Treatment and follow-up of vascular graft and endograft infection: Delphi consensus document

Abstract

Scope: Vascular graft or endograft infection (VGEI) is a severe complication requiring a multidisciplinary approach combining surgery and antimicrobial therapy. This study aimed to develop expert consensus on the management and follow-up of VGEI, with a focus on antimicrobial strategies.

Methods: A modified Delphi method was conducted to reach consensus on key aspects of VGEI care, including antimicrobial treatment, surgical management, and follow-up. An expert panel representing infectious diseases, vascular and cardiothoracic surgery, microbiology, and nuclear medicine participated in four rounds of surveys. Ten general and 35 specific statements were rated using a five-point Likert scale. Statements with ≥75% agreement (agree/strongly agree) were considered to have achieved consensus. Internal consistency across rounds was assessed using Cronbach's alpha (>0.80).

Questions addressed by the delphi method and recommendations: The panel agreed that empirical antimicrobial therapy should be initiated only in patients with complications (e.g. sepsis and bleeding) or when diagnostic intervention is delayed. Empirical therapy must be individualized based on graft location and risk factors. For abdominal VGEI without aorto-enteric fistula and unknown pathogens, initial coverage should target gram-positive cocci, gram-negative bacilli, and anaerobes, with consideration for Methicillin-Resistant Staphylococcus aureus (MRSA)/Methicillin-Resistant Staphylococcus epidermidis (MRSE) based on risk. For thoracic VGEI without fistula, gram-positive coverage is prioritized, with optional MRSA coverage. Postoperative treatment duration should be individualized. In cases of complete graft removal and replacement with autologous veins, a 6-week antibiotic course is recommended, with early oral switch if bioavailable options are available. If prosthetic material remains, at least 4 to 6 weeks of intravenous therapy followed by oral treatment for a total of 12 weeks is advised. Prolonged therapy should be considered in cases with virulent pathogens, incomplete source control, or persistent inflammatory markers. The study provides practical, expert-based antimicrobial guidance for VGEI management and emphasizes the importance of individualized, microbiologically informed therapy within a multidisciplinary care framework.

Keywords: Antimicrobial therapy; Delphi survey; Follow-up; Surgery; Vascular (endo)graft infection.