Kardio Lunch 18.01.2018 Prosthetic Valve Endocarditis with Mycobacterium Chimaera: Diagnosis, Therapy and Course of Disease. Oliver Reuthebuch
Mycobacterium Chimaera: what is it? nontuberculous, slow-growing mycobacteria (NTM) Ø well recognized pathogen Ø attributed to hospital water or exposure to contaminated devices (instruments, dialysis,..) Ø aerobic, gram-positive small out-breaks with fast-growing NTM Ø M. fortuitum, M. chelonae within the Mycobacterium avium complex (MAC) causative for Ø pulmonary disease Ø superficial lymphadenitis Ø disseminated signs (persistent fever, night sweat, weight loss) Ø skin and soft tissue infection
Mycobacterium Chimaera: what is it? Clinical appearance Prosthetic valve endocarditis Ocular Emboli Bony involvement (eg, vertebral ostemyelitis) Splenomegaly Pancytopenia Hepatitis Renal impairment
Mycobacterium Chimaera: what is it? Therapy Ø optimal duration has not yet been established ² in general for six months ² in bone/joints/implants(?) 12 months Ø macrolide-susceptible patient ² ethambutol ² rifamycin ² Aminoglycoside (amikacin (for intial 8-12 weeks)) Ø macrolide-resistant patient ² ethambutol ² rifamycin (e.g. Rifabutin) ² aminoglycoside (parenteral) ² +/- linezolide, clofazimine
Mycobacterium Chimaera: where does it come from?
Mycobacterium Chimaera: where does it come from?
Mycobacterium Chimaera: where does it come from? Sorin Stöckert 3T Heater-Cooler System (LivaNova, Milan, Italy) Front Front Side Side Back Side Perfusion.com
First check-up in Spring 2014 at USB Ø 2 HCU Sorin 3T Ø HCU water as well as aerosol Ø contamination confirmed Ø HCU taken out of service Ø replacement by new Sorin HCU as well as Maquet HCU 30 Strategic workshop July 2014 + Clinic for Cardiac surgery + Division of Hospital Epidemiology + Sorin Ø complete exchange of Sorin HCU`s Ø thorough surveillance of HCU`s Ø best strategy: displacement of HCU outside of OR, but..
Strategic workshop July 2014 Ø no constructional option (space, construction of walls,..) Ø no remote control of Sorin 3T Ø tube length inappropriate for Sorin 3T Summer 2015 Ø Sorin decontamination protocol Ø replacement of Maranon by Sanosil (H 2 O 2, Silver) Ø every second week instead of monthly January 2016 Ø replacement of Sorin 3T by Maquet HCU 40 30 weeks time of delivery remote control, length of tubing not restricted strict separation of water and aerosol
January 2016 Ø tightening of decontamination measures Ø 50% job for perfusionist Ø once/week decontamination, chlorine based disinfetion Ø protocol demands min of 4h decontamination February 2017 Ø publication of Swiss guideline (BAG) - recommendation for external HCU`s Winter 2017/2018 Ø relocation into new OR Ø HCU`s outside OR Ø equipped with separate air-condition
Mycobacterium Chimaera: clinical cases 6 clinical cases, male, HCU Stöckert 3T time period for first operation: 05/2013-05/2014 patient age at time of first operation: 60.6±7.16 years time period between first operation and onset of symptoms: 24.8±5.8 months time period between onset of symptoms and diagnosis: 11.2±8.1 (4-21months!) time period between diagnosis and re-operation: 3±1 months
Mycobacterium Chimaera: clinical cases Antibiotic pre-treatment, at least 2 months Ø Clarithromycin 2x500mg/d po Ø Moxifloxacin 1x400mg/d po Ø Rifabutin 2x150mg/d po Ø Ethambutol 1x200mg/d po Ø Amikacin 1x1g/d iv > reduction of bacterial load
Mycobacterium Chimaera: clinical cases Patient First Operation Re-Operation 1 biologic composite-graft homograft 2 biological aortic valve homograft, epipm 3 MVR ant.-lat., annuloplasty ring 4 David-operation, LIMA bypass re-mvr, ant.-lat., annuloplasty ring homograft, removal of endopm, implantation of epipm 5 biological aortic valve homograft, replacement of asc. aorta with bovine pericardium prosthesis
Mycobacterium Chimaera: clinical cases Patient 2: biological AVR vs. homograft replacement glucose enrichment in infected valve unsuppressed myocardial glucose enrichment, no glucose enrichment at the level of homograft
Mycobacterium Chimaera: clinical cases Patient 1: biological comp-graft vs. homograft replacement 08/2016 heart vertebrae, hip 03/2016
Mycobacterium Chimaera: clinical cases Patient 1: biological comp-graft vs. homograft replacement 08/2016 heart vertebrae, hip 12/2016
Mycobacterium Chimaera: clinical cases Patient 1: biological comp-graft vs. homograft replacement 08/2016 heart vertebrae, hip 05/2017
Mycobacterium Chimaera: clinical cases Patient 6: biological comp-graft vs. homograft replacement 12/2017 heart 11/2017
Mycobacterium Chimaera: conclusion in general: Ø symptoms and signs of NTM (MAC) are unspecific ² fever, weight loss, night sweats ² ocular emboli, bony involvement (vertebral osteomyelitis), splenomegaly, pancytopenia, hepatitis, renal impairment Ø diagnostic criteria: imaging studies and isolation of Mycobacteria Ø diagnosis months to years after surgical approach Ø infectious pathway: most likely contaminated HCU`s
Mycobacterium Chimaera: conclusion in our experience Ø all five patients are alive Ø treatment requires combined medical and surgical approach Ø long persistent antibiotics therapy (at least one year postoperatively) ² removal of complete foreign material ² implantation of biological material
Thank You Very Much!