patient were positive for a related organism, Pasteurella haemolytica.28 A further Medline search using search term combinations ([Pasteurella or multocida] and dialysis) and ([Pasteurella or multocida] and [ePTFE or polytetrafluoroethylene]) identified no previous reports involving P. multocida infection of hemodialysis access, prosthetic or otherwise. However, this search did identify nearly 30 reports of P. multocida peritonitis in patients undergoing peritoneal dialysis. Our patient was treated with standard techniques of total graft excision, open management of wounds, and culture-specific antibiotics. The complete disincorporation of the graft, presumably related only to the P. multocida infection and (again presumably) in only 1 week, was truly remarkable when contrasted with a more typical experience with S. aureus infection of an ePTFE graft where an 8-year-old previously incorporated graft would have been expected to have been still at least partially incorporated. Standard management of the infection, including complete excision of the graft, resulted in remarkable and rapid improvement in her clinical status, allowing early discharge and completion of therapy at home.
REFERENCES 1. Baker LD Jr, Johnson JM, Goldfarb D. Expanded polytetrafluoroethylene (PTFE) subcutaneous arteriovenous conduit: an improved vascular access for chronic hemodialysis. Trans Am Soc Artif Intern Organs 1976;22:382e7. 2. Butler HG 3rd, Baker LD Jr, Johnson JM. Vascular access for chronic hemodialysis: polytetrafluoroethylene (PTFE) versus bovine heterograft. Am J Surg 1977;134:791e3. 3. Tellis VA, Kohlberg WI, Bhat DJ, et al. Expanded polytetrafluoroethylene graft fistula for chronic hemodialysis. Ann Surg 1979;189:101e5.
Vol. 26, No. 8, November 2012
4. Nassar GM, Ayus JC. Infectious complications of the hemodialysis access. Kidney Int 2001;60:1e13. 5. Weber DJ, Wolfson JS, Swartz MN, Hooper DC. Pasteurella multocida infections. Report of 34 cases and review of the literature. Medicine (Baltimore) 1984;63:133e54. 6. Chikwe J, Bowditch M, Villar RN, Bedford AF. Sleeping with the enemy: Pasteurella multocida infection of a hip replacement. J R Soc Med 2000;93:478e9. 7. Goldstein EJ. Bite wounds and infection. Clin Infect Dis 1992;14:633e8. 8. Noel GJ, Teele DW. In vitro activities of selected new and long-acting cephalosporins against Pasteurella multocida. Antimicrob Agents Chemother 1986;29:344e5. 9. Braithwaite BD, Giddins G. Pasteurella multocida infection of a total hip arthroplasty. A case report. J Arthroplasty 1992;7: 309e10. 10. Gabuzda GM, Barnett PR. Pasteurella infection in a total knee arthroplasty. Orthop Rev 1992;21:601. 11. Guion TL, Sculco TP. Pasteurella multocida infection in total knee arthroplasty. Case report and literature review. J Arthroplasty 1992;7:157e60. 12. Antu~ na SA, M endez JG, Castellanos JL, Jimenez JP. Late infection after total knee arthroplasty caused by Pasteurella multocida. Acta Orthop Belg 1997;63:310e2. 13. Maradona JA, Asensi V, Carton JA, et al. Prosthetic joint infection by Pasteurella multocida. Eur J Clin Microbiol Infect Dis 1997;16:623e5. 14. Mehta H, Mackie I. Prosthetic joint infection with Pasteurella multocida following cat scratch: a report of 2 cases. J Arthroplasty 2004;19:525e7. 15. Polzhofer GK, Hassenpflug J, Petersen W. Arthroscopic treatment of septic arthritis in a patient with posterior stabilized total knee arthroplasty. Arthroscopy 2004;20:311e3. 16. Stiehl JB, Sterkin LA, Brummitt CF. Acute Pasteurella multocida in total knee arthroplasty. J Arthroplasty 2004;19:244e7. 17. Heym B, Jouve F, Lemoal M, et al. Pasteurella multocida infection of a total knee arthroplasty after a ‘‘dog lick’’. Knee Surg Sports Traumatol Arthrosc 2006;14:993e7.
Case reports 1128.e17
18. Serrano MTC, Menendez JN, Garcia BdlF, Fernandez MLG-A. Infecci on de pr otesis articular de rodilla por Pasteurella multocida [Knee prosthesis infection due to Pasteurella multocida]. Enferm Infecc Microbiol Clin 2007;25:492. 19. Heydemann J, Heydemann JS, Antony S. Acute infection of a total knee arthroplasty caused by Pasteurella multocida: a case report and a comprehensive review of the literature in the last 10 years. Int J Infect Dis 2010;14(Suppl 3): e242e5. 20. Nettles RE, Sexton DJ. Pasteurella multocida prosthetic valve endocarditis: case report and review. Clin Infect Dis 1997;25:920e1. 21. Reinsch N, Plicht B, Lind A, et al. Recurrent infective endocarditis with uncommon gram-negative Pasteurella multocida and Pseudomonas aeruginosa: a case report. J Heart Valve Dis 2008;17:710e3. 22. Mathieu D, Rodriguez H, Jacobs F. Breast prosthesis infected by Pasteurella multocida. Acta Clin Belg 2008;63: 351. 23. Mondon D, Bouillet B, Lesens O, Descamps S. Premiere description d’une prothese totale de genou infectee par Pasteurella canis. [First report of a total knee arthroplasty infected by Pasteurella canis]. Medecine et Maladies Infectieuses 2010;40:600e1. 24. Kalish SB, Sands ML. Pasteurella multocida infection of a prosthetic vascular graft. JAMA 1983;249:514e5. 25. Sannella NA, Tavano P, McGoldrick DM, et al. Aortic graft sepsis caused by Pasteurella multocida. J Vasc Surg 1987;5: 887e8. 26. Kessler AT, Caliendo AM, Kourtis AP. Vascular graft infection due to Pasteurella multocida. Infection 2004;32: 122e3. 27. Silberfein EJ, Lin PH, Bush RL, et al. Aortic endograft infection due to Pasteurella multocida following a rabbit bite. J Vasc Surg 2006;43:393e5. 28. Rivera M, Hunter GC, Brooker J, et al. Aortic graft infection due to Pasteurella haemolytica and Group C b-hemolytic Streptococcus. Clin Infect Dis 1994;19:941e3.
Infections are among the risks related to prosthetic hemodialysis access grafts. However, dialysis access graft infections caused by Pasteurella multocida have not been reported previously. We report a case of a P. multocida-infected nonfunctioning expanded polytetrafluoroethylene graft in the forearm after a cat bite. At surgery, the graft was completely unincorporated and was completely excised. Operative culture results were positive for P. multocida, a common oral flora found in cats and dogs. The patient was treated with intravenous ceftriaxone, and the wounds healed with local care.
Infections have been observed after placement of prosthetic hemodialysis access grafts. These have typically been due to common skin flora and less often due to other organisms. We encountered a patient with a Pasteurella multocida-infected prosthetic forearm hemodialysis access graft. This report documents the course and treatment of this patient.
CASE REPORT A 43-year-old woman complained of 1 week of progressive left forearm pain and ultimately spontaneous drainage of purulent fluid from the midulnar volar left forearm on the morning of the day of her presentation. The patient had been diagnosed with systemic lupus erythematosus at age 19 years and had initiation of hemodialysis at age 20 years. She had renal transplants at age 26 years and again at age 31 years, but both of these failed, and she returned to hemodialysis at age 35 years. She 1 Vascular and Interventional Program of Cadence Healthcare, Winfield, IL. 2 Section of Infectious Diseases of Cadence Healthcare, Winfield, IL. 3
Section of Nephrology of Cadence Healthcare, Winfield, IL.
Correspondence to: Joseph R. Schneider, MD, PhD, Vascular and Interventional Program of the Cadence Medical Group, Outpatient Services Building Suite 201, 25 North Winfield Road, Winfield, IL 60190, USA; E-mail: [email protected] Ann Vasc Surg 2012; 26: 1128.e15e1128.e17 DOI: 10.1016/j.avsg.2012.03.007 Ó Annals of Vascular Surgery Inc. Published online: July 26, 2012
had undergone previous vascular access for hemodialysis in the left forearm, and we were consulted for evaluation and treatment. All hemodialysis access procedures (at least two on the right and four on the left arm) had been performed elsewhere. Current access was a left transposed upper basilic vein fistula. There was a U-shaped area of erythema in the left volar forearm, extending from two antecubital well-healed surgical scars proximally to another well-healed surgical scar distally just superior to the wrist, typical for the course of a prosthetic brachial artery-based forearm dialysis bridge graft. There was a 5mm-diameter open wound draining cloudy fluid over the ulnar side of this, and what appeared to be a graft could be observed in the base of this draining ulcer. The patient stated that the graft had been placed about 8 years earlier and was never accessed owing to early thrombosis. There was a small scab on the dorsal left hand adjacent to the fourth metacarpophalangeal joint. On further questioning, the patient recalled that her cat had bitten her at this site 1 week before presentation at our hospital. She reported no fever, chills, or other signs suggestive of sepsis, and she was afebrile, with a normal pulse rate and blood pressure. She was not taking any corticosteroids or other immunosuppressive medications. Her leukocyte count was 7,400/mm3 with 77% neutrophils. The patient had already received 1 g of vancomycin intravenously. The patient was taken to surgery, with the diagnosis of infected prosthetic graft. The graft was confirmed to be expanded polytetrafluoroethylene (ePTFE) with the characteristic manufacturer’s blue markings. No portion of the graft, including the anastomoses, was
1128.e15
1128.e16 Case reports
incorporated into the surrounding tissue. The graft was excised completely; the arterial and venous anastomotic sites were oversewn; and the wounds were left open and treated with dressing changes. Operative culture results were positive for P. multocida, and antibiotic coverage was changed to 1 g of ceftriaxone given intravenously every 24 hours. The erythema cleared rapidly, and the patient was discharged home on the third postoperative day with continued ceftriaxone therapy as an outpatient. Wounds had all closed at 5 weeks after surgery.
COMMENT The ePTFE bridge grafts were first used and popularized for hemodialysis access in the mid-1970s,1 and by the late 1970s, infections had been recognized as a significant problem with these grafts.2,3 Such infections are most often due to skin flora including Staphylococcus aureus and Staphylococcus epidermidis and less frequently due to other organisms, all most likely introduced during cannulation for dialysis.4 One can easily understand how a functioning prosthetic arteriovenous graft could be infected during episodes of bacteremia. However, even nonfunctioning thrombosed grafts may become infected.4 A hematogenous mechanism for infection is less satisfying in such cases, and an alternative mechanism of lymphatic seeding is also plausible. Three blood cultures obtained from our patient before graft excision tested negative for organisms, although it is still possible that the patient had bacteremia and that graft seeding was hematogenous. However, the most common P. multocida infections in humans occur after cat or dog bites or scratches, classically associated with rapidly progressive cellulitis/lymphangitis,5 and the hand is a common site of initial infection.6 Our patient presumably had bacteria in the lymphatic fluid draining from the bite wound on the hand at least transiently, and this may have been the route of graft infection. P. multocida is found in the oral flora of most cats and dogs.5,7 More than 50% of cat bites become infected with P. multocida,7 likely related to puncture wounds from cats’ small teeth. P. multocida is usually susceptible to penicillins and higher-generation cephalosporins, but is generally resistant to firstgeneration cephalosporins.8 b-Lactamase-producing strains are rare. P. multocida has been described as the causative organism in a number of prosthetic orthopedic infections, prosthetic heart valve, and even in breast prostheses.6,9e23 A Medline search using a variety of search terms and a review of bibliographies of the identified previous publications found only four
Annals of Vascular Surgery
previous case reports of P. multocida infection of prosthetic vascular grafts. Kalish and Sands reported a case of a P. multocida-infected aortofemoral graft thought to be related to a dog licking an open toe amputation wound.24 Sannella et al reported a case of an infected aortofemoral graft presumed to be related to frequent dog bites, and cultures collected from the mouth of the culprit dog were positive for the same strain of P. multocida as had been cultured from the patient’s infection.25 Kessler reported a case of a P. multocida-infected aortofemoral graft after a lower extremity cat bite.26 Finally, Silberfein et al reported a case of a P. multocida-infected aortic endograft thought to be related to a bite from a household pet rabbit.27 Rivera et al reported a case of an infection of an aortobifemoral graft in a patient who had suffered dog bites, and cultures collected from the patient were positive for a related organism, Pasteurella haemolytica.28 A further Medline search using search term combinations ([Pasteurella or multocida] and dialysis) and ([Pasteurella or multocida] and [ePTFE or polytetrafluoroethylene]) identified no previous reports involving P. multocida infection of hemodialysis access, prosthetic or otherwise. However, this search did identify nearly 30 reports of P. multocida peritonitis in patients undergoing peritoneal dialysis. Our patient was treated with standard techniques of total graft excision, open management of wounds, and culture-specific antibiotics. The complete disincorporation of the graft, presumably related only to the P. multocida infection and (again presumably) in only 1 week, was truly remarkable when contrasted with a more typical experience with S. aureus infection of an ePTFE graft where an 8-year-old previously incorporated graft would have been expected to have been still at least partially incorporated. Standard management of the infection, including complete excision of the graft, resulted in remarkable and rapid improvement in her clinical status, allowing early discharge and completion of therapy at home.
REFERENCES 1. Baker LD Jr, Johnson JM, Goldfarb D. Expanded polytetrafluoroethylene (PTFE) subcutaneous arteriovenous conduit: an improved vascular access for chronic hemodialysis. Trans Am Soc Artif Intern Organs 1976;22:382e7. 2. Butler HG 3rd, Baker LD Jr, Johnson JM. Vascular access for chronic hemodialysis: polytetrafluoroethylene (PTFE) versus bovine heterograft. Am J Surg 1977;134:791e3. 3. Tellis VA, Kohlberg WI, Bhat DJ, et al. Expanded polytetrafluoroethylene graft fistula for chronic hemodialysis. Ann Surg 1979;189:101e5.
Vol. 26, No. 8, November 2012
4. Nassar GM, Ayus JC. Infectious complications of the hemodialysis access. Kidney Int 2001;60:1e13. 5. Weber DJ, Wolfson JS, Swartz MN, Hooper DC. Pasteurella multocida infections. Report of 34 cases and review of the literature. Medicine (Baltimore) 1984;63:133e54. 6. Chikwe J, Bowditch M, Villar RN, Bedford AF. Sleeping with the enemy: Pasteurella multocida infection of a hip replacement. J R Soc Med 2000;93:478e9. 7. Goldstein EJ. Bite wounds and infection. Clin Infect Dis 1992;14:633e8. 8. Noel GJ, Teele DW. In vitro activities of selected new and long-acting cephalosporins against Pasteurella multocida. Antimicrob Agents Chemother 1986;29:344e5. 9. Braithwaite BD, Giddins G. Pasteurella multocida infection of a total hip arthroplasty. A case report. J Arthroplasty 1992;7: 309e10. 10. Gabuzda GM, Barnett PR. Pasteurella infection in a total knee arthroplasty. Orthop Rev 1992;21:601. 11. Guion TL, Sculco TP. Pasteurella multocida infection in total knee arthroplasty. Case report and literature review. J Arthroplasty 1992;7:157e60. 12. Antu~ na SA, M endez JG, Castellanos JL, Jimenez JP. Late infection after total knee arthroplasty caused by Pasteurella multocida. Acta Orthop Belg 1997;63:310e2. 13. Maradona JA, Asensi V, Carton JA, et al. Prosthetic joint infection by Pasteurella multocida. Eur J Clin Microbiol Infect Dis 1997;16:623e5. 14. Mehta H, Mackie I. Prosthetic joint infection with Pasteurella multocida following cat scratch: a report of 2 cases. J Arthroplasty 2004;19:525e7. 15. Polzhofer GK, Hassenpflug J, Petersen W. Arthroscopic treatment of septic arthritis in a patient with posterior stabilized total knee arthroplasty. Arthroscopy 2004;20:311e3. 16. Stiehl JB, Sterkin LA, Brummitt CF. Acute Pasteurella multocida in total knee arthroplasty. J Arthroplasty 2004;19:244e7. 17. Heym B, Jouve F, Lemoal M, et al. Pasteurella multocida infection of a total knee arthroplasty after a ‘‘dog lick’’. Knee Surg Sports Traumatol Arthrosc 2006;14:993e7.
Case reports 1128.e17
18. Serrano MTC, Menendez JN, Garcia BdlF, Fernandez MLG-A. Infecci on de pr otesis articular de rodilla por Pasteurella multocida [Knee prosthesis infection due to Pasteurella multocida]. Enferm Infecc Microbiol Clin 2007;25:492. 19. Heydemann J, Heydemann JS, Antony S. Acute infection of a total knee arthroplasty caused by Pasteurella multocida: a case report and a comprehensive review of the literature in the last 10 years. Int J Infect Dis 2010;14(Suppl 3): e242e5. 20. Nettles RE, Sexton DJ. Pasteurella multocida prosthetic valve endocarditis: case report and review. Clin Infect Dis 1997;25:920e1. 21. Reinsch N, Plicht B, Lind A, et al. Recurrent infective endocarditis with uncommon gram-negative Pasteurella multocida and Pseudomonas aeruginosa: a case report. J Heart Valve Dis 2008;17:710e3. 22. Mathieu D, Rodriguez H, Jacobs F. Breast prosthesis infected by Pasteurella multocida. Acta Clin Belg 2008;63: 351. 23. Mondon D, Bouillet B, Lesens O, Descamps S. Premiere description d’une prothese totale de genou infectee par Pasteurella canis. [First report of a total knee arthroplasty infected by Pasteurella canis]. Medecine et Maladies Infectieuses 2010;40:600e1. 24. Kalish SB, Sands ML. Pasteurella multocida infection of a prosthetic vascular graft. JAMA 1983;249:514e5. 25. Sannella NA, Tavano P, McGoldrick DM, et al. Aortic graft sepsis caused by Pasteurella multocida. J Vasc Surg 1987;5: 887e8. 26. Kessler AT, Caliendo AM, Kourtis AP. Vascular graft infection due to Pasteurella multocida. Infection 2004;32: 122e3. 27. Silberfein EJ, Lin PH, Bush RL, et al. Aortic endograft infection due to Pasteurella multocida following a rabbit bite. J Vasc Surg 2006;43:393e5. 28. Rivera M, Hunter GC, Brooker J, et al. Aortic graft infection due to Pasteurella haemolytica and Group C b-hemolytic Streptococcus. Clin Infect Dis 1994;19:941e3.